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The Internalization of the Strong Black Woman Schema and Mental Health Help-Seeking

Submitted by

Breanna Marie Fulton

A Dissertation Presented in Partial Fulfillment

of the Requirements for the Degree

Doctorate of Education

Grand Canyon University

Phoenix, Arizona

August 15, 2018

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GRAND CANYON UNIVERSITY

The Internalization of the Strong Black Woman Schema and Mental Health Help-Seeking

I verify that my dissertation represents original research, is not falsified or plagiarized,

and that I accurately reported, cited, and referenced all sources within this manuscript in

strict compliance with APA and Grand Canyon University (GCU) guidelines. I also

verify my dissertation complies with the approval(s) granted for this research

investigation by GCU Institutional Review Board (IRB).

_____________________________________________ ______________________

Breanna Marie Fulton Date

Abstract

The purpose of this quantitative correlational research was to determine if, and to what

extent, a correlation existed between the internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking in Black women aged 18-65 in the

Southern region of the United States. Data were collected from 153 Black women utilizing

the Strong Black Woman Attitudes Scale to measure internalization of the Strong Black

Woman schema. The Inventory of Attitudes Toward Seeking Mental Health Services

measured attitudes toward mental health help-seeking. This study utilized gender schema

theory and the Theory of Planned Behavior as the theoretical framework. The guiding

research questions analyzed using Spearman’s rho correlation were: (1)Is there a

correlation between internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking, (2) Is there a correlation between the internalization of

the Strong Black Woman schema and psychological openness, (3) Is there a correlation

between the internalization of the Strong Black Woman schema and help-seeking

propensity, (4) Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma. Results of research question one found a significant

correlation, rs (153) =.230, p = .005; two-tailed. Results of research question three

suggested a significant correlation propensity, rs (153) =.281, p = .001; two-tailed. This

research may be significant for mental health care providers to gather a more complete

framework for understanding how internalization of the Strong Black Woman schema may

influence mental health help-seeking behaviors.

Keywords: Strong Black Woman schema, mental health, help-seeking attitudes,

gender schema theory

Dedication

First, I give honor to the Most High. It is your word, “For I know the plans I have

for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you

hope and a future” (Jeremiah 29:11, NIV) that motivated me to apply to this program. It

has been your promise, “And we know that in all things God works for the good of those

who love him, who have been called according to his purpose” (Romans 8:28, NIV) that

has sustained me to see it to the end of this journey.

To my mother, please know that I am eternally grateful for every sacrifice that

you have made for me since I formed in your womb. Thank you for continuously keeping

me lifted in prayer, as well as showering me with your love and support. To my

grandmother and Aunt Faith, I am tremendously thankful for every reminder that I am

capable, phenomenal, and inspirational. To the one my heart beats for, Lee, you have

been the most amazing support system throughout this arduous process. Thank you for

standing by me during numerous hours of research and writing, believing and pushing me

to continue when I felt like pushing my computer on the floor and giving up, and for

reminding me of my divine purpose and dopeness. For these reasons and countless more,

I love you beyond measure. To my siblings, Reginald and Jazmine, your faith in my

abilities mean more to me than you will ever be able to comprehend. Finally, to every

Black woman on this planet, may you always walk in your purpose, remember your

magic, bend but never break, and never lose your spirit or your sparkle for you are

fearfully and wonderfully made.

vii

Acknowledgments

I would like to acknowledge my phenomenal committee including Dr. Tibbs, Dr.

Pernsteiner, and Dr. Robinson. I truly appreciate all the knowledge, patience, and

persistence that you have given me. I am grateful to have you all as my doctoral

cheerleaders.

I would like to extend a special acknowledgement to my Georgian Hills family

for their support. Principal Dandridge, Dean Miller, and Ms. Washington were always

around to give me that special dose of encouragement that I needed to get my life

together and persevere. Thank you O’Neal and Robinson for consistently motivating me

to get this done and reminding me how awesome graduation will be when the process is

finally over.

Also, I would like to acknowledge Dr. Segura and the English department at

Alcorn State University. It is the time that I spent beneath the shade of giant trees with

those wonderful professors that motivated me to pursue this journey. Thank you for

sharpening my reading, writing, and critical thinking skills.

Dr. Whitfield, thank you for all your help throughout this process. Without your

knowledge and expertise, I wouldn’t be where I am today. Finally, I want to extend my

gratitude to every family member, friend, soror, and colleague that offered me

encouragement and motivation on the days that I needed it the most.

viii

Table of Contents

List of Tables .................................................................................................................... xii

List of Figures .................................................................................................................. xiii

Chapter 1: Introduction to the Study ....................................................................................1

Introduction ....................................................................................................................1

Background of the Study ...............................................................................................3

Problem Statement .........................................................................................................6

Purpose of the Study ......................................................................................................7

Research Questions and/or Hypotheses .........................................................................9

Advancing Scientific Knowledge and Significance of the Study ................................12

Rationale for Methodology ..........................................................................................15

Nature of the Research Design for the Study ...............................................................16

Definition of Terms......................................................................................................18

Assumptions, Limitations, Delimitations ....................................................................21

Summary and Organization of the Remainder of the Study ........................................22

Chapter 2: Literature Review .............................................................................................25

Introduction to the Chapter and Background to the Problem ......................................25

Identification of the Gap ..............................................................................................27

Theoretical Foundation ................................................................................................30

Review of the Literature ..............................................................................................34

The strong black woman in contrast to white women. .......................................35

Strong black woman schema. .............................................................................37

Role strain and the strong black woman schema. ...............................................43

Mental health help-seeking. ................................................................................46

Measurements of help-seeking attitudes. ............................................................49

Health disparities in the black community. ........................................................51

Discrimination based disparities. ........................................................................51

Medical distrust...................................................................................................54

Psychological distress in black women. .............................................................55

Coping strategies of black women. .....................................................................57

Religious coping. ................................................................................................62

Methodology. ......................................................................................................63

Instrumentation. ..................................................................................................65

Summary ......................................................................................................................68

Chapter 3: Methodology ....................................................................................................73

Introduction ..................................................................................................................73

Statement of the Problem .............................................................................................74

Research Questions and/or Hypotheses .......................................................................75

Research Methodology ................................................................................................78

Research Design...........................................................................................................79

Population and Sample Selection.................................................................................80

Instrumentation ............................................................................................................83

Validity ........................................................................................................................85

Reliability .....................................................................................................................86

Data Collection and Management ................................................................................87

Data Analysis Procedures ............................................................................................89

Ethical Considerations .................................................................................................94

Limitations and Delimitations ......................................................................................95

Summary ......................................................................................................................98

Chapter 4: Data Analysis and Results ..............................................................................100

Introduction ................................................................................................................100

Descriptive Findings ..................................................................................................102

Descriptive Statistics ..................................................................................................105

Data Analysis Procedures ..........................................................................................111

Instrument Reliability for the Sample ........................................................................122

Results ........................................................................................................................125

Research question one/hypothesis one. ............................................................126

Research question two/hypothesis two. ............................................................127

Research question three/hypothesis three. ........................................................127

Research Question Four/Hypothesis Four. .......................................................127

Summary ....................................................................................................................128

Chapter 5: Summary, Conclusions, and Recommendations ............................................129

Introduction and Summary of Study ..........................................................................129

Summary of Findings and Conclusion .......................................................................133

Correlation of internalization of the strong Black woman schema and attitudes

toward mental health help-seeking. ..................................................................134

Correlation of internalization of the strong Black woman schema and

psychological openness.....................................................................................135

Correlation of internalization of the strong Black woman schema and help-

seeking propensity. ...........................................................................................135

Correlation of internalization of the strong Black woman schema and

indifference to stigma. ......................................................................................136

Implications................................................................................................................137

Theoretical implications. ..................................................................................137

Practical implications. .......................................................................................138

Future implications. ..........................................................................................139

Strengths and weaknesses of the study. ............................................................139

Recommendations ......................................................................................................142

Recommendations for future research ..............................................................142

Recommendations for future practice. ..............................................................144

References 146

Appendix A. Site Authorization Letter ............................................................................179

Appendix B. IRB Approval Letter ...................................................................................180

Appendix C. Informed Consent .......................................................................................181

Appendix D. Copy of Instruments and Permission Letters to Use the Instruments ........183

Appendix E. Power Analyses for Sample Size Calculation ............................................188

Appendix F. Data Source Table .......................................................................................190

List of Tables

Table 1. Dimensions of the Strong Black Woman Schema .............................................. 8

Table 2. Dimensions of Attitudes toward Mental Health Help-Seeking .......................... 8

Table 3. Age Group........................................................................................................ 103

Table 4. Marital Status ................................................................................................... 104

Table 5. Education Level ............................................................................................... 104

Table 6. Household Income ........................................................................................... 105

Table 7. Descriptive Statistics........................................................................................ 106

Table 8. Shapiro-Wilk Normality Test Results.............................................................. 112

Table 9. Reliability Coefficients .................................................................................... 122

Table 10. Correlation Matrix ......................................................................................... 126

xiii

List of Figures

Figure 1. Internalization of the strong Black woman schema. ....................................... 107

Figure 2. Black/African American females’ attitudes toward mental health help-seeking.

......................................................................................................................... 108

Figure 3. The psychological openness of Black/African American females. ................. 109

Figure 4. The help-seeking propensity of Black/African American females. ................ 110

Figure 5. The indifference to stigma of Black/African American females. .................... 111

Figure 6. Normal histogram for internalization of the strong Black woman schema. .... 113

Figure 7. Histogram for attitude toward mental health help-seeking. ............................ 114

Figure 8. Box and whisker plot for attitude toward mental health help-seeking. ........... 115

Figure 9. Histogram for psychological openness. ........................................................... 116

Figure 10. Box and whisker plot for psychological openness. ....................................... 117

Figure 11. Histogram for help-seeking propensity. ........................................................ 118

Figure 12. Box and whisker plot for help-seeking propensity. ....................................... 119

Figure 13. Histogram for indifference to stigma. ........................................................... 120

Figure 14. Box and whisker plot for indifference to stigma. .......................................... 121

Chapter 1: Introduction to the Study

Introduction

A myriad of factors may impact the mental health of women in the United States.

Yet, Black women in the United States have high rates of exposure to stressors that can

negatively influence their mental health (Lacey et al., 2015). However, cultural-based

notions may determine if individuals seek mental health help (Campbell & Long, 2014).

Current research characterizes the Strong Black Woman schema as a culturally imposed

notion of emotional resilience and has been explored as one possible coping mechanism

for African American women (Hamin, 2008; Romero, 2000; Thompson, 2003).

The aim of dissertation study was to determine if, and to what extent, a correlation

existed between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking. This research was based on the premise that mental

health services are underutilized in the Black community even after removing

socioeconomic barriers such as transportation and cost of care (Jimenez, Cook, Bartels, &

Alegría, 2013). The assertion by Jimenez et al. (2013) suggests that even when barriers to

accessing care are eliminated, mental health services are still being underutilized in the

Black community.

Although mental health underutilization has been noted, there is a shortage of

literature regarding the role of cultural factors in the decision to seek mental health help

(Abrams, Maxwell, Pope, & Belgrave, 2014; Watson & Hunter, 2015; Watson & Hunter,

2016). Additionally, Donovan and West (2015) suggested that researchers further

examine the correlation between the Strong Black Woman schema and mental health

given the negative implications of the endorsement of the schema implied by the results

of their study regarding the schema and stress. Further, Watson-Singleton (2017)

recommended that future research be conducted to assess the Strong Black Woman

schema’s impact on Black women’s health experiences. Consequently, this dissertation

research expanded the knowledge base of mental health help-seeking attitudes and the

Strong Black Woman schema using quantitative measures.

Watson and Hunter (2015) suggested that additional studies regarding the Strong

Black Woman schema be conducted among women of various socioeconomic,

educational, and regional backgrounds. As a result, this research provides a unique

perspective because it utilized data from a range of age groups and diverse backgrounds.

Additionally, the researcher explored the possibility of cultural factors, such as gender

role schemas, playing a role in the underutilization of mental health services. The results

of this research are valuable because it offers a platform for future research to further

evaluate the Strong Black Woman schema and its correlation to mental health-help-

seeking. Since the Strong Black Woman schema has been associated with mental and

physical outcomes (Black & Woods-Giscombé, 2012), understanding the internalization

of the schema may allow mental health professionals to improve effectiveness and

cultural appropriateness of health care delivery service to Black women. Furthermore,

this research provides value to the literature and expands the knowledge base by

extending research on the Strong Black Woman schema from a perspective that has not

been explored sufficiently.

Chapter 1 provides an introduction and rationale for the need to investigate the

correlation between the Strong Black Woman schema and help-seeking attitudes.

Additionally, it contains a review of previously conducted empirical research which

indicates a knowledge gap in the literature. Further, the purpose statement for this study,

the research questions, and hypotheses stated for this study are based on the

internalization of the Strong Black Woman schema and dimensions of the Inventory of

Attitudes toward Seeking Mental Health Service (Mackenzie, Knox, Gekoski, &

Macaulay, 2004).

Each research question focuses on the correlation between the internalization of

the Strong Black Woman schema and attitudes toward mental health help-seeking.

Chapter 1 includes the background of the study, states the research problem and purpose,

presents the research questions and hypotheses, and provides the rationale for the

research methodology and design. The significance of the study and advancing scientific

knowledge are also discussed in Chapter 1. In addition, the researcher defines key terms

and discusses the assumptions, limitations, and delimitations of this study. Finally,

Chapter 1 concludes with a summary.

Background of the Study

Researchers have suggested that the Strong Black Woman schema can be traced

to slavery and remains pervasive due to the adversities that Black women experience,

such as financial hardship and primary caretaking responsibilities (Romero, 2000;

Thomas, Witherspoon, & Speight, 2004). The capture and subsequent enslavement of

Africans thrust them into an unfamiliar context and culture. However, many Africans

retained their cultural norms and values as Rodgers-Rose (1980) pointed out in her

overview of the history of Black women. Consequently, many of the social norms of

African womanhood were passed down within the new cultural context of slavery and

servitude.

Because of the genesis in slavery, the Strong Black Woman schema relies heavily

on a discourse of strength. The discourse of strength mirrors the primary factors of self-

reliance, caretaking, and affects regulation as identified by Romero (2000) and validated

in a scale by Thompson (2003) and Hamin (2008). The concept of strength, although

generally acknowledged and accepted within the Black cultural context as positive

(Watson & Hunter, 2015), can also be associated with detrimental psychological

outcomes for those attempting to embody this ideal of womanhood (Donovan & West,

2015).

During slavery, Black women found themselves not only responsible for taking

care of their own families and children in the community, but also acting as caretaker in

the slave master’s household (Rodgers-Rose, 1980). Performing the primary caretaking

roles in the slave master’s household called for frequent contact with the master’s family.

It is this recurring contact that may have contributed to the development of the third

component of the Strong Black Woman schema—a need to control the expression of

negative feelings.

Black women in captivity did not have the opportunity to express all the pain,

anger and negative emotions that resulted from their societal position (Broussard, 2013).

Throughout slavery, the Black woman may have developed a façade to mask the true

feelings associated with the subservient position as an enslaved person. Robinson (1983)

detailed the ways the enslaved African woman suffered abuse, exploitation, and

oppression at the hands of her enslavers. Not only was she expected to perform the same

back-breaking work as a man, for as long as a man, but she was also subject to sexual

abuse, physical violence, and the constant threat of the disintegration of her family at the

behest of her enslavers. Therefore, Black women concealing their true feelings may have

developed as a coping mechanism in response to the double bind of experiencing abuse

and oppression while simultaneously having to mask emotional vulnerability (Broussard,

2013).

The ideal of independence as a pertinent characteristic of Black women has been

reflected in both past and present social contexts and reflects cultural expectations as well

as social and economic realities (Wallace, Moore, & Curtis, 2014). Contemporary Black

women descended from women who maintained heavy work ethics and independence

(Robinson, 1983). Thus, the context of slavery potentially exacerbated the traits of

independence and strength. Black men had little opportunity to effectively protect their

women or their families. Accordingly, these factors necessitated the Black woman’s need

to rely on herself (Hurt, McElroy, Sheats, Landor, & Bryant, 2014).

The self-reliance, caretaking, and affect regulation characteristics of the Strong

Black Woman schema may correlate to the underutilization of mental health services in

the Black community. Considering the current underutilization of mental health services

in the Black community, researchers have conducted qualitative research regarding the

association of health outcomes along the intersection of race and gender (Abrams et al.,

2014; Thomas, Hoxha, & Hacker, 2013). Although some research was conducted,

Abrams et al. (2014), Watson-Singleton (2017), and Watson and Hunter (2015) identified

the need for future studies to assess the correlation between the internalization of the

Strong Black Woman schema and mental health help-seeking behaviors among various

socioeconomic, educational, and regional backgrounds.

Problem Statement

It was not known if, and to what extent, there were statistically significant

correlations between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking. Given that the core expectations of the Strong Black

Woman schema include self-reliance, caretaking, and affect regulation, Black women

may feel that seeking mental health help is inconsistent with their culture (Turner et al.,

2016). Although prior studies show that there is a negative link between the Strong Black

Woman schema and depression in middle class Black women, hardly any quantitative

studies have been conducted regarding Black women’s attitudes toward seeking mental

health help using women ages 18-65 which indicates a gap in the literature (Abrams et

al., 2014; Donovan & West, 2015; Watson & Hunter, 2015; Watson & Hunter, 2016;

Watson-Singleton, 2017). Black women in the southern region of the United States ages

18-65 were used as the unit of analysis for this research.

This research may assist in closing the gap regarding the Strong Black Woman

schema and attitudes toward mental health help-seeking by adding to the body of

knowledge regarding minorities and mental health help-seeking behaviors. Various

studies have attempted to determine causation for the lack of mental health utilization in

the Black community (Hines, Cooper, & Shi, 2017; Jang, Park, Kang, & Chiriboga, 2014;

Lee, Xue, Spira, & Lee, 2014; Lindsey, Chambers, Pohle, Beall, & Lucksted, 2013).

Additionally, previously conducted research containing Black women has documented an

association between the internalization of the Strong Black Woman schema and

psychological distress, low self-esteem, chronic health conditions, and participation in

risky sexual behaviors (Brown, Webb-Bradley, Cobb, Spaw, & Aldridge, 2014; Lewis &

Neville, 2015; Woods-Giscombé, Lobel, Zimmer, Wiley Cené, & Corbie-Smith, 2015).

However, mental health services are still being underutilized in the Black community.

Mackenzie, Erickson, Deane, and Wright (2014) stated that due to the fact mental

health services are still being underutilized, researchers must continuously develop

understandings of help-seeking attitudes as a means of improving access to professional

treatment. Ultimately, this research may contribute to solving the problem by assisting

clinicians in understanding the cultural barriers and attitudes holding Black women ages

18-65 in the South back from seeking mental health help. Additionally, investigating the

correlation between the Strong Black Woman schema and attitudes toward mental health

help -seeking may help inform relevant research and aide in development of mental

health interventions for Black women.

Purpose of the Study

The purpose of this quantitative correlational research was to determine if, and to

what extent, a correlation existed between the internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking in Black women aged 18-65 in

the Southern region of the United States. This study may address gaps in the literature by

assessing the correlation between the internalization of the Strong Black Woman schema

and attitudes toward mental health help-seeking along each of the Inventory of Attitudes

toward Mental Health Help Seeking subscales.

One interval scale variable of this research study was the internalization of the

Strong Black Woman schema as measured by the Strong Black Woman Attitudes Scale.

The predictor variable of the internalization of the Strong Black Woman schema was

defined from the literature as the internalization of the cultural values of self-reliance,

caretaking, and affect regulation as seen in Table 1 (Hamin, 2008).

Table 1.

Dimensions of the Strong Black Woman Schema

Dimensions of the Strong

Black Woman Schema

Definition of Dimension

Self-reliance Black women having the ability to meet their own needs without

depending on others (Hamin, 2008).

Caretaking A nurturing characteristic in Black women stemming from an

exaggerated sense of commitment to helping others before themselves

(Hamin, 2008).

Affect regulation A façade of composure and emotional control in the face of stressful

situations (Hamin, 2008).

There were multiple interval scale criterion variables for this dissertation study.

These included attitudes toward mental health help-seeking, psychological openness,

help-seeking propensity, and indifference to stigma as measured by the Inventory of

Attitudes Toward Mental Health Help-Seeking Scale. Attitudes toward mental health

help-seeking was defined as psychological openness, help-seeking propensity, and

indifference to stigma as seen in Table 2 (Mackenzie, Gekoski, & Knox, 2006).

Table 1.

Dimensions of Attitudes toward Mental Health Help-Seeking

Dimensions of Attitudes

Toward Mental Health Help-seeking

Definition of Dimension

Psychological Openness The willingness to acknowledge mental health issues

(Mackenzie et al., 2006).

Help-Seeking Propensity The willingness to seek help for mental health issues

(Mackenzie et al., 2006).

Indifference to Stigma

Extent to which an individual is concerned with how a

significant individual in their life may perceive help-seeking

(Mackenzie et al., 2006).

Investigating the correlation between the internalization of the Strong Black

Woman schema and attitudes toward mental health help-seeking fills an important gap in

psychological literature (Abrams et al., 2014; Nelson, Cardemil, & Adeoye, 2016;

Watson & Hunter, 2015). Further, doing this through a cultural lens could provide more

information on the unique influences of cultural constructs on mental health help-seeking

in Black populations.

Research Questions and/or Hypotheses

The interval predictor and interval criterion variables for this study were as

follows:

PV1: Internalization of the Strong Black Woman schema; Interval scale

CV1: Attitudes Toward Mental Health Help-Seeking; Interval scale

CV2: Psychological Openness; Interval scale

CV3: Help-Seeking Propensity; Interval scale

CV4: Indifference to Stigma; Interval scale

The research questions and hypotheses for this dissertation study were generated

by the research problem: It was not known if or to what extent a correlation existed

between internalization of the Strong Black Woman schema and attitudes toward mental

health help-seeking. The researcher sought to determine the correlation between the

internalization of the Strong Black Woman schema using the Strong Black Woman

Attitudes Scale and attitudes toward mental health help-seeking through the three

domains of psychological openness, help-seeking propensity, and indifference to stigma

from the Inventory of Attitudes toward Seeking Mental Health Services. The Strong

Black Woman Attitudes Scale (Green, 2012) was the measurement tool used to capture

the internalization of the Strong Black Woman schema variable that aligned to gender

schema theory (Bem, 1981). This valid and reliable questionnaire used Likert scale

indices that provided measurements for the variable of internalization of the Strong Black

Woman schema. The Inventory of Attitudes toward Seeking Mental Health Services

(Mackenzie et al., 2004), a reliable and valid Likert-scale survey instrument, measured

attitudes toward mental health help-seeking.

A correlational analysis using IBM SPSS (version 24), generated correlation

coefficients between the two variables of internalization of the Strong Black Woman

schema as measured by Strong Black Woman Attitudes Scale, and the variable of

attitudes toward mental health help-seeking from data collected from the Inventory of

Attitudes Toward Mental Health Help-Seeking. To determine which statistical test

accurately measured the data collected from Black women, assumptions must be met and

not violate the requirements for correlation tests of the Pearson’s Product-Moment.

Trajkovski (2016) provided the assumptions that must not be violated to use IBM SPSS

(version 24) tests for correlation. Correlation coefficients determined the significance, if

any, between the correlations of the variables presented in this study.

The four specific research questions, with corresponding null and alternative

hypotheses are as follows:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking?

H10: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

H1a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

H20: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

H2a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

H30: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

H3a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

H40: There is not a statistically significant correlation between the internalization of

the Strong Black Woman schema and indifference to stigma.

H4a: There is a statistically significant correlation between the internalization of the

Strong Black Woman schema and indifference to stigma.

Advancing Scientific Knowledge and Significance of the Study

The underutilization of mental health services in the Black community needs to be

addressed to offer insight into surrounding the under-researched correlation between the

Strong Black Woman schema and attitudes toward mental health help-seeking based on a

call in the literature (Abrams et al., 2014; Nelson et al., 2016; Watson & Hunter, 2015).

This research may assist in creating a more informed understanding of the Strong Black

Woman schema and its correlation to mental health help-seeking. The current study may

address this need and knowledge gap in the research literature regarding the potential

correlation between the internalization of the schema and attitudes toward mental health

help-seeking across a variety of ages and diverse backgrounds within the Black

community.

Gender schema theory was utilized to support this research. According to Kessler

and McKenna (1978), gender roles are culturally reinforced rules that shape the

appropriate behaviors for men and women. Therefore, gender schema theory allows

researchers to view the Strong Black Woman schema as a Black female gender role that

informs appropriate behavior. Additionally, it is suggested that adherence to masculine

and feminine roles can limit the range of socially acceptable behaviors available to

women and men (Matud, Bethencourt, & Ibáñez, 2014). As a result, gender schema

theory supports the idea that internalization of the Strong Black Woman schema may be

related to attitudes toward mental health help-seeking.

Traditionally, gender schema theory has not been used as a theoretical foundation

for research involving diverse populations such as people of color (Starr & Zurbriggen,

2017). As a result, this research may advance scientific knowledge by expanding the use

of the theory to Black women who are not traditionally represented in research utilizing

gender schema theory. Additionally, gender schema theorists believe that psychological

well-being was improved when the fulfilled gender role corresponded to the individual’s

gender, and gender-typed people enjoyed better mental health, however, empirical

evidence regarding this theory is incomplete (DiDonato & Berenbaum, 2013).

Consequently, this research may contribute to the gender schema theory by providing

data concerning the way a Black woman’s beliefs around surrounding archetypal female

traits influence her mental health help-seeking behaviors.

The contributions of this study would be of interest to scholars in the fields of

psychology and counseling. Studies on gender schemas and attitudes toward mental

health help-seeking are core areas of research in the field of psychology, to which this

study would be significant. The field of psychology has largely considered

socioeconomic factors as barriers to the underutilization of mental health services, but

seldom explores cultural factors, such as the Strong Black Woman schema, as a barrier

(Kim, Cho, Park, & Park, 2015; Stepanikova, & Oates, 2017). Further, empirical findings

have demonstrated that internalization of the Strong Black Woman schema is associated

with emotional dysregulation, increased distress, and obesity (Romero, 2000; Woods-

Giscombé, 2010). Yet, the correlation between internalization of the Strong Black

Woman schema and attitudes toward mental health help-seeking remains unclear

(Watson & Hunter, 2015). Based on the findings, this study addresses the gap related to

the Strong Black Woman and help-seeking attitudes by quantitatively examining the

correlation between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking.

From a practical application standpoint, this study is relevant and timely for the

healthcare sector, which is currently undergoing significant changes in the way patient-

care is delivered with a focus on culturally competent care (Huey, Tilley, Jones, & Smith,

2014). Thus, this research may help clinicians provide more culturally competent care to

Black women. Additionally, the growing interest on identifying predictors of help-

seeking such as culture is important (Guo, Nguyen, Weiss, Ngo, & Lau, 2015). This

proposed study contributes to the literature by considering cultural constructs such as the

Strong Black Woman schema as having a potential correlation to attitudes toward mental

health help-seeking. From this perspective, mental health utilization does not stop at

having access, but also encompasses the role that culture may play in impacting mental

health related decisions. Consequently, this research may assist clinicians in gathering a

better understanding of attitudes toward mental health help-seeking in the Black

community.

In addition, untreated mental health issues in Black women not only impact the

overall health and stability of the African American community, but it could additionally

pose a threat to society. Carrington (2006) argued that mental health issues, left untreated,

can attribute to over use of emergency health care, decrease in quality of life, social and

family problems, employment instability and thereby pose an adverse fiscal impact on the

national economy. Consequently, this research is significant not only for the southern

region in which participants will be from, but potentially for other regions and states

looking to enhance their current understanding of mental health help-seeking in Black

women. Overall, it is important to understand mental health help-seeking in the Black

community and the implications of this include improved psychological care for Black

women along with increased utilization of mental health care (Allen, Balfour, Bell, &

Marmot, 2014).

Rationale for Methodology

The researcher sought to quantify the strength of the correlation between the non-

manipulated predictor variable, internalization of the Strong Black Woman schema, and

the criterion variables of attitudes toward mental health help-seeking, psychological

openness, help-seeking propensity, and indifference to stigma. To meet this objective, a

quantitative approach was used. Studies that are conducted to examine and measure the

strength of causal or correlational relationships between variables through the statistical

analysis of numerical data are best accomplished using quantitative methodologies

(Ingham-Broomfield, 2014; Johnson & Christensen, 2012).

Research has been conducted regarding the Strong Black Woman schema and its

effects on Black women. However, most of the research has investigated the phenomenon

qualitatively (Abrams et al., 2014; Watson & Hunter, 2016). As a result, a quantitative

study investigating the correlation between the Strong Black Woman schema and

attitudes toward mental health help-seeking fills a gap in the literature by utilizing a

different methodology (Abrams et al., 2014).

Since the research questions address the correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-seeking using

statistical data from validated measurement scales, a quantitative design was the

appropriate research approach. Quantitative methods collect numerical data from large

samples and require limited to no interaction between researchers and participants

(McCusker & Gunaydin, 2015). Further, this methodology is supported by Groeneveld,

Tummers, Bronkhorst, Ashkiali, and Thiel (2015) who suggested that research problems

addressing human attitudes and behavior be achieved through quantitative measures.

A qualitative methodology would not be the best choice. Yin (2014) noted

qualitative research is needed when “A ‘how’ or ‘why’ question is being asked about a

contemporary set of events over which a researcher has little or no control” (p. 14).

Additionally, qualitative methodology generally consists of structured interviews (Bluhm,

Harman, Lee, & Mitchell, 2011). Qualitative methodologies are best when the researcher

wants to utilize a small number of participants and use their subjective experiences to

amass a deeper understanding of the phenomena (Miles, Huberman, & Saldaña, 2014).

However, the goal of the research was to determine if, and to what extent, a correlation

exists, therefore making a quantitative methodology the best choice.

Nature of the Research Design for the Study

The researcher of this correlational study used survey methods to collect data

from Black female participants to determine the extent, if any, statistically significant

correlations existed between the internalization of the Strong Black Woman schema and

attitudes toward mental health help-seeking. The target population consisted of Black

women ages 18-65 who lived in the Southern region of the United States. The data

collected included information about participants’ demographic characteristics,

information about the Strong Black Woman schema, and attitudes toward mental health

help-seeking. The data collected from Black female participants provided the necessary

data to run IBM SPSS (version 24) correlational tests. This was to determine the

statistically significant correlations between variables from Likert-scale item responses.

To conduct correlational test, either a Pearson’s correlation test, linear regression models,

or a nonparametric, Spearman’s rho tests could be utilized for reporting data collected

(Hoare & Hoe, 2013).

According to Curtis, Comiskey, and Dempsey (2016), correlational research can

be used to determine correlations among variables, and to forecast events from current

data and knowledge. Additionally, correlational research analyzes the correlation

between variables without any manipulation from the researcher (Curtis et al., 2016).

Further, a correlational design was appropriate for the study because it allows the

researcher to test the hypotheses regarding the correlations between continuous variables

in sample data (Shaughnessy, Zechmeister, & Zechmeister, 2012). Consequently,

correlational research was the best design for this proposed research study seeking to

determine a correlation between mental health help-seeking and internalization of the

Strong Black Woman schema and mental health help-seeking. Differences in attitudes

toward mental health help-seeking among Black women from the Southern region of the

United States established if, and to what extent, a correlation existed between the

predictor variable (internalization of the Strong Black Woman schema) and the criterion

variables (attitudes toward mental health help-seeking, psychological openness, help-

seeking propensity, and indifference to stigma).

Other quantitative research designs would not have provided the data sought in

this research. The present study did not meet the standards required to be considered an

experimental design. These standards include random assignment of cases to groups,

manipulation of the predictor variable, and control over extraneous variables that might

influence the criterion variable (Balaz & Williams, 2015).

A causal-comparative study was considered but rejected since it would require the

establishment of a cause and effect correlation (Cohen, Manion, & Morrison, 2013).

Consequently, the research did not reveal the causation of any in correlations discovered

in the data due to the fact it was non-experimental (Cohen et al., 2013; Johnson &

Christensen, 2012). A true experimental design was ruled out for use in this study

because experimental research designs require that the researcher be able to manipulate

the predictor variable and measure the resulting changes in the criterion variable (Johnson

& Christensen, 2012). However, the researcher cannot manipulate the internalization of

the Strong Black woman schema thus eliminating true experimental design as an option.

Quasi-experimental design was not deemed appropriate for this research as it involves

intervention and a control group (Polit & Beck, 2010).

Based on a G*Power sample (Appendix E), 84 Black women were needed to

participate in this research. Consequently, the researcher recruited 200 participants from

the one nonprofit site in the Southern region that provided site authorization for the

researcher. An email invitation to participate in the study was sent to the Black women

participants ages 18-65, that included a link to an online survey including the Strong

Black Woman Attitudes Scale (Green, 2012) and the Inventory of Attitudes Toward

Seeking Mental Health Services (Mackenzie et al., 2004) hosted by SurveyMonkey.

Since the participants were gained through voluntary participation, the sample was

considered a volunteer sample.

Definition of Terms

The following terms were used operationally in this study:

Affect regulation. A façade of composure and emotional control in the face of

stressful situations (Hamin, 2008). In the context of the Strong Black woman, it is

presented as a coping mechanism that is necessary to effectively fulfill life demands, such

as caregiving and student responsibilities (Watson & Hunter, 2015).

Behavioral health. The connection between an individual’s behaviors and well-

being (Barrera, Castro, Strycker, & Toobert, 2013). Behavioral health issues can be

changed by addressing the behavior causing the problem (Baranowski, Cullen, Nicklas,

Thompson, & Baranowski, 2003).

Black. A term used to describe a person with origins of African descent. Black is

often used interchangeably with the term African American. In the United States, the

term “Black people” is a socially-based racial classification related to being African

American with a family history associated with institutionalized slavery (Glenn, 2009).

Caretaking. A nurturing characteristic that causes Black women’s needs to come

second to the needs of others (Hamin, 2008). This characteristic has been described as an

exaggerated sense of commitment to helping others, which leads to self-neglect (Hopkins

& Jackson, 2002).

Culture. A set of values and beliefs people have about how the world works. This

includes the norms of behavior derived from that set of values (Gorodnichenko &

Roland, 2016)

Help-seeking Propensity. The willingness to seek help for mental health issues

(Mackenzie et al., 2006). Additionally, this also includes the aptitude an individual has

for finding help for a mental health issue after they have determined they are willing to

receive help (Mackenzie et al., 2006).

Indifference to stigma. Extent to which an individual is concerned with how a

significant individual in their life may perceive help-seeking (Mackenzie et al., 2006).

The perceptions of mental illness by others lead to stigmatizing attitudes, prejudices, and

actions by families and members of their community (Latalova, Kamaradova, & Prasko,

2014).

Internalization. Reflects an individual’s tendency to integrate and adopt the

practices of others into their own beliefs (Ryan, Rigby, & King, 1993). This process

involves an integration of attitudes, values, and opinions of others into one's own identity

(Van de Vijver, 2013).

Mental health. An individual’s attitudes toward s themselves regarding, the

realization of potentials, social influences, self-respect, feelings, the perceiving of the

world, and the control of one’s own life (Podgornik & Kovačič, 2014). Keyes (2002)

argued that it takes a combination of emotional, psychological, and social well-being to

be considered mentally healthy.

Psychological openness. The willingness to acknowledge mental health issues

(Mackenzie et al., 2006). Additionally, this includes an individual’s receptiveness to

receiving services after acknowledging a mental health issue (Mackenzie et al., 2006).

Schema. A process of organizing and interpreting information (Piaget, 1970).

Schemas inform a person about what to expect from a variety of experiences and

situations. Schemas are developed based on information provided by life experiences and

are then stored in memory (Anohina-Naumeca, 2016).

Self-reliance. Black women having the ability to meet their own needs without

depending on others (Hamin, 2008). In the context of the Strong Black woman, this is a

necessity due to lack of supportive networks, especially in the absence of male partners

(Abrams et al., 2014).

Assumptions, Limitations, Delimitations

This section will provide an overview of the assumptions, limitations, and

delimitations present in this research study. Assumptions are described as beliefs held by

the researcher to be true without concrete evidence (Ellis & Levy, 2009). Limitations are

constraints that are beyond the control of the researcher but may affect the outcome of the

study (Ellis & Levy, 2009). Conversely, delimitations are constraints resulting in choices

by the researcher (Ellis & Levy, 2009).

The following assumptions were made in this proposed study:

1. It was assumed that survey participants were honest in their completion of the online survey items. This assumption was made because participants were told

that their information would be kept confidential thereby potentially

increasing the likelihood that responses would be accurate due to knowing the

information would not be shared. Assuring the confidentiality of the

participant’s data is recommended in the literature to increase survey

participation and valid responses (Johnson & Christensen, 2012; Sauermann

& Roach, 2013). In addition, Keipi, Oksanen, & Räsänen (2015) suggested

that surveys conducted online enhance respondents’ sense of anonymity

thereby increasing their willingness to express their true sentiments.

2. The measurements utilized are valid and reliable measures of the variables as claimed by the authors of the instruments. The validity of conclusions drawn

from quantitative research are no greater than the validity of the instruments

that provide the data.

The research had the following limitations:

1. Sampling by volunteer means that study participants were self-selected and

thus there are no guarantees that the resulting samples are representative of the

target populations.

2. Self-rating surveys were used to collect data. There is no way to verify that self-rated responses are accurate.

3. Correlational research can determine relationships; however, it cannot imply causation (Yilmaz, 201). As a result, exploring the correlation between the

Strong Black Woman schema and attitudes toward mental health help-seeking

did not indicate if one variable is the cause of another.

4. The reliability coefficients for the Inventory of Attitudes Toward Seeking Mental Health Services instrument ranged from poor to acceptable. As a

result, caution must be exercised when generalizing the findings.

5. Data were collected from participants in one geographical location which also limits the generalizability of the findings.

The following delimitations were present in this study:

1. Because the purpose of this research is to determine if, and to what extent, a correlation existed between the variables, the researcher only collected

quantitative data. This delimitation prohibited the collection of information

that might have broadened the scope and increased the depth, if a qualitative

or mixed method approach had been selected.

2. This research used a volunteer sample from one geographic region. This sample may not be representative of Black women in other regions of the

Unites States of America.

3. Access to the internet was necessary to participate in this study. Although this method of data collection was more convenient regarding time and distance,

those without internet access would have had to travel to a place with access

to participate.

Summary and Organization of the Remainder of the Study

A myriad of factors may impact the underutilization of mental health services in

contemporary Black women. While some of these influences may be related to

socioeconomic factors, cultural and historical factors may also influence attitudes toward

mental health help-seeking in this population (Donovan & West, 2015). The Strong Black

Woman schema consists of the factors of caretaking, self-reliance, and affect regulation

as identified by Romero (2000). As a result, social scientists and social critics have

examined the construct of the Strong Black woman as a historical, social, and cultural

idea that informs the well-being and identity development of Black women (hooks,

1993). While the schema is generally acknowledged as positive within the Black cultural

context (Watson & Hunter, 2016), it can also be associated with detrimental

psychological outcomes for Black women (Donovan & West, 2015).

Although research has been conducted regarding the Strong Black Woman

schema, there is a call in the literature to quantitatively examine the schema along with

attitudes toward mental health help-seeking (Donovan & West, 2015). This call in the

literature is present because more of the research regarding phenomenon has been

conducted qualitatively (Abrams et al., 2014; Watson & Hunter, 2016). Therefore, the

purpose of this quantitative, correlational research was to determine if, and to what

extent, a correlation existed between the internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking in 153 Black women aged 18-65

in the Southern region of the United States.

This study utilized gender schema theory (Bem, 1981) as the theoretical

foundation. Gender schema theory asserts that gender roles are culturally transmitted and

inform individuals of appropriate behavior. Conventionally, gender schema theory is not

utilized as a theoretical foundation for research involving people of color (Starr &

Zurbriggen, 2017). Consequently, this research may advance scientific knowledge

through its use of a theoretical foundation which is generally not used with minorities

thereby offering insight into ways to utilize the theory in diverse populations.

Additionally, this research is significant because of the information it may provide to help

clinicians understand how cultural factors may impact the utilization of mental health

services as well as aiding in providing information to implement more culturally

competent mental health care.

This study utilized a quantitative, correlational design to answer the four research

questions used to analyze the correlation between the internalization of the Strong Black

Woman schema and attitudes toward mental health help-seeking. Quantitative

methodology was selected because it allows numerical statistical analysis with limited

interaction from the researcher (McCusker & Gunaydin, 2015). Conversely, qualitative

methodology was rejected due to its use with answering research questions asking how or

why (Yin, 2014) which does not align with the research questions of this study.

Correlational research was selected as the design because of its use in determining the

correlation between variables (Curtis et al., 2016).

In the research study, the predictor variable was the internalization of the Strong

Black Woman schema. The criterion variables include attitudes toward mental health

help-seeking, psychological openness, help-seeking propensity, and indifference to

stigma. The predictor variable was measured using the Strong Black Woman Attitudes

Scale (Green, 2012). The criterion variables were measured using the Inventory of

Attitudes Toward Seeking Mental Health Services (Mackenzie et al., 2004). The existing

literature regarding the Strong Black woman schema and other related themes will be

reviewed in Chapter 2. Chapter 3 will include further explanation of the methods used to

collect and analyze data gathered on the variables. After receipt of IRB approval, data

collection commenced and was completed within approximately three days, following the

procedures outlined in detail in Chapter 3. Chapter 4 will provide both a written and

graphic summary of the findings of the analysis. Further, Chapter 5 will include an

interpretation and discussion of the results as they relate to the dissertation topic and the

existing body of research.

Chapter 2: Literature Review

Introduction to the Chapter and Background to the Problem

The purpose of this quantitative correlational study was to see to what degree

statistically significant correlations existed between the internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking. Research on the

Strong Black Woman schema has continued to generate attention in the scholarly

community over the past several decades. However, there is still more to learn

concerning this construct that has implications for various organizations (Abrams et al.,

2014). In fact, research on the strong Black woman and mental health help-seeking is

scarce. The bulk of the existing research is restricted to studying how internalization of

the schema increases vulnerability to stress, anxiety, and depression (Norris & Mitchell,

2013).

Historically, the Strong Black Woman schema has been considered a necessity for

survival of the Black woman. The sociopolitical setting of Black women’s lives forced

Black women to take on the roles of mother, nurturer, and breadwinner out of economic

and social necessity (Schulz & Mullings, 2006). Consequently, the schema developed

because of Black women’s efforts to counterbalance adverse societal characterizations of

Black womanhood, such as Mammy and Welfare Queen, as well as to highlight

unacknowledged qualities that developed and continue to exist despite oppression and

adversity (Beauboeuf-Lafontant, 2003; Harris-Lacewell, 2001). However, in recent years,

research has suggested that the affect-regulation, self-reliance, caretaking, and affect-

regulation self-silence dimensions of the Strong Black Woman schema may have adverse

effects on African American women’s psychological health (Donovan & West, 2015).

Further research regarding the association of health outcomes in Black women along the

intersection of race and gender has received qualitative investigation (Abrams et al.,

2014; Thomas et al., 2013). Although research was conducted, Watson and Hunter (2015)

identified the need for future studies to assess the correlation between the internalization

of the Strong Black Woman schema and health and mental health issues, thereby

indicating a gap in the literature which evolved into the problem statement for this

research.

This chapter provides an analysis of the historical background and recent

empirical literature related to the Strong Black Woman schema. Five key themes were

considered and addressed regarding the topic including: (a) Strong Black Woman

schema, (b) Help-seeking Attitudes in African Americans, (c) Health Disparities in the

African American Community, (d) Psychological Distress in Black Women, and (e)

Coping Strategies. There are also various subthemes aligned to each key theme including:

(a) Strong Black Woman in Contrast to White Women, (b) Role Strain, (c) Measurements

of Help-seeking Attitudes, (d) Discrimination Based Disparities, (e) Medical Distrust

Based Disparities, (f) John Henryism, (g) Informal Social Support, and (h) Religious

Coping.

The survey of the literature for this chapter derived from various online databases,

textbooks, and peer-reviewed journals. The researcher conducted a comprehensive

literature review using Grand Canyon University’s Library and Google Scholar. The

databases utilized included eBook Collection, ebrary, EBSCO, Sage Research Methods,

and ProQuest Central. The following keywords and combination of keywords utilized in

the database search were: a strong Black woman schema, psychological distress, help-

seeking attitudes, and discourse of strength. The search for keywords and combinations

of keywords yielded peer reviewed articles, dissertations, books, and other reliable

sources, of which the majority will be cited.

Due to the underutilization of mental health services in Black women, it is critical

that the correlation between the internalization of the schema and attitudes toward mental

health help-seeking is explored to gain further understanding of this dynamic. Further,

this information can help mental health organization leadership grasp the importance of

the schema and its influence on help-seeking decision-making. The absence of this

research along with the call from the scholarly community to explore this construct in

diverse ages, socioeconomic status, and educational backgrounds demonstrates a present

knowledge gap in the literature that needs to be addressed (Abrams et al., 2014; Nelson et

al., 2016; Watson & Hunter, 2015).

Chapter 2 includes a discussion of the gender schema theory as the theoretical

framework for this study. Additionally, this chapter contains a review of the methodology

and instrumentation utilized throughout the literature. A synopsis of gaps in the research

related to the internalization of the Strong Black Woman schema and mental health help-

seeking decisions will provide context and additional justification for this research and

the chosen methodology. Finally, a summary will provide an overview of the material

discussed in Chapter 2.

Identification of the Gap

It has been declared that African American adults generally do not seek

professional mental health services to manage psychological stress (Dean, Long,

Matthews, & Buckner, 2017). Generally, cultural factors are known to play a role in

minority group members’ professional health help-seeking attitudes and behaviors

(Cheng, Kwan, & Sevig, 2013). Empirical research findings have established that the

Strong Black Woman schema prompts African American women to exhibit strength, self-

reliance, and self-silence as a response to stressors (Woods-Giscombé, 2010). This form

of coping with stressors can negatively affect the mental health of African American

women (Beauboeuf-Lafontant, 2007). However, limited research has been conducted

regarding the Strong Black Woman schema and mental health help-seeking. As a result,

when determining the direction of this research it was discovered that research gaps

existed in both quantitative and qualitative studies conducted within the last five years.

The current body of literature regarding the Strong Black Woman schema has

principally emphasized the risks associated with the internalization of the schema.

Harrington, Crowther, and Shipherd (2010) found trauma exposure and distress predicted

greater internalization of the Strong Black Woman schema, which was associated with

emotional difficulties, eating for psychological reasons, and, ultimately, binge eating.

Further, developing research has linked the schema to adverse outcomes, like depression,

anxiety, and binge eating for African American women (Donovan & West, 2015; West,

Donovan, & Daniel, 2016).

Other research has highlighted the schema’s correlation to stress and health. In a

study investigating the association between the Strong Black Woman schema, stress, and

breast cancer screening among African American women, Black and Woods-Giscombé

(2012) found that the schema’s coping methods were related to endorsement of “strength

behaviors,” such as deferment of self-care and emotional suppression. Such “strength

behaviors” can have serious health consequences when used over time. For example,

emotional suppression is interrelated to an assortment of negative health outcomes,

including poor immune functioning (Pietromonaco, & Powers, 2015), cardiovascular

disease morbidity (Fernandez & Smith, 2015), and HIV disease progression (Sawamoto

et al., 2016). The schema is hypothesized to increase susceptibility to disease because of

frequent physiological adjustments to psychological stress, resulting in increasing wear

and tear on the body’s regulatory systems (Woods-Giscombé, 2010), leading to

debilitated immune functioning and disease advancement.

The Strong Black Woman schema also has an impact on mental health. Donovan

and West (2015) found internalization of the Strong Black Woman schema to increase

the correlation between stress and depressive symptoms. Donovan and West (2015)

suggested that future research regarding the Strong Black Woman schema explore the

correlation between the schema and health compromising behaviors. Further, West et al.

(2016) completed a thematic analysis of the Strong Black Woman schema which revealed

perceived definitions of the schema as well as the paradox it presents to those who adhere

to it. Consequently, West et al. (2016) suggested several areas for future research. The

authors call for research concerning the Strong Black Woman schema to include women

who are in college, as well as those who never attended. Expanding the range of women

included in future studies has potential to increase the generalizability of the results.

Thus, the gap in the literature addressed by these authors can be filled through this

research study which included women from diverse backgrounds.

Watson and Hunter (2015) found that African American women who internalize

the schema experience increased anxiety and depression and decreased psychological

openness and help-seeing propensity. Additionally, the study revealed that participants

considered the utilization of counseling and medication to be signs of weakness and

mental instability. The preliminary findings of Watson and Hunter (2015) indicated that

the inherent tensions presented by the Strong Black Woman schema have implications for

help-seeking behaviors. Consequently, Watson and Hunter (2015) noted a gap in the

literature by suggesting that additional research is needed to assess the correlation

between the internalization of the Strong Black Woman schema and psychological help-

seeking attitudes among African American women. As a result, this noted gap in the

literature is being used as the basis for this research and the problem statement: it was not

known if, and to what extent, there was a correlation between the internalization of the

Strong Black Woman schema and attitudes toward mental health help-seeking.

Theoretical Foundation

Gender schema theory (Bem, 1981) was used as a theoretical foundation of this

study since it has been shown to provide insight about the process of gender schema

development and maintenance. Gender schema theory is a social cognitive theory which

proposes that humans schematically organize our thoughts and experiences thus creating

categories and groupings based on similarities or differences. Bem (1981) noted that

gender-linked associations that create a gender schema are intrapersonal. Consequently,

early socialization teaches individuals to associate certain traits with their gender. As

opposed to existing on a continuum, traits are placed in one gender schema or the other

(Bem, 1981).

Bem proposed that children self-select traits not from a wide variety of human

characteristics, but from their own narrow gender schema, thus “cultural myths become

self-fulfilling prophecies” (1981, p. 355- 356). This schema is then reinforced by society

through interpersonal relationships, communities, organizational structures, and the

media (Ridgeway, 2009). Therefore, gender schema theory asserts that individuals

cognitively process and encode what it means to be male or female from the culture that

they live in. As a result, behavior is adjusted to fit in with gender norms and expectations

of their culture. Accordingly, the Strong Black Woman schema is pervasive throughout

the African American community (Woods-Giscombé, 2010).

Lips (2016) suggested that one of the most significant impacts of Bem’s work has

been to bring the invisible but pervasive processes of gender categorization into focus,

and then to use that new visibility to drive social change. Bem (1974) proposed that being

concerned with being a typical girl or boy was limiting and might lead to negative

psychological adjustment. Therefore, gender schema theory may provide insight into the

Strong Black Woman schemas impact on attitudes toward mental health help-seeking. In

order to explore how the Strong Black Woman schema displays a correlation with help-

seeking, the Theory of Planned Behavior could be used. The Theory of Planned Behavior

is a useful framework for predicting intentions to utilize mental health services. The

theory states that intentions to perform specific behaviors can be predicted by three

beliefs: attitudes toward the behavior, subjective norms, and perceived behavior control

(Ajzen, 1991). Research that has incorporated individual constructs of the Theory of

planned behavior (e.g. attitudes, perceived social norms, or perceived control) in help-

seeking has been mostly correlational and has demonstrated some support for applying

this model to help seeking behaviors (Hammer & Vogel, 2013; Stolzenburg et al., 2018).

However, it seems that the attitudes construct may be more predictive of intention than

the others (Schomerus, Matschinger, & Angermeyer, 2009).

The Theory of Planned behavior provides a framework for the investigation of an

individual’s intent to execute context-specific actions. Therefore, the Theory of Planned

Behavior assumes that human behavior is goal-directed, influenced by the social climate,

and that individuals are logical and rational in their decision making (Ajzen, 1991).

Accordingly, the Theory of Planned Behavior has been identified as one of the well-

studied theories to explain individuals’ social behaviors (Davis, Campbell, Hildon,

Hobbs, & Michie, 2015). Subsequently, the Theory of Planned Behavior is discussed as a

source of decision-making for individuals considering mental health help.

Although Theory of Planned Behavior is one of the most used theories to explain

individual’s social behavior, it has not been without criticism. Sniehotta, Presseau, and

Araujo-Soares (2014) called for retirement of the theory. The authors suggested what is

needed instead of Theory of Planned Behavior is new theories that can be used to explain

behavioral phenomena. Sniehotta et al. (2014) noted that these new hypotheses may

better help people change their behavior and to help those who design and deliver

interventions to help people to do so. Additionally, the theory has been criticized for its

exclusion of unconscious influences on behavior (Sheeran, Gollwitzer, & Bargh, 2013)

and the role of emotions beyond anticipated affective outcomes (Conner, Gaston,

Sheeran, & Germain, 2013).

Conversely, many have responded to the call for the theory to retire. Ajzen (2015)

asserted that the criticism is misguided and based on misunderstandings of the theory.

Additional support for the theory has been provided by previous research showing that

including a measure of attitudes toward not performing a behavior, in addition to attitudes

toward performing the behavior, can significantly improve prediction of intentions

(Ajzen & Sheikh, 2013). Despite the criticism presented, the theory of planned behavior

is useful for investigating behaviors that warrant individual decisions but have varying

levels of social acceptability (Betsch & Haberstroh, 2014).

In sum, the Theory of Planned Behavior uses evaluations of attitudes, subjective

norms, and perceived behavioral control to successfully predict intentions to engage in a

behavior. Although the theory has successfully predicted a multitude of behaviors,

including mental health help-seeking, that prediction may be enhanced by including

cultural factors such as the Strong Black Woman schema into consideration. The current

study seeks to build upon past research by adding to the paucity of theory-based research

on help-seeking while considering the influence of culture and gender. When used

together, gender schema theory would work to provide insight into the Strong Black

Woman schema while the Theory of Planned Behavior would work to provide an

understanding of one’s attitudes toward help-seeking impact their potential utilization of

mental health help. Understanding how these two theories work together can assist

mental health professionals in understanding the cultural barriers that are holding Black

women back from seeking mental health help.

What is known is how the Strong Black Woman schema relates to anxiety and

depressive symptoms based on prior research in the field (Watson & Hunter, 2015). What

was not known was the correlation between the internalization of the Strong Black

Woman schema and attitudes toward mental health help-seeking. This quantitative study

may contribute information about how the internalization of the Strong Black Woman

schema relates to attitudes toward mental health help-seeking which therefore impacts the

utilization of mental health services in the Black community. The researcher addressed

this issue within the context of women from diverse socioeconomic, educational, and

partnered/marital status because of the dearth of research within this environment.

Finally, this study responded to the call by authors to extend the literature regarding the

correlation between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking (Abrams et al., 2014; Watson & Hunter, 2015).

Review of the Literature

Behavioral health diseases have biological correlates that are subject to influence

by modifiable social, economic, and environmental conditions that affect not only the

individual but the whole community, neighborhood, and population (Shim et al., 2014).

As a result, the underutilization of mental health services continues to be a concern

within the Black culture. As established above, these concerns are widespread and

various studies have attempted to determine causation for the lack of mental health

service utilization in the Black community (Hines et al., 2017; Jang et al., 2014; Lee et

al., 2014; Lindsey et al., 2013). Additionally, previously conducted research containing

Black women has documented an association between the internalization of the Strong

Black Woman schema and psychological distress, low self-esteem, chronic health

conditions, and participation in risky sexual behaviors (Brown et al., 2014; Lewis &

Neville, 2015; Woods-Giscombé et al., 2015).

Although studies have been conducted, there is limited research regarding the

cultural factors, especially gender schemas such as the Strong Black Woman schema,

which may be impacting the decision to seek mental health help. This restricted

availability of research exposes a knowledge gap in the literature signifying that

developing a study in this area could prove to be valuable to the field. It is with these

thoughts in mind that a literature review will be conducted to examine the concepts

related to the Strong Black Woman schema which potentially influences the decision to

seek mental health help.

To fully develop the topic of the Strong Black Woman schema and mental health

help-seeking, there must be consideration of several themes which have been identified

as leading to this construct. First, the Strong Black Woman schema will be examined,

which will lead into a discussion of the Strong Black Woman Attitudes Scale (SBWAS).

Next, help-seeking attitudes will be examined, consequently leading to a discussion of the

Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS) scale. Finally,

an overview of content related to health disparities in the Black community,

psychological distress in Black women, and coping strategies will provide additional

context to the dissertation topic.

The strong black woman in contrast to white women. In addition to describing

and measuring what the strong Black woman is, theorists have also focused on what she

is not. Specifically, the strong Black woman has been contrasted against the normative

female gender norms stereotypically embodied by White, middle-class women (Baker,

Buchanan, Mingo, Roker, & Brown, 2015). Descriptions of Black women as strong,

independent, and aggressive are in stark contrast to descriptions of the mainstream female

gender role as sensitive, emotional, dependent, submissive, and passive (Adams-Bass,

Bentley-Edwards, & Stevenson, 2014). Some have argued that Black women would have

to be stronger than other women, because of the history of slavery and the current

presence of discrimination, single-parent households, and poverty among Black women

(Roberts, 2014; Umberson, Williams, Thomas, Liu, & Thomeer, 2014). Harris (1995)

theorized that this contrast between Black and White women arose during slavery as

Black women were seen working in the fields alongside men and entering White

women’s homes only to take care of their children, cooking, and house cleaning. The life

of a Black woman during this time was defined by struggle and survival, whereas the life

of a wealthy White woman was stereotypically defined as one of privilege and ease

(Harris-Lacewell, 2001).

Qualitative work has also captured Black women’s thoughts and feelings about

their identity in relation to their White counterparts. In a study of Black Caribbean

women from the United Kingdom, participants asserted that the struggle and survival

history of Black women has endowed them with strength and resilience unavailable to

White women from relatively less strife-marked histories (Edge & Rogers, 2005). A

participant in a study of Black West-Indian women from Ontario, Canada echoed a

similar sentiment, “I think Black women are stronger [than Whites]. They’ve been, I

mean, I’m talking about going back with generations, so you were raised to be, you

know, the strength of the home, the mother” (Schreiber, Stern, & Wilson, 2000, p. 41).

This participant owed the greater strength of Black women to managing life as the head

of the household.

Interviews with Black women have uncovered similar comparisons to those

noted by Edge and Rogers (2005) as well as by Schreiber, Stern, and Wilson (2000). In

one study, Black women described other Black females whose lives were not marked

with struggle as “weak,” “not Black,” and “White” (Beauboeuf-Lafontant, 2007, p. 38).

A 29-year-old divorced mother described her cousin as “livin’ the White life” because

she was a successful business owner: “being a Black woman means, you know: You’re at

home, you struggle, you get out once in a while, and that’s supposed to be meaningful to

you” (p. 38). This indicates that some Black women believe that life without struggle

prevents one from being authentically Black and female.

Strong black woman schema. The Strong Black Woman is defined by her

physical strength, emotional invulnerability, struggle, perseverance, self-reliance, and

caretaking (Stanton, Jerald, Ward, & Avery, 2017). The Strong Black Woman schema

mandates that Black women appear physically and emotionally strong in front of others.

It is important to discuss how Black women experience early exposure to the

characteristics associated with the ideal of these socially and culturally based norms of

Black womanhood to garner a deeper understanding of the Strong Black Woman schema

(Belgrave & Abrams, 2016).

In an attempt to integrate overlapping attributes of existing constructs into a single

term, while also expounding upon the defining characteristics of the SBW schema,

Abrams et al. (2014) conducted a thematic analysis to gather a better understanding of the

Strong Black Woman schema. Data were gathered from 44 Black women ranging in age

from 18-91 located in the Mid-Atlantic region of the United States. Prominent themes

that emerged as characteristics of the Strong Black Woman schema were (a) Embodies

and Displays Multiple Forms of Strength, (b) Possesses Self/Ethnic Pride in Spite of

Intersectional Oppression, (c) Embraces Being Every Woman, and (d) Anchored by

Religion/Spirituality. Further, the authors advocate for future research to investigate how

identification with the Strong Black Woman schema influences self-care, including

health promoting and health-compromising behaviors thereby enforcing the thought that

there is a gap in the literature.

As noted in the research by Abrams et al. (2014), the discourse of strength is a

pervasive factor in the Strong Black Woman schema. The discourse of strength is

embraced by Black women to secure a position in the social world. However, the

internalization of the Strong Black Woman schema creates overwhelming feelings and

obligations that often manifest as physical illness and neglectful behavior as revealed in

the literature by Black and Woods-Giscombé (2012). The authors theorized strength as a

culturally suggested coping style that asserts resilience, self-reliance and psychological

hardiness as a survival response to race-related and gender-related stressors. Using

qualitative methods, the researchers investigated the potential for strength as a coping

mechanism to manifest as extraordinary caregiving, emotional suppression and self-care

postponement. The results from this research concluded that these manifestations arise

and often result in a lack of time dedicated to scheduling and attending health screening

appointments, deficient or delayed acknowledgement of breast health symptoms and low

prioritizing of breast care. This research further deduced that the discourse of strength

aspect of the Strong Black Woman schema has the potential to cause Black women to

engage in health compromising behaviors, such as refusing to acknowledge the need to

seek mental health help.

West et al. (2016) highlighted the paradox of the Strong Black Woman schema. A

thematic analysis of approximately 113 participants from an urban university in New

England revealed definitions of a strong Black woman, including, strong, independent,

hardworking, and caring (West et al., 2016). Additionally, participants disclosed that

internalization of the Strong Black Woman schema can lead to positive self-image but

cause individuals from other ethnic groups to view the strong Black woman negatively.

Further, the authors asserted that the Strong Black Woman schema may be a positive

practice of coping and a defensive technique for ideal mental health; on the other hand, it

may be an adverse form of coping and a predictive factor for poor mental health

comparable to the findings of Abrams et al. (2014). West et al. (2016) suggested several

areas for future research. First, the authors call for research concerning the Strong Black

Woman schema to include women who are in college, as well as those who never

attended. Expanding the range of women included in future studies has potential to

increase the generalizability of the results. Thus, the gap in the literature addressed by

these authors can be filled through the proposed research study which will include

women from diverse backgrounds.

Nelson et al. (2016) examined perceptions of the strong Black woman in a

sample of 30 Black women utilizing qualitative methodology. The authors determined

that participants characterize the Strong Black Woman/superwoman role through five

characteristics: independence, caretaking, hardworking and high achieving, overcoming

adversity, and emotionally contained. Like the aforementioned study conducted by West

et al. (2016), many participants defined the roles in ways that were empowering and

freeing versus constraining. Contrarily, numerous participants were critical of and

rejected the Strong Black Woman role thus concentrating on its challenging and

inflexible discourse of strength. These negative perceptions highlight the significance of

increasing attentiveness of limiting gendered and racialized role expectations.

Additionally, the results from this study underscored the pervasiveness of the discourse

of strength and familiarity with the Strong Black Woman/superwoman role among Black

women (Nelson et al., 2016). The stories these women shared were very expressive, but

many seemed only to touch the surface. This lack of depth may be a result of the

relentless stigmatization in the Black community, contributing to an unwillingness to

appear vulnerable and underplaying issues of physical and mental health. Consequently,

the authors suggested that future researchers explore how the characteristics of the Strong

Black Woman schema relate to how Black women comprehend and pursue help for their

mental and physical health which indicates a gap in the literature that can be filled

through this proposed research study.

Four measurements of the Strong Black Woman schema were previously

developed to assess the internalization of the Strong Black Woman schema. The first was

developed in a dissertation by Thompson (2003) describing preliminary validation of a 30

questions-item entitled “Strong Black Woman Attitudes Scale.” Factor analysis suggested

a three-factor structure: Self-Reliance, Affect Regulation, and Care-Taking. Although the

factor structure is in line with previous descriptions of the Strong Black Woman ideal set

forth by Romero (2000), the internal consistency of the total and subscales was low (total

score: alpha = .74; Self-Reliance: alpha = .69; Affect Regulation: alpha = .72; Care-

Taking: alpha = .66). Additionally, self-reliance was negatively correlated with affect

regulation although theoretical and qualitative literature would predict positive

correlations between the three factors. Since counterintuitive results were produced,

Thompson (2003) considered whether the construct of self-reliance was adequately

measured by the scale items. Also, the validation study included both Black and White

women, but did not directly compare groups to determine whether the construct was

specific to Black women. The Strong Black Woman Attitudes scale development study

has not been used in any published studies.

The second measure developed to assess the Strong Black Woman schema was

the Superwoman subscale of the Stereotypic Roles for Black Women Scale (Thomas et

al., 2004). In addition to the Strong Black Woman subscale, the 34-item scale included

subscales for three other stereotypes of Black women: Jezebel, Sapphire, and Mammy.

As the only published quantitative measure of the Strong Black Woman ideal, it is

unfortunate that the reported internal consistency of the Superwoman subscale was low

(alpha = .67). Also, with only 11-items in the subscale, the scale did not adequately cover

the breadth and depth of characteristics outlined by previous literature on the Strong

Black Woman schema. The subscale does not include items that referred to a life defined

by struggle and only included one item related to self-reliance. Also, included were five

items to represent the affect regulation domain but solely signified it with items

discussing the ease/difficulty of sharing problems with others (e.g., “I do not want others

to know if I experience a problem,” “It is difficult for me to share problems with others,”

and “It is easy for me to tell other people my problems.”).

In a follow-up to the Thompson (2003) study, Hamin (2008) revised the Strong

Black Woman Attitudes Scale to further explore the cultural components of the Strong

Black Woman schema, as well as examine its correlation to stress and social support

among Black women. In addition to confirming the existence of a three-factor model, the

results of the study also indicated that the Strong Black Woman schema is a possible

coping mechanism used in relation to stress and issues related to racial identity.

Additionally, Hamin changed the name of the Strong Black Woman Attitudes Scale to

the Strong Black Woman Cultural Construct Scale. The internal consistency on the

revised scale total score (.76) and subscales; caretaking, affect regulation, and self-

reliance were (.75, .64, and .62) respectively.

Hamin (2008) also measured the Strong Black Woman Cultural Construct

Scale’s ability to predict outcome variables such as racial identity, social support, and

stress. Multiple regression analyses were used to measure the predictability of the Strong

Black Woman Cultural Construct Scale in relation to the variables. Regarding stress, a

construct central to the study, Hamin found that high levels on Strong Black Woman

Cultural Construct Scale predicted both perceived stress and number of stressful events.

Specifically, the overall Strong Black Woman Cultural Construct Scale, as measured by

the total score, predicted stress among study participants. However, the correlation

between the caretaking, affect regulation, and self-reliance subscales and stress varied.

According to Hamin, higher levels of caretaking, as well as higher levels of affect

regulation, were associated with higher levels of perceived stress. In contrast, self-

reliance was found to be negatively associated with perceived stress. In other words,

women who scored higher on the self-reliance subscale had lower levels of perceived

stress.

The most recent measurement of the schema is a revision to Thompson’s Strong

Black Woman Attitudes scale by Green (2012). Green indicated 11 factors on the original

scale did not have adequate factor loadings. As a result, Green’s version of the scale is

comprised of 30 questions with adequate factor loadings. Additionally, responses are

measured on a 4-point Likert scale, ranging from 1 (Never) to 5 (Almost always). Higher

scores indicate greater internalization of the schema. After revising Thompson’s scale,

Green found adequate internal consistency: α = .80 for the total scale, and the three

subscales of caretaking (.64), affect regulation (.78) and self-reliance (.82).

Throughout the literature, the Strong Black Woman schema is a double-edged

sword representing both an asset and a vulnerability. The results of Black and Woods-

Giscombé (2012), Nelson et al. (2016), West et al. (2016) are similar because they have

all highlighted both positive and negative aspects of the schema. Each author has

suggested that although the schema can be used as a positive coping mechanism it can

lead to health compromising behaviors (Black & Woods-Giscombé, 2012; West et al.,

2016). Romero has stated that, “an overused asset that develops uncritically without

ongoing evaluation and attention to changing needs and demands runs the risk of

becoming a liability” (2000, p. 225). Therefore, examining how this phenomenon

contributes to the current health status of Black women would be significant to the field.

For the purposes of this quantitative research, the instrument used to measure the

internalization of the Strong Black Woman schema by Black women ages 18-65 was be

the Strong Black Woman Attitudes Scale, which has been confirmed by Green (2012) as

valid and reliable.

Role strain and the strong black woman schema. Viewing Black women as

unidimensional obscures the detrimental effects of over functioning on their well-being.

Intersectionality occurs when Black women incorporate aspects of stereotypical ideas and

contemporary functions into their lives (Brah & Phoenix, 2013). Literature regarding the

multiple roles that Black women experience and the distress it causes is lacking (Martin,

Boadi, Fernandes, Watt, & Robinson-Wood, 2013).

Multiple roles and multiple expectations can contribute to role strain. Role strain

exemplifies only one possible manifestation of the correlation between historical notions

of African American womanhood and mental health. Contemporary researchers have

begun to explore psychological functioning in Black women in correlation to having

various roles. Although findings have been mixed, such as Giurgescu et al.’s (2015) study

of pregnant Black women, who found that these Black women engaged in multiple roles

lived in lower quality neighborhoods and had increased depressive symptoms while other

studies have found more positive outcomes.

Societal factors such as the historical employment discrimination against African

American men, has left the burden of supporting the African American family on the

woman, thus contributing to the need for her autonomy (Hagelskamp & Hughes, 2014).

Collins (1990) reviewed the socio-historical context of Black women in her exposition on

the politics of gender and sex within the African American community and described

how factors such as high incarceration rates of African American men have subsequently

affected gender roles for African American women.

Comparably, Wyatt (2008) further described how the African American woman’s

multiple roles as primary breadwinner in the household coupled with her already existent

child care responsibilities have compounded her responsibilities as head of household.

Here, again is a social and economic reality which necessitates the over-functioning of

African American women. Therefore, viewing Black women solely through the

stereotypical lens of strength obscures these social pressures and inappropriately locates

her tendency to over function in an inherent character trait rather than as a mechanism for

survival.

The 2010 U.S. Census found that Black women headed 30.1 percent of single

family households as opposed to 9.9 percent of White women. Although in the past

decade, the overall amount of U.S. households headed by women has increased across

races (18.2 percent), African American female headed households have grown far faster

than other races (Lofquist, 2012). As such, the likelihood of Black women as the primary

caretakers of themselves and others seems increasing more likely.

Similarly, Elliott, Powell, and Brenton (2015) pointed out in their qualitative

study of 16 low-income, single Black women that many Black women find themselves

carrying the bulk of responsibility within the home in addition to work duties outside of

the home, as they often are the primary breadwinners in the household. In comparison,

West (1995), who defined role strain as the difficulty in fulfilling role obligations,

discusses this concept as an important barrier to health for African American women.

West (1995) explored role strain in the context of many Black women carrying the sole

responsibility for maintaining their households and on average having fewer finances to

work with as they earn less money than their White counterparts.

However, not all Black women perceive the schema as having deleterious effects.

Contrary to the research of Wyatt (2008), Abrams et al. (2014), in a qualitative study of

the strong Black woman, found that role stress (which is like role strain) can positively

impact coping resources and that multiple role stress does not always negatively impact

mothering roles. One participant commented, “Strong Black Women like our mothers,

our grandmothers, and godmothers, aunts…taught us how to be strong and how to work

with or without a man in our lives, making us Strong Black Women” (Abrams et al.,

2014, p. 18). Essentially, the research denotes that these women, who undertake multiple

roles, also experienced high levels of stress are taught how to navigate these roles and

given ways to cope. Overall, beliefs about the centrality of nurturing, and the controlled

expression of emotions as other aspects of the stereotypical notions of Black womanhood

have also shown negative effects on Black women’s well-being, particularly perceptions

of stress and depression (Rosenthal & Lobel, 2016). Given societal expectations to

smoothly handle multiple responsibilities and support others, Black women may learn to

internalize their problems instead of seeking help for them.

Mental health help-seeking. In the mental health context, help-seeking is an

adaptive coping process that results in the attempt to obtain assistance to deal with a

mental health concern. Several studies have been conducted regarding help-seeking

attitudes (Bromley et al., 2016; Hammer & Vogel, 2013; Henderson, Evans-Lacko, &

Thornicroft, 2013; Reynders, Kerkhof, Molenberghs, & Van Audenhove, 2014; Rüsch et

al., 2013). It has been suggested that belief in the Strong Black Woman schema may limit

self-care activities like seeking psychological services due to the mandate of self-reliance

and caretaking (Jerald, Cole, Ward, & Avery, 2017). The time and additional resources

needed to engage in psychotherapy may be detracting from resources needed to serve the

family, church, and community. Further, it has been concluded that stigma related to

seeking help for mental disorders may cause a service seeking delay which makes it

important to this research regarding the decision to seek mental health help (Pattyn,

Verhaeghe, Sercu, & Bracke, 2014; Sickel, Seacat, & Nabors, 2014; Turner, Jensen-

Doss, & Heffer, 2015). Because the strong Black woman is expected to handle her

problems independently, receiving mental health services may be seen as an admission of

weakness or failure (Harris, 1995; Littlefield, 2003; Thomas et al., 2004). Therefore, it is

important to discuss help-seeking and Black women to garner a better understanding of

the relationship.

Due to the negative attributions associated with seeking help, women who strive

to attain this archetypal image often suffer in silence, feeling frustrated and isolated

because they cannot ask for the support they need (Ashley, 2014; Macías, 2015).

Quantitative research has also suggested that depressed Black women may choose to

uphold the mask of strength rather than seek therapy (Williams, Foye, & Lewis, 2016).

For these reasons, the current study will examine if and to what extent there is a

correlation between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking

Researchers have proposed that some individuals may evade seeking mental

health information because it is too threatening due to self-stigma and negative attitudes

(Clement et al., 2015; Corrigan, Druss, & Perlick, 2014; Lannin, Guyll, Vogel, & Madon,

2013; Swan, Heesacker, & King, 2016). However, the link to actual help-seeking

decisions has not been tested; therefore, Lannin, Vogel, Brenner, Abraham, and Heath

(2015) examined if, and to what extent, self-stigma and attitudes negatively influence

decisions to pursue information about mental health concerns and counseling. Using 370

undergraduates, the researchers utilized probit regression models and discovered that

self-stigma negatively predicted decisions to pursue both mental health and counseling

information. Also, participant’s attitudes concerning counseling mediated self-stigma’s

effect on these decisions. Higher levels of distress predicted the likelihood of seeking

mental health information (8.5%) and counseling information (8.4%) for those with high

self-stigma were nearly half of those with low self-stigma (17.1 percent and 15.0 percent,

respectively). These results propose that self-stigma may deter initial decisions to seek

mental health and counseling information. They further denote the need for the

development of interventions aimed at the reduction of mental health help-seeking

barriers.

Cheng et al. (2013) conducted a study using structural equation modeling (SEM)

to explore the effects of psychological distress on perceived stigmatization by others and

self-stigma for seeking psychological help. The sample consisted of 260 Black, 166

Asian American, and 183 Latino American students. Across all 3 groups it was

concluded that higher levels of psychological distress along with perceived racial/ethnic

discrimination accurately predicted higher levels of perceived stigmatization by others for

seeking psychological help. Also, it was concluded that higher levels of psychological

distress along with perceived discrimination predicted higher levels of perceived

stigmatization by others for seeking psychological help. Further, these results accurately

predicted greater self-stigma for seeking psychological help. Moreover, lower levels of

self-stigma for seeking psychological help across all groups was seen in participants with

higher levels of other-group orientation. Interestingly the only group where higher levels

of ethnic identity predicted lower levels of self-stigma of seeking psychological help was

for Blacks which supports the findings of Lannin et al. (2015).

Although stigma has been greatly researched as a barrier to mental health, Abdou

and Fingerhut (2014) proposed that stereotype threat continue to be investigated as a

potential barrier to heath behaviors and outcomes of Black women. Jones et al. (2013)

conducted a study to develop a measure of health- related stereotype threat using sample

of 280 Black collegiate. The findings revealed that Blacks scored significantly higher (M

= 5.4; SD = 1.31) than the midpoint (4.0) on the black-white health-related stereotype

awareness item. These results are indication that participants were conscious of the Black

health inferiority stereotype. Ultimately, the findings suggested that, if Blacks are unable

to protect themselves from health-related stereotype threat, they may delay preventive

measures that might improve their health thus delaying help-seeking.

In accordance with empirical research regarding help-seeking, Sosulski and

Woodward (2013) conducted a study which utilized data from the National Survey of

American Life to examine the usage of professional services and informal support among

Black women with in psychological distress. Forty-seven percent of participants utilized

a combination of both professional services and informal support, fourteen percent relied

on professional services only, two percent used informal support only, and sixteen

percent did not seek help at all. Due to the results, Sosulski and Woodward (2013)

suggested that quantitative and qualitative studies of gender-role-related variables will

explain how much expectations for women within families and communities impact help-

seeking behavior which is like the assertion of Donovan and West (2015) regarding

Black women and mental health help-seeking behavior. The authors noted that the studies

should be designed to conclude whether race plays a substantial role in assisting or

deterring women from seeking help. The authors’ suggestion for future research may

result in improved psychological interventions with increased awareness about culture

and gender. As a result, Black women may seek more help thereby increasing mental

health utilization.

Measurements of help-seeking attitudes. For the purposes of this quantitative

research, the instrument to measure help-seeking attitudes in Black women ages 18-65

will be the Inventory of Attitudes Toward Seeking Mental Health Services (Mackenzie et

al., 2004), a modified version of Fischer and Turner’s (1970) Attitudes toward Seeking

Professional Psychological Help Scale. The Inventory of Attitudes Toward Seeking

Mental Health Services is a 24-item scale and has three internally consistent factors:

psychological openness, help-seeking propensity, and indifference to stigma. According

to the authors of the scale, (1) psychological openness, the extent to which individuals

recognize psychological problems and are open to the possibility of seeking professional

help; (2) help-seeking propensity, the extent to which individuals are willing and able to

seek professional psychological help; and (3) indifference to stigma, the extent to which

individuals are concerned about what important others might think if they were to find

out that he or she was receiving professional psychological help. Example items include:

“There are certain problems which should not be discussed outside of one’s immediate

family” (psychological openness), “If I believed I were having a mental breakdown, my

first inclination would be to get professional attention” (help-seeking propensity), and

“Having been mentally ill carries with it a burden of shame” (indifference to stigma).

Answers could range on a Likert scale from disagree (0) to agree (4).

In the first published study using the Inventory of Attitudes Toward Seeking

Mental Health Services with an all-Black population, Ward, Wiltshire, Detry and Brown

(2013) determined the subscales presented adequate construct validity and internal

consistencies were adequate ranging from 0.73 to 0.81. Results of the study indicated that

the participant’s attitudes suggested they are not very open to acknowledging

psychological problems, are very concerned about stigma associated with mental illness,

and are somewhat open to seeking mental health services, but ultimately prefer religious

coping. Although participants were concerned about the stigma associated with mental

illness and possessed psychological openness, participants were slightly open to pursuing

mental health services. The participant’s openness to seeking mental health services is

consistent with the positive findings of Pedersen and Paves (2014) but in opposition with

the research that suggested that Blacks hold negative attitudes toward help-seeking

(Cheng, McDermott, & Lopez, 2015; Parcesepe & Cabassa, 2013; Wei, Hayden, Kutcher,

Zygmunt, & McGrath, 2013).

Health disparities in the black community. Health disparities are large gaps in

the rates of disease and death between ethnic and socioeconomic status subgroups in a

population (Dunkel Schetter et al., 2013). Belgrave and Abrams (2016) suggested that

there is a need to garner a greater understanding of the complex nature of health

disparities experienced by Black women to move the field forward in making progress

toward achieving health equity for this population. As a result, it is important to discuss

the causes of health disparities in the Black community. This discussion leads to a greater

understanding of the barriers that may contribute to the underutilization of mental health

care in the population.

Research spanning three decades supports the idea that oppressive systems and

discrimination are obstacles that often lead to poorer health for marginalized people

(Williams & Mohammed, 2013). Recently, racism and discrimination as determinants of

health inequalities has received increased attention (Black, Johnson, & VanHoose, 2015;

Chae et al., 2015; Feagin & Bennefield, 2014).

Discrimination based disparities. As cited in Kang and Burton (2014), critical

race research supports that racism produces psychological and emotional injuries that

parallel the posttraumatic effects of combat and other interpersonal traumas. Kang and

Burton (2014) noted that survivors of racism, like survivors of other interpersonal

traumas, experience the event as negative, sudden, and uncontrollable. Aftereffects

include intrusive re-experiencing, avoidance of similar threats in the future, and arousal

manifesting in hypervigilance and sleeplessness (Kang & Burton, 2014).

Similar to the research conducted by Kang and Burton (2014), Versey and Curtin

(2016) investigated both mental and physical health consequences of discrimination, as

well as mediating correlations among African American and White women. The study

utilized data from the Women’s Life Path Study (N = 237). The findings suggested that

discrimination is both directly and indirectly associated with health outcomes for both

Black and White women, mediated by both individual and group level processes such as

self-esteem and structural awareness. Results from this study also indicated that

discrimination is associated with intensified structural awareness and lower self-esteem,

which are both related to poorer health. Therefore, it can be concluded that perceived

discrimination can be associated with health disparities.

Numerous studies have explored the correlation between depression, cultural

stigma regarding depression, and attitudes regarding the Strong Black Woman schema.

However, a definitive link between these has not been found, nor is there a clear

understanding of normative versus distressed Black womanhood. Like Versey and Curtin

(2016), Chen and Yang (2014) conducted a study regarding discrimination and distrust

and came to similar conclusions. Using 9,880 adults from a Southeastern region, Chen

and Yang (2014) found a positive association between discrimination and distrust. More

than 9 percent of the participants reported experiencing discrimination when seeking

health care and possessed significantly higher rates of chronic diseases and depression

than those who reported not being discriminated against. Moreover, those reporting

experiencing discrimination also held greater distrust for the medical system.

Interestingly, more than half of participants who reported discrimination and distrust

were Black. Comparably, Armstrong et al. (2013) investigated the contribution of self-

reported experiences of racial discrimination to racial differences in health care system

distrust 762 Black adults and 1,267 White adults living in 40 metropolitan areas in the

United States. Similar to the results of Chen and Yang (2014), most Black participants

reported experiencing discrimination with 80% of the Black participants reported

discrimination as opposed to the 34% of Whites. Despite presenting information from

both Blacks and Whites, Armstrong et al. (2013) presented only statistics, failing to

provide individual opinions and feelings beyond general insights of perceived racism,

discrimination, and lack of trust for the white healthcare system. The inclusion of these

views could have provided examples of coping strategies used to offset the participants’

perceptions of racism and discrimination.

Perceived racial discrimination is subjective. However, when such the perception

may determine an individual’s perspective of their future, then the perception needs to be

addressed. Chao, Longo, Wang, Dasgupta, and Fear (2014) conducted a study of 394

African Americans to determine whether there was a significant association between

perceived racism, self-esteem, shyness, and psychological distress. The individual

experience of racism was found to have a significant negative impact on preexisting

psychological difficulties, including capacity for coping, stress management, and

vulnerability to the effects of future instances of racism. In other studies cited by Chao et

al. (2014), it was found that more exposure to racism was associated with African

Americans experiencing increased emotional isolation and alienation, less resilience,

fewer coping resources, more difficulty initiating conversations with strangers, lower

usage of counseling services, and greater difficulty trusting counselors who were not

Black.

Medical distrust. The utilization of Black bodies for scientific and medical

breakthrough shaped Black American’s views of the medical profession and medical

institutions (Schwei, Kadunc, Nguyen, & Jacobs, 2014). Throughout history, poor and

enslaved people were used as guinea pigs for doctors to practice medical procedures

which resulted in medical distrust (Feagin & Bennefield, 2014). This “legacy of

mistrust,” or the continuation of a discomfort of medical institutions, carried on after

slavery into the 20th century. By the 1930s, the fear and suspicion became justified again

as Tuskegee Syphilis Study began (Moore et al., 2013). As a result, Black people report

greater levels of medical distrust for the values domain encompassing beliefs about the

honesty, motives, and equity in the medical system as opposed to Whites (Armstrong et

al., 2013).

The Tuskegee Legacy Project surveyed 1133 racially diverse adults in four US

cities. The findings revealed no difference in self-reported willingness to participate in

research between groups, yet Black participants were significantly more likely than white

participants to have a higher fear of participation based on the Guinea Pig Fear Factor

scale (Garza et al., 2017). Given the myriad of factors affecting Black women’s health,

i.e. the historical and contemporary context of unequal access to healthcare, unequal

access to and receipt of medical and psychological treatment, environmental factors,

economic hardship, and the effects of gendered racism, it seems important to consider the

interface of culture with these factors. As a cultural construct, the Strong Black Woman

has been conceptualized as a psychological defensive style and coping mechanism

(Hamin, 2008; Romero, 2000; Thompson, 2003). While this construct may relate to

protecting one’s self against one’s own vulnerabilities and social harms, it may also have

some correlation to how Black women manifest and handle psychological distress as well

as consequently seek help for that distress.

Psychological distress in black women. Black women are at a greater risk for

exposure to multiple traumatic events and are less likely to seek mental health services

than White women (Gobin & Allard, 2016; Stevens-Watkins, Perry, Pullen, Jewell, &

Oser, 2014). Accordingly, many Black women report using avoidant and passive coping

strategies which increases their risk for lower psychological adjustment (Giurgescu et al.,

2015; Lewis, Mendenhall, Harwood, & Huntt, 2013; Stevens-Watkins, Sharma,

Knighton, Oser, & Leukefeld, 2014). Because of low psychological adjustment combined

with the underutilization of mental health services, research on psychological distress in

Black women is prevalent. It is important to this research to examine the literature

regarding psychological distress to gain an understanding of its role in Black women’s

seeking of mental health help.

Watson and Hunter (2015) investigated if, and to what extent, Black women’s

internalization of the Strong Black Woman schema predicted increased symptoms of

anxiety and depression and if, and to what extent, attitudes toward professional

psychological help-seeking intensified psychological distress. The researchers collected

data from 95 Black women ranging in age from 18 to 65. Through hierarchical regression

analysis, it was revealed that individuals who demonstrated greater adherence to the

Strong Black Woman schema also demonstrated greater symptoms of anxiety and

depression. Further, it was determined that Black women’s attitudes toward professional

help-seeking did not moderate the associations between endorsement of the Strong Black

Woman schema and anxiety or depression. Consequently, the findings of this study offer

empirical support for the role of cultural factors, like the Strong Black Woman schema, in

Black women’s experience of underutilization of mental health services.

Stress has also been researched as a type of psychological distress in Black

women. Norris and Mitchell (2013) conducted a study that investigated the stress process

for Black women by developing a model that examined the correlation between (a)

source and type of stress exposure, (b) perceived social support, and (c) the resulting

manifestation of psychological distress. Utilizing data from a 2003 survey by the Center

for the Study of Public Health Impacts of Hurricanes at Louisiana State University, the

researchers completed ordinary least squares (OLS) regression to analyze how the stress-

support-distress process functions with Black women. It was determined that Black

women who reported greater exposure to traumatic life events reported greater levels of

psychological distress. Contrarily, it was reported that chronic stressors had no effect on

psychological distress for Black women. Additionally, younger women and those who

reported lower levels of income reported greater levels of psychological distress than

their older and/or wealthier counterparts.

Continuing with research regarding psychological distress, Donovan and West

(2015) conducted a study using a sample of 92 Black female college students to address a

gap in the literature by quantitatively investigating the correlation among Strong Black

Woman internalization, stress, and anxious and depressive symptoms in this population.

The results revealed that both moderate and high levels of Strong Black Woman

endorsement increase the correlation between stress and depressive symptoms. However,

low levels of Strong Black Woman endorsement do not. This data extends preceding

qualitative discoveries and propose that embracing the Strong Black Woman role

increases Black women’s susceptibility to depressive symptoms associated with stress.

Conversely, Sumra and Schillaci (2015) investigated the interplay between

engagement of seven roles and perceived stress and life satisfaction in a small non-

random sample of women in North America (N = 308). The researchers found a

significant negative correlation between perceived stress and life satisfaction, and role

satisfaction. Additionally, data from multiple regression models did not detect the level of

role engagement as a significant predictor of perceived stress or life satisfaction. Further,

the researchers hypothesized that women engaged in the “superwoman” role would

display higher levels of perceived stress. However, the results revealed that the women in

these roles do not experience higher levels of perceived stress than non-superwomen.

Therefore, the results of this study suggested that engagement in multiple roles, even at

high levels such as those experienced by “superwomen,” is not associated with greater

levels of higher stress, or reduced life satisfaction.

Coping strategies of black women. The Strong Black Woman schema has been

cited as prompting women to use self-reliance and self-silence as coping strategies in

response to stressors (Watson & Hunter, 2015). Coping refers to “cognitive and

behavioral efforts to manage specific external and/or internal demands that are appraised

as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141).

Most prior studies of coping focus on how individuals cope with problems once they

occur, particularly around onset of disease (Jaser, Linsky, & Grey, 2014; Szymanski,

2012).

However, due to the underutilization of mental health services by Black women,

other studies have attempted to understand the coping strategies used by Black women

(Ward et al., 2013). Consequently, studies have found that Black women use a variety of

coping strategies including: support networks, religious coping, and self-care (Holder,

Jackson, & Ponterotto, 2015). It is important to examine the literature regarding the

coping strategies of Black women as alternatives that are used in opposition of mental

health help-seeking. Furthermore, Dunn and Conley (2015) asserted that an enhanced

understanding of the functioning behind differences in coping style may lead to the

advancement and formation of more effective coping interventions.

John henryism. James (1994) constructed the John Henryism hypothesis on the

legend of John Henry. Henry was a Black man with the ability to drive steel pins in

railroad tracks. However, overtime a machine was developed that could complete

Henry’s job. In efforts to remain relevant, John Henry raced against the machine. Henry

won the competition but died from the physical and emotional exhaustion from the

rivalry. Consequently, John Henryism was defined as the sustained, high-effort

psychological response to psychosocial stressors (James, 1994).

John Henryism is regarded as having the willpower to succeed despite barriers

and adversity (Kramer, Johnson, & Johnson, 2015). This coping style may be particularly

prominent in the Black population because of experiences with discrimination and

economic hardships (James, 1994). Furthermore, individuals utilizing this active coping

style possess determination to thrive, a need to have control, and a broad propensity to

not seek help (Griffith, Cornish, McKissic, & Dean, 2016). Ultimately, this sense of

control is used as a problem-solving tactic, especially in an oppressive society.

John Henryism is significant to the experience of Blacks in the United States.

Empirical research supports this assessment by demonstrating that this coping style is

more predominant in Blacks than in Whites (Hudson, Neighbors, Geronimus, & Jackson,

2016). Additionally, the John Henry coping style is theoretically associated to the image

of a “Strong Black Woman,” (Bronder, Speight, Witherspoon, & Thomas, 2014) since

Black women are often perceived to be strong, psychologically impenetrable, and

emotionally secure (Romero, 2000).

Stevens-Watkins et al. (2014) examined the role of culturally relevant factors such

as spirituality, self-esteem, and social support as significant correlates of John Henryism

Active Coping among African American female trauma survivors. The study utilized

secondary data from the B-WISE project (Black Women in a Study of Epidemics) with a

sample of 161 community-based Black women with a self-reported history of trauma.

Results indicate that participants with higher self-esteem and existential well-being were

more likely to cope actively with daily life stressors. Conversely, perceived social support

from family and significant others was not significantly associated with active coping

among the women.

Similarly, Bronder et al. (2014) investigated the John Henryism coping strategy as

a contributor to health disparities in both Black women. The study utilized 314 Black

participants aged 18-70 in the Midwest. Although their study found a negative correlation

between John Henryism and depressive symptomatology, the results did address the

struggle that Black women face with the Strong Black Woman schema. According to the

results, individuals possessing less depressive symptomatology showed increased

internalization of John Henryism. Further, income was inversely related to depression

suggesting that there is a correlation between lower income and depressive symptoms.

Additionally, perceived family support displayed the strongest correlation with John

Henryism. Therefore, informal supports available to an individual may impact the

amount of support they perceive themselves to have.

Informal social support. Informal social support refers to any form of aid from

members of an individual’s social network, such as family, friends, and neighbors

(Taylor, Chatters, Woodward, & Brown, 2013). Prior research has indicated that informal

African Americans report receiving recurrent support from family (Lincoln, Taylor, &

Chatters, 2013). Additionally, social support is associated to less depressive symptoms

and decreased levels of psychological distress (Sultan, Norris, Avendano, Roberts, &

Davis, 2014; Taylor, Chae, Lincoln, & Chatters, 2015;) and African Americans with

reporting low levels of social support report increased suicidal ideation (Kleiman & Liu,

2013).

Considering that studies regarding the social support of ethnic minorities and

social support was lacking, Nguyen, Chatters, Taylor, and Mouzon (2016) examined the

social supports and interaction to diverse subjective well-being indicators in 837 African

Americans aged 55 or older. According to the results, subjective closeness to family was

related to higher levels of life satisfaction and happiness, but not self-esteem. However,

closeness to friends was associated with higher levels of happiness and self-esteem, but

not life satisfaction.

In a longitudinal study, Seawell, Cutrona, and Russell (2014) examined the role of

general and tailored social support in mitigating the deleterious impact of racial

discrimination on depressive symptoms and optimism in 590 Black participants.

Participants reported racial discrimination however, participants also reported being very

optimistic as well as reported relatively few depressive symptoms. Although it was

hypothesized that social support for racial discrimination would reduce depressive

symptoms and increase optimism received mixed results, the data did not support this.

Results indicated that the unique effect of tailored social support was apparent in its

ability to decrease depressive symptoms over time if it increased over the same period.

Further, results indicated that Black women who received high levels of social

support for racial stressors were protected from the negative impact of racial

discrimination on their depressive symptoms. In contrast, women who received low

levels of race-related social support and reported high levels of racial discrimination

experienced the highest level of depressive symptoms. Taken together, results suggested

that Black women should be encouraged to develop and maintain social support networks

that provide tailored support to cope with the deleterious effects racism can have on

psychological well-being.

To give further insight to the topic, Levine, Taylor, Nguyen, Chatters, and Himle

(2015) investigated the informal support networks and Social Anxiety Disorder (SAD) in

a population of 3,570 African Americans and 1,621 Blacks of Caribbean descent.

Overall, the results indicated that emotional closeness and contact with family or friends

can be protective factors for SAD and that negative interaction with family is a risk factor

for SAD for these populations. Additionally, more frequent negative interaction with

family members was associated with lifetime and 12-month SAD for both African

Americans and Black Caribbeans. These results support previous findings regarding that

more frequent negative interactions with family has also been linked to increased odds

for having higher levels of psychiatric distress and depression in U.S. Black populations

(Taylor et al., 2015).

Religious coping. The church has historically been the primary source of support,

spirituality, and connectedness for Black women. Research into religious coping has

increased in recent years as well (Gall & Guirguis-Younger, 2013). Many successful

health promotion interventions have been implemented in collaboration with Black

churches (Rowland & Isaac-Savage, 2014; Williams, Gorman, & Hankerson, 2014).

Religion provides ways to respond to events, such as praying, seeking spiritual support,

and engaging in religious rituals. These religious schemas and behaviors may, in turn,

facilitate positive coping outcomes by helping caregivers to process negative events, find

meaning, develop positive or hopeful expectations, and execute coping plans (Pearce,

Medoff, Lawrence, & Dixon, 2016). As a result, the use of religion and religious coping

methods may be particularly relevant in exploring the lack of psychological help-seeking

in Blacks.

Holt, Clark, Debnam, and Roth (2014) examined the role of religious coping as a

mediator of the correlation between religious involvement and health behaviors among

2,370 Black adults. Individuals high in religious beliefs tended to report high levels of

positive and low levels of negative religious coping. Further, findings suggested that

religious beliefs, such as having a close personal correlation with a higher power, are

associated with greater, more positive health behaviors such as vegetable consumption.

Conversely, negative religious coping appeared to play a role in the correlation between

religious beliefs and more negative health behaviors, such as greater alcohol

consumption.

Shervin (2014) investigated the main and buffering effects of positive religious

coping on the association between the number of chronic medical conditions and major

depressive disorder (MDD) among 3,750 African Americans, 1,438 Caribbean Blacks

and 891 Non-Hispanic Whites. Results of the study indicated that multiple chronic

conditions were associated with higher odds of MDD across all ethnic groups.

Additionally, religious coping was associated with lower rates of MDD among Caribbean

Blacks but not African Americans and non-Hispanic Whites. Overall, these findings are

similar to the research that suggested African Americans and Caribbean Blacks have

higher levels of religious coping than non-Hispanic Whites (Assari, 2014).

Kidwai, Mancha, Brown and Eaton (2014) assessed the effect of religious

attendance and spirituality on the correlation between negative life events and

psychological distress using 1,071 individuals aged 30-65 years old from Baltimore.

Results of the study indicate that negative events during the past year are positively

related to current distress. Additionally, respondents who attended religious services had

significantly lower distress as compared to those who never attended services.

Methodology. The purpose of this quantitative correlational research is to

determine if, and to what extent, a correlation existed between the internalization of the

Strong Black Woman schema and attitudes toward mental health help-seeking in 84

Black women aged 18-65 in the Southern region of the United States. Quantitative

methods allow for a narrow focus on a specific set of data (Hussein, 2015). In addition,

quantitative data analysis focuses on numerical correlations though statistical testing as

opposed to patterns and trends which are outcomes of qualitative data.

Most of the research collected on the Strong Black Woman schema has been

qualitative. For example, Robinson, Esquibel, and Rich (2013) explored how

undergraduate women view their Black femininity. Participants revealed the themes of

feeling like ‘the only one’ and Black women’s strength. Further research conducted by

Abrams, Javier, Maxwell, Morgan, Belgrave, and Nguyen (2016) utilized a qualitative

methodology to explore the differences and similarities in gender role beliefs among

Black and Vietnamese women with the results revealing similarities in the embodiment

of strength and self-reliance. Watson and Hunter (2016) also utilized a qualitative

methodology when exploring the competing messages presented in the Strong Black

Woman schema. Similarly, Abrams et al. (2014) utilized a qualitative methodology when

investigating the characteristics of the Strong Black Woman schema.

On the other hand, West et al. (2016) noted that additional studies regarding the

Strong Black Woman need to be conducted to inform quantitative research which

continues to be “limited in sound psychometrics” for the construct. As a result, limited

empirical articles regarding the Strong Black Woman schema and mental health have

utilized a quantitative methodology. Watson and Hunter (2015) utilized quantitative

methodology when analyzing the main effects of the Strong Black Woman schema and

anxiety and depression. Additionally, Donovan and West (2015) quantitatively examined

the correlations among Strong Black Woman schema internalization, stress, and anxious

and depressive symptoms and suggested that researchers further examine the correlation

between the schema and mental health. Further, Watson-Singleton (2017) used

quantitative methodology to investigate the correlation between the Strong Black Woman

schema and psychological distress. Consequently, the researcher made the choice to

employ a quantitative methodology with a correlational design

The Inventory of Attitudes Toward Seeking Mental Health Services has been

used to collect quantitative data in previous studies of mental health help-seeking across a

wide variety of organizations and settings (Brown & McCreary, 2014; Reger et al., 2016;

Segal, Diaz, Nezu, & Nezu, 2014; Ward & Brown, 2015). One study conducted by

Dunford and Granger (2017) sought to assess the correlation between postnatal

depression and help-seeking attitudes utilizing a correlational design. Further, Drapeau,

Cerel, and Moore (2016) employed a correlational study when seeking to determine the

correlation between personality, coping, and perceived closeness with help-seeking.

For the purposes of this study, the methodology and design were selected in the

effort to allow the researcher to investigate if, or to what extent, a correlation existed

between the Strong Black Woman schema and help-seeking attitudes. Therefore, the

research questions can be explored using a quantitative perspective. Accordingly, after

careful consideration of the rationale for other similar studies as well as the objectives of

this proposed study, it has been determined that the characteristics of a quantitative study

with a correlational research design is the best suited methodology.

Instrumentation. Since this researcher seeks to determine if and to what extent a

correlation existed between the Strong Black Woman schema and help-seeking attitudes,

two quantitative measures were needed. As a result, the researcher chose to use the

Strong Black Woman Attitudes Scale and the Inventory of Inventory of Attitudes Toward

Seeking Mental Health Services. These measures were selected based on their ability to

capture the valid and reliable quantitative data based on the variables presented.

The 29-item Attitudes Toward Seeking Professional Psychological Help Scale

(Fischer & Turner, 1970) has been used in many previously conducted studies regarding

gender and help-seeking (Yousaf, Popat, & Hunter, 2015). Although the Attitudes

Toward Seeking Professional Psychological Help Scale has been widely used, it has

limitations. Two limitations of the Attitudes Toward Seeking Professional Psychological

Help Scale are that it does not mention general practitioners as mental health contacts and

was originally only validated with a sample of students (Mackenzie et al., 2004), which

limits the generalizability of the findings.

Due to a lack of generalizability, Mackenzie et al. (2004) created the Inventory of

Attitudes Toward Seeking Mental Health Services in response to concerns that previous

measures of attitudes toward psychotherapy tended to yield inconsistent results in terms

of correlating with actual help-seeking behaviors (Rogers-Sirin, 2013). The Inventory of

Attitudes Toward Seeking Mental Health Services has been utilized in a variety of

populations including (a) geriatrics (Stewart, Jameson, & Curtin, 2015), (b) college

student athletes (Wahto, Swift, & Whipple, 2016), (c) education (Perry et al., 2014), and

(d) military (Segal et al., 2014; van den Berk-Clark, Balan, Shroff, Widner, & Price,

2016). Further, the Inventory of Attitudes Toward Seeking Mental Health Services has

been used in several different cultural contexts including Asia (Found, 2016; Pilkington,

Msetfi, & Watson, 2012; Tuliao, Velasquez, Bello, & Pinson, 2016) and Africa (Gesinde

& Sanu, 2015).

The Inventory of Attitudes Toward Seeking Mental Health Services has also been

utilized in a variety of studies regarding mental health and help-seeking behaviors.

Watson and Hunter (2015) utilized the measurement to determine whether attitudes

toward professional psychological help-seeking intensified psychological distress.

Additionally, Mesidor and Sly (2014) employed the measurement during their

investigation of the mental health-help seeking intentions among international and

African American college students. Further, Tuliao et al. (2016) utilized the measurement

when exploring the intent to seek mental health help among Filipinos. The Inventory of

Attitudes toward Mental Health Service has been used in a variety of populations and

cultural contexts including Black women of diverse age groups; therefore, the Inventory

of Attitudes Toward Seeking Mental Health Services was selected as a reliable measure

for assessing attitudes toward mental health help-seeking.

As mentioned previously, there is a lack of sound psychometric measures

available to quantitatively asses the Strong Black Woman schema (Donovan & West,

2015). Donovan and West (2015) utilized the Stereotypic Roles for Black Women Scale

in their study regarding stress and the Strong Black Woman schema. However, the

authors reported adapting the measurement for consistency and ease in participant self-

reporting. Additionally, Donovan and West (2015) only utilized one out of the five

subscales and obtained a Cronbach’s alpha of α =.77. Similarly, Watson and Hunter

(2015) utilized the Stereotypic Roles for Black Women Scale to measure the Strong

Black Woman schema but combined two of the subscales and maintained a Cronbach’s

alpha of α =.77.

The Strong Black Woman Attitudes Scale was created and validated in a

dissertation (Thompson, 2003). Thompson found adequate internal consistency for the

scale, as measured by Cronbach’s alphas: α= .74, for the total scale and the three

subscales were caretaking: α=.66, affect regulation α=.72, and self-reliance α=.60. This

scale was later revised, validated, and used to measure the correlation between the Strong

Black Woman schema and suicidality in another dissertation (Green, 2012). Green (2012)

found adequate internal consistency: α = .80 for the total scale, and the three subscales of

caretaking α =.64, affect regulation α =.78 and self-reliance α =.82. Consequently, the

Strong Black Woman Attitudes Scale was used to collect quantitative data for the

internalization of the Strong Black Woman schema due to the higher internal consistency

and lack of need for researcher manipulation of the measurement.

Summary

Black women exist in a socio-historical context which has included a past of

enslavement, racial discrimination and oppression and a legacy of discrimination that has

resulted in the uneven allocation of resources evident today (Broussard, 2013). In a

contemporary context, these women have dealt with stereotypical notions of themselves

in conjunction with social and economic realities that have impacted their psychological

and overall well-being (Abrams et al., 2014). The Strong Black Woman schema has been

introduced to explain one way that Black women have learned to cope with these various

realities.

Although many themes related to this construct exist, the proposed study will

utilize a version of the construct that has theoretical and empirical underpinnings. This

construct is comprised of the three factors of caretaking, self-reliance and affect

regulation, and have been shown to relate to the psychological health of Black women

(Watson & Hunter, 2015). Although researchers have begun to investigate this construct

and have demonstrated its correlation to stress and social support in Black women, this

construct has not been examined in correlation to mental health help-seeking within this

population thereby resulting in a gap in the literature as noted by Watson and Hunter

(2015).

In the review of the literature, the researcher examined several themes related to

the Strong Black Woman schema and attitudes toward mental health help-seeking

including the schema itself, health disparities in the Black community, psychological

distress, and coping strategies of Black women. In the mental health context, help-

seeking is an adaptive coping process that results in the attempt to obtain assistance to

deal with a mental health concern. Several studies have been conducted regarding help-

seeking attitudes (Bromley et al., 2016; Hammer & Vogel, 2013; Henderson et al., 2013;

Reynders et al., 2014; Rüsch et al., 2013). Currently, the literature indicates many gaps

regarding the Strong Black woman schema and mental health help-seeking (Abrams et

al., 2014; Donovan & West, 2015; Watson & Hunter, 2015; Watson & Hunter, 2016;

Watson-Singleton, 2017). It has been suggested that belief in the Strong Black Woman

schema may limit self-care activities like seeking psychological services due to the

mandate of self-reliance and caretaking (Jerald et al., 2017). According to Abrams et al.

(2014), strength is a prevalent aspect of the Strong Black Woman schema. Similarly,

Black and Woods-Giscombé (2012) hypothesized that strength is a culturally suggested

coping style that results as a response to race-related and gender-related stressors. The

results of the research by Abrams et al. (2014) as well as Black and Woods-Giscombé

(2012) has suggested that the discourse of strength aspect of the Strong Black Woman

schema has the potential to cause Black women to engage in health compromising

behaviors such as refusing to acknowledge the need to seek mental health help. However,

not all Black women perceive the schema as having deleterious effects. Contrary to the

research of Wyatt (2008), Abrams et al. (2014), found that role stress can positively

impact health-promoting coping strategies.

Recently, racism and discrimination as factors of health disparities has received

increased attention (Black et al., 2015; Chae et al., 2015; Feagin & Bennefield, 2014).

Accordingly, many Black women report using avoidant and passive coping strategies

which increases their risk for lower psychological adjustment (Giurgescu et al., 2015;

Lewis et al., 2013; Stevens-Watkins et al., 2014). Watson and Hunter (2015) investigated

if, and to what extent, Black women’s internalization of the Strong Black Woman schema

predicted increased symptoms of anxiety and depression as well as if and to what extent

attitudes toward professional psychological help-seeking intensified psychological

distress. The findings of this study offer empirical support for the role of cultural factors,

like the Strong Black Woman schema, in Black women’s underutilization of mental

health services.

Additionally, Bem’s (1981) gender schema theory is being used as the primary

theoretical foundation. The theoretical foundations reviewed connects gender schema

theory and the Theory of Planned Behavior as the most relevant to address the study

parameters and are related to the Strong Black Woman schema and attitudes toward

mental health help-seeking. Assessment of the non-manipulated, interval scale predictor

variable, the internalization of the Strong Black Woman schema, was measured using the

Strong Black Woman Attitudes Scale which was proven to be reliable and valid by Green

(2012). Further, the Attitude Toward Seeking Mental Health Services (Mackenzie et al.,

2004) was used to measure the non-manipulated, interval scale criterion variables of

attitudes toward mental health help-seeking, psychological openness, help-seeking

propensity, and indifference to stigma. The Strong Black Woman schema is proposed as

a cultural coping mechanism and as a possible variable in the correlation between mental

health help-seeking in Black women. Therefore, this research seeks to add a culturally

relevant investigation of the Strong Black Woman schema and mental health help-

seeking to the literature. Additionally, this research seeks to contribute to gender schema

theory by providing a tangible foundation for mental health leaders to produce more

culturally competent and engaging mental health practices for Black women.

Since the researcher sought to determine a correlation between two variables as

opposed to causality, a quantitative, correlational design was used. Correlational research

was the best design because studies that numerically investigate the strength of

correlations between variables require a quantitative methodology (Johnson &

Christensen, 2012). This methodology and research design were specifically chosen to

investigate the research variables to address the proposed research questions and

associated hypotheses. The target population was Black women ages 18-65 who live in

the Southern region of the United States Instruments will be discussed to show the

alignment of the data collection tools to the research questions of the study, as well as the

reliability and validity of the scales.

Chapter 3 highlights the methodology and research design derived from the

research questions. Furthermore, the following chapter includes a review of the problems

statement, research questions and hypotheses, as well as, additional discussion on

instrumentation, population, and sample size, as well as, specific details related to data

collection and analysis. Finally, the proceeding chapter addresses ethical considerations,

limitations and delimitations of the research findings and closes with a summary of

Chapter 3.

Chapter 3: Methodology

Introduction

Gender schemas, such as the Strong Black Woman schema may impact decisions

of Black women to seek mental health help. Although studies have been conducted, there

is limited research regarding the cultural factors, especially gender schemas such as the

Strong Black Woman schema, which may be impacting the decision of Black women to

seek mental health help (Watson & Hunter, 2015). As a result, the purpose of this

quantitative correlational research was to determine if and to what extent a correlation

existed between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking in 153 Black women aged 18-65 in the Southern

region of the United States. The Strong Black Woman schema has been investigated in

several studies regarding internalization of the Strong Black Woman schema and

psychological distress, low self-esteem, chronic health conditions, and participation in

risky sexual behaviors (Brown et al., 2014; Woods-Giscombé et al., 2015).

This chapter begins with a review of the problem statement and restatement of the

research questions and hypotheses. The methodology and research design will then be

presented with special care taken to connect the methodology with the goals of the

research. In the next section of the chapter, the researcher will describe the research

population and sampling method to be used. Included in this section will be the results of

a G power analysis used to determine sample size requirements for anticipated statistical

analyses.

A section on instrumentation will follow in which the survey to be used in this

study will be described, with emphasis on the Strong Black Woman Attitudes Scale and

the Intentions to Seek Mental Health Services which was used to measure the

internalization of schema and the attitudes toward mental health help-seeking

respectively (see Appendix D). The researcher will then turn the discussion to examine

the validity of the selected measurements. The chapter will then move on to consider

questions of reliability. Data from the existing literature on the reliability of both

measurements will be presented.

Next, the researcher will describe the details of data collection and data

management in sufficient detail so that other researchers could replicate the study if they

desired to do so. Plans for data analysis will follow, which outline the steps through

which data were prepared for analysis and then statistically evaluated to address the

study’s research questions and hypotheses. Measures taken to protect the rights and

confidentiality of study participants and to otherwise meet the ethical principles and

guidelines of the Belmont Report (Resea & Ryan, 1978) will be discussed and the

researcher will conclude the chapter by noting study limitations and delimitations as well

as a summary of the chapter.

Statement of the Problem

Given that the core expectations of the Strong Black Woman schema include

affect regulation, caretaking, and self-reliance, caretaking, and affect regulation, Black

women may feel that seeking mental health help is inconsistent with their culture

(Watson & Hunter, 2015). Consequently, it was not known if, and to what extent, there is

a correlation between the internalization of the Strong Black Woman schema and

attitudes toward mental health help-seeking. Although prior studies show that there is a

negative link between the Strong Black Woman schema and depression in middle class

African American women, few quantitative studies have not been conducted regarding

attitudes toward seeking mental health help (Offutt, 2013; Snowden, Libby, & Thomas,

2014; Ward et al., 2013).

Several studies have laid the foundation for the current understanding of the

Strong Black Woman schema and associated characteristics (Abrams et al., 2014;

Donovan & West, 2015; Watson & Hunter, 2015). Black women often refer to strength

whenever discussing their race and gender (Jones & Shorter-Gooden, 2003). However,

there remains a need to better understand the correlation between internalization of the

Strong Black Woman schema and the decision to seek mental health help (Abrams et al.,

2014; Donovan & West, 2015; Watson & Hunter, 2015; Watson & Hunter, 2016;

Watson-Singleton, 2017). As a result of this gap, this research determined if and to what

extent there was a correlation between the internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking.

Research Questions and/or Hypotheses

Accessibility and availability of mental health care services are essential, but the

only reasons individuals choose to seek help for mental health issues. Attitudes and

stigma related to help seeking also determine help seeking intentions (Reynders et al.,

2014). Determining cultural factors that correlate to mental health help seeking attitudes

may increase the utilization of mental health services (Yorke, Voisin, Berringer, &

Alexander, 2016). There was a present gap in the literature that suggested it needed to be

determined if, or to what extent, statistically significant correlations existed between

internalization of the Strong Black Woman schema and attitudes toward mental health

help-seeking. This study could promote further studies in this field for future work on

cultural factors that impact the utilization of mental health services.

A correlational analysis carried out using IBM SPSS (version 24), generated

correlation coefficients between the variables. Internalization of the Strong Black Woman

schema was the non-manipulated, interval scale predictor variable for this research. The

interval scale criterion variables included attitudes toward seeking mental health help as

well as psychological openness, help-seeking propensity, and indifference to stigma. The

instrument used to measure internalization of the Strong Black Woman schema was the

Strong Black Woman Attitudes Scale, originally created by Thompson (2003) and

revised by Green (2012), which is described in detail in the instrumentation section of

this chapter. Permission to use this instrument was given by Dr. Green. Additionally, the

instrument used to measure attitudes toward mental health help-seeking is the Inventory

of Attitudes Toward Seeking Mental Health Services (Mackenzie et al., 2004) and did not

require permission to use. Gender schema theory supported both variables as outlined in

Chapter 2.

Four research questions will be addressed in the study as listed below, with

corresponding null and alternative hypotheses:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking?

H10: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

H1a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

H20: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

H2a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

H30: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

H3a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

H40: There is not a statistically significant correlation between the internalization of

the Strong Black Woman schema and indifference to stigma.

H4a: There is a statistically significant correlation between the internalization of the

Strong Black Woman schema and indifference to stigma.

Research Methodology

Previous researchers have chosen to collect qualitative data on the Strong Black

Woman schema (Abrams et al., 2014; Watson & Hunter, 2016). Conversely, researchers

utilizing the Inventory of Attitudes toward Seeking Mental Health Services measurement

have chosen to collect quantitative data (Kessler, Agines, & Bowen, 2015; Nam et al.,

2013; Watson & Hunter, 2015). However, studies where the researcher evaluates

precisely the strength of correlations between variables that are measured numerically

require using a quantitative methodology (Johnson & Christensen, 2012). Thus,

quantitative methodology was chosen for use in the proposed study. The goal of the

research was to evaluate the strength and statistical significance of the correlation

between the predictor (internalization of the Strong Black Woman schema) and the

criterion (attitudes toward mental health help-seeking, psychological openness, help-

seeking propensity, and indifference to stigma) as measured by the Strong Black Woman

Attitudes Scale and Inventory of Attitudes Toward Seeking Mental Health Services.

Additionally, the selected methodology answers the call of previous research to extend

the literature regarding the Strong Black Woman schema and mental health help-seeking

behaviors in a quantitative manner (Abrams et al., 2014; Nelson et al., 2016; Watson &

Hunter, 2015).

It was not appropriate to utilize a qualitative method in the proposed study.

Qualitative studies explore in great depth and detail a limited number of participants’

subjective experiences and perceptions using a data gathering process that typically

utilizes interviews, direct observations, narrative self-reports, and similar methods (Miles

et al., 2014). However, in the context of this study, the purpose was to determine if and to

what extent a correlation existed between the variables as opposed to providing a deeper

understanding of each variable.

A mixed-method methodology is appropriate in situations where, in addition to

analyzing numerical data, the researcher interacts directly with study participants through

interviews or direct observation to collect qualitative data (Johnson & Christensen, 2012).

As noted above, this study did not involve any such interaction, so a mixed-method

methodology would also be inappropriate here. In sum, a quantitative methodology is the

most appropriate approach to addressing the research questions posed in this study.

Research Design

Although there were several research designs from which to choose, it was

decided that data be collected for this study using a correlational design. Quantitative

correlational research can be defined as a study in which two variables are measured

between the same sample groups to determine if there is a correlation between the

variables (Yilmaz, 2013). This design was selected because it allowed the researcher to

relate internalization of the Strong Black Woman schema and attitudes toward mental

health help-seeking in Black women from the Southern region of the United States.

Correlational research is non-experimental in nature (Bryman, 2012). Therefore, cause

and effect are not considered.

A true experimental design was ruled out for use in this study because

experimental research designs require that the researcher be able to manipulate the

predictor variable and measure the resulting changes in the criterion variable (Johnson &

Christensen, 2012). Kerlinger (1986) expressed that, “Nonexperimental research is

systematic empirical inquiry in which the scientist does not have direct control of

predictor variables because their manifestations have already occurred or because they

are inherently not manipulable” (p. 348). The alternative to an experimental design is a

non-experimental design, where two commonly used options are available, i.e., the

correlational research design and the causal-comparative research design (Johnson &

Christensen, 2012).

However, correlational research is a better choice than causal comparative

research because Schenker and Rumrill (2004) noted that causal comparative research

design is appropriate when the researcher uses pre-existing or derived groups to explore

differences between or among those groups. In this study, the researcher did not seek to

stratify the participants into groups to determine differences between or among those

groups. Consequently, the correlational approach is appropriate for the study because the

focus is to investigate the potential correlation between the variables are opposed to cause

and effect. Furthermore, a correlational research design allows the examination of the

strength of correlation between variables. Consequently, this research investigated the

strength of the correlation between internalization of the Strong Black Woman schema

and attitudes toward mental health help-seeking on an individual level based on the

survey responses from Black women in the Southern region of the United States who

agreed to participate in the study.

Population and Sample Selection

The population of interest for this proposed study is Black women ages 18-65 in

the United States and the target population of this proposed study is Black women

associated with the non-profit that has granted site authorization. Further, the sample

required a minimum of 84 Black women ages 18-65 based on a G*Power Sample size

calculation found in Appendix E. The G*Power parameters were set to provide statistical

power equal to 80 percent to detect a medium-strength effect in the population (𝜌= .30)

using a significance level of α = .05. At the end of the study there were 153 participants.

A G*Power a post hoc analysis detected statistical power equal to .97 with a medium-

strength effect in the population (f = .30) using a significance level of α = .05 with this

sample size. Other quantitative studies investigating the Strong Black Woman schema

have utilized comparable sample sizes. Donovan and West (2015) utilized a sample of 92

participants to investigate the role of the Strong Black Woman schema and stress.

Additionally, Watson and Hunter (2015) utilized 95 participants to determine the

correlation between the Strong Black Woman schema and anxiety.

All Black female participants between ages 18-65 were recruited to participate in

the research through the non-profit organization located in Tennessee that granted site

authorization. The non-profit educates and inspires over 300 women to create change in

their communities. To obtain site authorization, the researcher emailed the director of the

nonprofit a summary of the proposed research topic and ask for permission for site

authorization to ask if surveys flyers could be put up onsite asking for participants. As a

result, the director approved this and drafted a site authorization letter granting the

researcher access to post flyers at the site.

As a result of the process, the sample of Black women who agreed to participate

in the study were deemed a volunteer sample. Unlike probability sampling procedures

(e.g., simple random sampling), which produces a sample that can be assumed to be

representative of the population from which the sample was drawn (at least if the sample

is relatively large), non-probability sampling suffers from the disadvantage of producing

a sample that cannot be assumed to be equivalent to the population from which the

sample was drawn (Landers & Behrend, 2015). Consequently, the population or

populations to which results can be generalized must be defined after the fact. This fact

constrains the external validity of the findings and the degree to which study findings can

be generalized to the intended population. However, the characteristics of the sample will

describe the characteristics of the population to which findings can be generalized

(Etikan, Musa, & Alkassim, 2016). In the present study, the population to which findings

were generalized was Black women aged 18-65 in the Southern region of the United

States based on those who were willing to participate in a research study regarding the

Strong Black Woman schema and attitudes toward mental health help-seeking.

To ensure that participants’ rights as human subjects were protected, the proposed

study protocol and materials were reviewed and approved by the Grand Canyon

University Institutional Review Board (IRB) before any data collection began. The IRB

approval letter is included as Appendix B in the dissertation. The online survey, into

which participants received an email invitation to participate, began with an informed

consent document as seen in Appendix C. Only participants who agreed to the terms of

the informed consent by checking the appropriate box at the end of the document were

allowed to proceed to the rest of the survey where data were collected on demographic

characteristics, internalization of the Strong Black Woman schema, and attitudes toward

mental health help-seeking.

Participation in the study was entirely voluntary and participants were free to

discontinue their participation at any time without penalty of any kind by clicking the exit

button at the top of the survey. Additionally, no data were collected that could be used to

identify individual participants. Although SurveyMonkey can collect the IP addresses of

respondents, this feature was turned off to ensure that respondents have complete

anonymity. Data collected for this study will be stored for a minimum of three years on

an independent USB flash drive in a secure location that is accessible only to the

researcher. The flash drive will be physically destroyed following the end of that three-

year period.

Instrumentation

The survey that was used in this study began with the informed consent statement

and demographics. The remaining sections of the survey consisted of the latest, 30-item

version of the Strong Black Woman Attitudes Scale developed in 2003 by Thompson and

revised by Green in 2011 (Appendix D) as well as the 24-item version of the Inventory of

Attitudes Toward Seeking Mental Health Services by Mackenzie et al., in 2004

(Appendix D). Permission to use the Strong Black Woman Attitudes Scale was obtained

from Dr. Brandeis Green, on March 16, 2017. This letter of permission for use can be

found in Appendix D. No permission is required to use the Inventory of Attitudes Toward

Mental Health Services and a copy of this scale denoting no permission for use can be

found in Appendix D.

Responses for the Strong Black Woman Attitudes Scale are measured on a Likert

scale, ranging from 1 (Never) to 5 (Almost always). Higher scores indicate greater

identification with this coping style. Items include statements such as ―It pleases me

when others give me feedback that they see me as strong, and ―People think I am strong.

Factor analysis has revealed three subscales: self-reliance, caretaking, and affect

regulation (Green, 2012; Thompson, 2003). Additionally, total scores can be obtained for

the entire scale or for the subscales alone. The original author, Thompson (2003), found

adequate internal consistency for the scale, as measured by Cronbach’s alphas: α= .74,

for the total scale and the three subscales were caretaking α =.66, affect regulation α =.72,

and self-reliance α =.60. After revision, Green (2012) also found adequate internal

consistency: α = .80 for the total scale, and the three subscales of caretaking α =.64, affect

regulation α =.78 and self-reliance α =.82.

The Inventory of Attitudes Toward Mental Health Services is a 24-item scale and

has three internally consistent factors: psychological openness, help-seeking propensity,

and indifference to stigma (Mackenzie et al., 2004). Response options range from 0

(“Somewhat Disagree”) to 4 (“Agree”). Internal consistency reliability coefficients for

the overall measure and the subscales have been found to be strong with Cronbach’s

alphas of α = .82 for psychological openness, α =.76 for help-seeking propensity and α

=.79 for indifference to stigma (Mackenzie et al., 2004) and Mackenzie et al. (2006)

reported that the Inventory of Attitudes Toward Mental Health Services demonstrated

good convergent validity. Participants are asked to indicate which response best

represents their level of agreement with statements such as, “Important people in my life

would think less of me if they were to find out that I was experiencing psychological

problems.”

Ultimately, both scales of measurement produce results from the use of Likert-

type rating scales which was described by Likert (1932) as summative response data

because of his belief that it is rational to obtain an individual’s total scale score by adding

the ratings from subscale scores. However, data obtained using Likert scales are

continuously debated. Dawes (2008) argued that the data from rating scales are ordinal

since there is no way to determine with certainty that equal rating differences (e.g., the

difference between a rating of 1 and 2 or between 4 and 5). Conversely, Meyers, Gamst,

and Guarino (2013) summarized the argument by noting that, “…the vast majority of

research published in the behavioral and social sciences over the past half century or

more has used summative response scales as though they met interval properties. In our

view, this treatment of summative response scales is acceptable, appropriate, and quite

useful” (p. 23). Although the argument of regarding the treatment of Likert scale data is

ongoing, the present research will treat the data produced by the Strong Black Woman

Attitudes Scale and the Inventory of Attitudes Toward Seeking Mental Health Services as

interval scale data.

Validity

Hammersley (2008) noted that a study’s validity springs from three sources: (a)

Validity of the measures (i.e., construct validity, the degree to which study instruments

measure the constructs that are claimed); (b) internal validity (i.e., the degree to which

observed causal effects can be unambiguously attributed to the predictor variable whose

effects are being evaluated); and (c) external validity (i.e., the degree to which the study’s

findings can be generalized to other people, places, and times. Elmore (2010) noted that

validity does not reside in the results of a study but rather in the researcher’s

interpretation of those results. Further, Elmore (2010) asserted that researchers who

provide evidence of validity strengthen their arguments and rule out potential confounds.

Consequently, the validity of the measures and external validity must be discussed.

The Inventory of Attitudes Toward Mental Health Services initially included 41-

items, however the authors reduced the number of items in the scale to 24 because of the

results an exploratory factor analysis (EFA) using maximum likelihood estimation among

a sample of 208 adult volunteers (Mackenzie et al., 2004). Mackenzie et al. (2004)

reported validity analyses for both a community sample as well as a replication sample.

The reliability for the community sample was reported as r =.33. Reliability for the

replication sample was reported as r =.21.

Recently, Hyland et al. (2015), investigated the construct validity and concurrent

validity of the IASMHS. The results found of their study provided further support for the

construct validity of the scale. All items of the IASMHS displayed statistically significant

factor loadings greater than .30 on each of the respective of the latent factors when

analyzed by Hyland et al. (2015). Thompson (2003) reported the construct validity of the

Strong Black Woman Attitudes Scale as r =.37. Similarly, Green (2012) reported a

construct validity of r =.41.

Reliability

Yilmaz (2013) asserted that reliability means consistency or the degree to which a

research instrument measures a given variable consistently every time it is used under the

same condition with the same subjects. One way to determine if the scores on an

instrument are stable over repeated assessments than to administer the instrument once,

wait an appropriate period, administer the instrument again to the same individuals, and

then evaluate the consistency of the two sets of scores using a correlation or other

measure of score agreement. That methodology, whether used with the same form of the

instrument or alternative forms, is called test-retest reliability (Miller, Lovler, &

McIntire, 2013).

No reports of the test-retest reliability of the Strong Black Woman Attitudes Scale

nor the Inventory of Attitudes Toward Mental Health Services were found in the

literature. However, the Cronbach’s alpha coefficients for both instrument’s subscales

have been reported by several authors (Green, 2012; Hyland et al., 2015; Mackenzie et

al., 2004; Thompson, 2003). Each measurement has consistently been associated with

alpha coefficient values ranging from α = .64 to α =.82. It is important to note that the

care-taking subscale of the Strong Black Woman Attitudes Scale has consistently scored

in the questionable range according to Cronbach’s alpha. Consequently, this lowers the

generalizability of the results regarding the caretaking subscale.

Data Collection and Management

The population for this study included all Black women aged 18-65 in the United

States. The target population consisted of Black women aged 18-65 in the Southern

region of the United States. The site authorization letter can be found in Appendix A. The

sample was comprised of 153 participants associated with the authorized site. To ensure

that participant’s rights as human subjects were protected, the study protocol and

materials were reviewed and approved by the Grand Canyon University Institutional

Review Board before any data collection began. That Institutional Review Board

approval letter is included as Appendix B.

To collect data, the researcher recruited participants from a non-profit site that

educates and inspires women to create change in their communities. One week before the

start of data collection, the researcher posted recruitment flyers at the non-profit with the

requirements for participation and contact information of the researcher. Additionally, the

researcher emailed the contact at the site and asked her to send the flyer to her clients.

Therefore, the researcher did not have personal contact with the organization’s client list

unless the individuals were interested and decided to pursue completing the survey on

their own. One day following the initial email invitation to participate in the study, a

second email was sent to all participants who expressed interest to encourage those who

had not yet completed the survey to do so and to thank those who already completed the

survey. Three days later, the response rate was examined, and it was determined that the

minimum sample size had been achieved and surpassed. As a result of the sample size

requirement being achieved, the survey was closed for responses and data were exported

to SPSS. The researcher utilized listwise deletion to remove participants survey data with

missing values to prepare the data file for analysis, as described in the next section of this

chapter.

Only participants who agreed to the terms of the informed consent were able to

proceed to the remainder of the survey containing demographic information, the Strong

Black Woman Attitudes Scale and Inventory of Attitudes Toward Seeking Mental Health

Services. Those who declined the prompts for consent were directed to a message that

invited them to return to the study URL if they decided later that they would like to

participate. Participation in the study was entirely voluntary and participants were free to

discontinue their participation at any time without penalty of any kind. Once consent was

obtained, the women were directed to continue to the survey instruments.

The data were collected and stored on SurveyMonkey, a professional survey site.

No data were collected that could be used to identify individual participants. Although

SurveyMonkey can collect the IP addresses of respondents, this feature was turned off to

ensure that respondents have complete anonymity. Data collected for this study will be

stored for a minimum of three years on an independent USB flash drive in a secure

location that is accessible only to the researcher. The flash drive will be physically

destroyed following the end of that three-year period.

Data Analysis Procedures

It was not known if, and to what extent, there were statistically significant

correlations between the internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking. A quantitative correlational design framed this

research. The tool, IBM SPSS (version 24), analyzed the data received from Strong Black

Woman Attitudes Scale survey and data received from the Inventory of Attitudes Toward

Mental Health Services by running multiple statistical test that determined the

appropriate correlation test to determine statistical significance of the variables (Prion &

Haerling, 2014). The Likert-scaled responses collected from these two instruments were

used to conduct correlation tests between variables. The internalization of the Strong

Black Woman schema was calculated by determining the mean of each of the scores from

the scale. The total scale score for attitude toward seeking mental health services was

calculated by determining the mean of each of the scores from the scale. The mean score

was determined for psychological openness subscale items 1,4,7,9,12,14,18, and 21.

Scores for the help-seeking propensity subscale were calculated for each item by

determining the mean of participant’s ratings to items 2,5,8,10,13,15,19, and 22. Scores

for the indifference to stigma subscale were calculated by determining the mean of

participant’s ratings to items 3,6,11,16,17,20,23, and 24. Each instrument was

psychometrically valid and reliable. Score reporting followed the strict adherence to the

design and reporting of values from the psychometric data provided by the authors of the

instruments.

The findings could show either a positive, negative or a null correlation between

internalization of the Strong Black Woman schema and attitudes toward mental health

help-seeking. The Strong Black Woman Attitudes Scale measured the internalization of

the Strong Black Woman schema. Higher scores on the Strong Black Woman Attitudes

Scale indicated greater internalization of the schema. For the purposes of the Inventory of

Attitudes Toward Mental Health Services, higher scores indicated positive attitudes

toward mental health services, whereas lower scores showed lower positive attitudes

toward mental health services.

Each research question was tested independently to investigate the statistically

significant findings of Black women in this study. The data collected from the

participants determined what type of statistical tests to calculate. Nonparametric

(Spearman’s rho) correlation testing was justified according to its respective assumptions.

This was completed in IBM SPSS (version 24). Shapiro-Wilk Test of Normality,

histograms, and box and whisker plots were conducted to determine the linearity,

monotonicity, normal distribution of data, and if any outliers were present.

Spearman’s rho correlation tests were determined to be the accurate statistical

tests to determine correlations of the variables of this study. Spearman’s rho correlational

analysis is a measure of the relationship and direction of association between two ranked

variables (Hauke & Kossowski, 2011). Analysis using Spearman’s rho correlation

requires the researcher to make assumptions. The first assumption is that the variables are

ordinal, interval or ratio scale. The second assumption is that the assumptions of the

Pearson correlation are violated (Green & Salkind, 2008).

The following research questions and hypotheses were stated as a framework for

this study:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking?

H10: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

H1a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

H20: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

H2a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

H30: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

H3a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

H40: There is not a statistically significant correlation between the internalization of

the Strong Black Woman schema and indifference to stigma.

H4a: There is a statistically significant correlation between the internalization of the

Strong Black Woman schema and indifference to stigma.

To test the hypotheses presented in this study, survey data from a volunteer

sample of all 153 Black women who agreed to participate in the research was used. The

data needed to address the four research questions came from participant's individual

survey responses. These responses included an indication of each respondent’s

internalization of the Strong Black Woman schema thus representing the level of the

interval predictor variable represented by that case. In addition, the survey provided

participant’s responses to the Inventory of Attitudes toward Seeking Mental Health

Services, from which scores on the 3 dimensions of help-seeking were calculated:

psychological openness, help-seeking propensity, and indifference to stigma. These 3

dimensions that comprised attitudes toward mental health help-seeking served as the

interval criterion variables in analyses that answered the research questions. Additional

data on participant’s demographics supported analyses designed to describe the sample.

Except for power analysis, which was completed using G*Power software, all

data analyses were completed using IBM Statistical Package for the Social Sciences

(SPSS) statistical software. In all analyses, missing data were handled by using listwise

deletion of cases with missing data, i.e., if a participant was missing a score on any of the

variables involved in an analysis, that case was excluded entirely from the analysis. The

statistical tests in IBM SPSS (version 24) that included Shapiro-Wilk Test of Normality,

histograms, box and whisker plots, and correlation tests visually represented the data

collected to describe the statistically significant correlations present between the variable

of internalization of the Strong Black Woman schema with each variable of attitudes

toward mental health help-seeking.

Following the testing for normalcy and linearity, the appropriate correlational

testing, done in IBM SPSS (version 24), determined the coefficient of correlation, the R2

value and the corresponding p-value. Shapiro-Wilk Test of Normality, histograms, and

box and whisker plots also determined if there were no significant outliers and the

monotonicity of the data collected. Various demographics were collected and included

age, relationship status, and educational attainment.

As an initial step for data analysis, scatterplots were conducted first using the

IBM SPSS (version 24), commercial software program. Sainani (2013) reported that for

researchers to understand fully their data points without error, the first step in data

analysis was to create Shapiro-Wilk Test of Normality, histograms, and box and whisker

plots for each variable that determined if there were any outliers or wild data points when

analyzing all data points. Conducting this step first in the data analysis procedures was

needed to satisfy the correlation test assumption of not having outliers. Analyzing the

scatter plots determined whether the parametric Pearson, multiple linear regression

modeling, or the nonparametric Spearman’s rho correlation tests was the more

appropriate. Once the assumptions for the appropriate correlation tests were satisfied

correlation tests were conducted on the data collected on the Black women in this

research. Completing the IBM SPSS (version 24) correlation modeling determined the

presence of statistically significant correlations between variables. Computing the

strength of the correlations from the correlational models by the reporting of the

coefficient along with the significance of the correlation as measured by the p-value were

the statistical tests followed. Utilizing the function of the bivariate tests on IBM SPSS

(version 24), there was a comparison of the correlation strength and the direction between

data points from the Strong Black Woman Attitudes Scale and the Inventory of Attitudes

Toward Mental Health Services.

In this study, the correlation analyses measured the strength of the correlation

between the variables, and the statistical significance of the relationship. The study

followed the direction of Gay, Mills, and Airasian (2009) view of correlation coefficients,

r, vary from 0 (no relationship) to 1 (perfect linear relationship) or -1 (perfect negative

linear relationship). Following the hypotheses, if correlations are statistically significant (

p <0.05) the results reject the null hypothesis. On the contrary, if correlations are not

significant (p >.05), then the results fail to reject the null hypothesis. The G*Power

analysis provided in Appendix E shows that the sample size would be adequate to support

the analysis if the projected sample size and response rate was achieved. A total sample

size of 84 cases was needed to provide statistical power equal to 80 percent to detect a

medium-strength effect in the population (𝜌 = .30) using a significance level of α = .05.

Ethical Considerations

Few ethical challenges rose from the research. The researcher acquired proper

Institutional Review Board review and complied with specific consent requirements to

maintain the integrity of the study and reduce ethical concerns. The Institutional Review

Board approval letter is attached as Appendix B to the dissertation. To further ensure the

ethical procedures, this research complied with the basic principles of the Belmont

Report.

One principle of the Belmont report is the respect of persons. Thus, informed

consent was obtained before the participant could answer any survey questions.

Additionally, participation in the study was entirely voluntary and participants were free

to skip questions that they did not want to answer or to withdraw from the study entirely

at any point with no negative consequences. Another principle of the Belmont Report is

beneficence. Although SurveyMonkey can collect respondents’ IP addresses, this feature

was turned off. Additionally, in the reporting of results, data were aggregated and no

information from any single respondent was presented. As a result of this protection,

participants in the study did not risk having personal information exposed. Further, the

final principle of the Belmont Report, justice, was addressed using adults who volunteer

participation.

Lastly, there is always a risk of loss of confidentiality when information is

transmitted electronically, but confidentiality was protected to the greatest extent

possible. SurveyMonkey is an established survey engine platform with state-of-the-art

security features. Data collected for this study will be stored for three years on an

independent USB flash drive in a secure location that is accessible only to the researcher.

The flash drive will be physically destroyed following the end of the three-year period.

Limitations and Delimitations

As with any empirical study, there were limitations and delimitations of this

dissertation study. A limitation is a potential weakness of the study that is out of the

researcher’s control while delimitations are choices made by the researcher about the

study.

This research had the following limitations:

1. Sampling by volunteer means that study participants are self-selected and thus there are no guarantees that the resulting samples will be representative of the

target populations.

2. Self-rating surveys will be used to collect data. There is no way to verify that self-rated responses are accurate.

3. Correlational research can determine relationships; however, it cannot imply causation (Yilmaz, 2013). As a result, exploring the correlation between the

Strong Black Woman schema and attitudes toward mental health help-seeking

will not indicate if one variable is the cause of another.

4. The reliability coefficients for the Inventory of Attitudes Toward Seeking Mental Health Services instrument ranged from poor to acceptable. As a

result, caution must be exercised when generalizing the findings.

5. Data were collected from participants in one geographical location which also limits the generalizability of the findings.

One limitation in the study was that the assessments used are self-rated. While

self-rating is common on quantitative instruments (Meyers et al., 2013), it presents

limitations as the study participants may not rate themselves honestly and accurately. A

strategy that can be used to mitigate this limitation is to ensure participants that their

information will be kept confidential in attempts to increase participant honesty and

accuracy in their ratings. Another limitation was that those who agreed to participate in

the study likely have a higher interest in the Strong Black Woman schema and mental

health help-seeking. As a result, this may have provided a set of responses that do not

represent the entire target population including those with a lower level of interest in the

topic. However, the researcher anticipated that individuals would be honest on the

measurements due to their expressed interest in the topic of internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking. Additionally, the

low reliability coefficients for the Inventory of Attitudes Toward Mental Health Services

instrument and use of a single geographical region limited the generalizability of the

study’s results.

The following delimitations were present in this study:

1. Because the purpose of this research is to determine if and to what extent a correlation existed between the variables, the researcher will be collecting

only quantitative data. This delimitation prohibited the collection of

qualitative information that might have broadened the scope and increased the

depth if a mixed method approach had been selected.

2. This research will use of a volunteer sample from one geographic region. This sample may not be representative of Black women in other regions of the

Unites States of America.

3. Access to the internet is necessary to participate in this study. Although this method of data collection may be more convenient regarding time and

distance, those without internet access must travel to a place with access to

participate.

One delimitation of this study was that volunteer sampling is being considered for

use. Since this study included measurements that self-rated, the researcher wanted to

ensure that those who participated were interested in the study to increase the likelihood

of accurate responses. Another delimitation was that the survey will be administered

online. This limited participation to those who had access to internet. The researcher

chose to use an online assessment method to increase the convenience and efficiency for

those not near the researcher. To mitigate the effects of this delimitation, the researcher

provided a list of places with internet access to the director of the site that provided

authorization for the study. However, considering that computers are available in many

schools and libraries, the researcher felt that the survey was accessible to most of the

target population. The location of the study was also a delimitation. The researcher

considered using a larger sample area to include individuals from all states in the United

States but due to the infeasibility of this concept the researcher rejected this

consideration. The researcher felt that keeping the sample size to a single region allows

for analysis among those in the sample. However, that means that caution should be

exercised when trying to generalize findings from the study outside of the region in

which it was completed.

Summary

Although mental health help-seeking has been explored in a variety of contexts,

there is a dearth of research regarding the cultural schema of the Strong Black Woman

and mental health help-seeking. Given the underutilization of mental health services in

the Black community, it is important that the study of mental health help-seeking be

examined in this population (Watson & Hunter, 2015). The purpose of this quantitative,

correlational research study was to determine if and to what extent a correlation existed

between the internalization of the Strong Black Woman schema and attitudes toward

mental health help-seeking in 84 Black women aged 18-65 in the Southern region of the

United States. To determine if a correlation was present, the researcher utilized a

quantitative methodology with a correlational design. As a result of seeking to determine

a correlation between two variables a quantitative methodology was appropriate

(McCusker & Gunaydin, 2015). Since the research questions were designed to determine

the correlation between the two variables without any manipulation from the researcher, a

correlational design was best (Curtis et al., 2016)

In the research design, the non-manipulated, interval scale predictor variable was

internalization of the Strong Black Woman schema. Samples of Black women provided

data on attitudes toward mental health help-seeking, the interval scale criterion variables.

The study used two measurements to gather data for analysis from a volunteer sample of

84 Black women ages 18-65. The measurements included the Strong Black Woman

Attitudes Scale (Green, 2012) which was proven to be reliable and valid (Green, 2012;

Thompson, 2003), as well as the Inventory of Attitudes Toward Seeking Mental Health

Services (Mackenzie et al., 2004) which was also proven to be reliable and valid (Hyland

et al., 2015). Additionally, questions pertaining to demographics were asked. Further,

maintaining strong ethical considerations and protections for the participants, such as

guaranteeing anonymity and safeguarding all data on a USB drive for three years within a

fire-proof safe only accessible to the researcher, met necessary IRB requirements.

The correlation between the dimensions of both measurements were analyzed

using Spearman’s rho correlation. Spearman’s rho correlation is appropriate for use when

data is ordinal, interval, or ratio (Schmid & Schmidt, 2007). Statistics from the analysis

quantified the strength and direction of the correlation between internalization of the

schema and attitudes toward mental health help-seeking. The results of the analyses are

presented in Chapter 4. Findings were explained in order of hypotheses before Chapter 4

concludes with a summary. Chapter 5 provides a thorough discussion of the data and

explains its implications for future research.

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Chapter 4: Data Analysis and Results

Introduction

The purpose of this quantitative correlational study was to determine if, and to

what extent, a correlation existed between the internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking in Black women aged 18-65 in

the Southern region of the United States. Additionally, the researcher assessed the

correlation between the Strong Black Woman schema and attitudes toward mental health

help-seeking along each of the Inventory of Attitudes Toward Mental Health Services

subscales.

Chapter 4 outlines the descriptive data of the Black female participants, and the

significant correlations found between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking. Correlation tests determined the

statistically significant correlations found between variables. This quantitative

correlational research supports the following four specific research questions with

corresponding null and alternative hypotheses:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking?

H01: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

H1: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

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RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

H02: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

H2: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

H03: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

H3: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

H04: There is not a statistically significant correlation between the internalization of

the Strong Black Woman schema and indifference to stigma.

H4: There is a statistically significant correlation between the internalization of the

Strong Black Woman schema and indifference to stigma.

Chapter 4 is organized by a discussion of the sample demographics, reliability analysis,

descriptive statistics, data screening, research question/hypothesis testing, and

conclusions. Data were analyzed with SPSS 24 for Windows.

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Descriptive Findings

This research study evaluated the statistical significant relationships between the

variables of internalization of the Strong Black Woman schema and attitudes toward

mental health help-seeking, psychological openness, help-seeking propensity, and

indifference to stigma in Black women ages 18-65 in the southern region of the United

States. As outlined in Chapter 3, the minimum sample size computed by G*Power for

completing a correlation bivariate normal model exact test with a statistical significance,

power of .80 and an effect size of .30, produced a calculation of 84 as the minimum

sample size (see Appendix E). 153 Black women participated in the study. Over the

course of data collection, the sample size increased from the minimum requirement of 84

a priori to a total participant count of 153 Black women. Once the sample size was

determined to be a sufficient number to begin data analysis, post hoc G*Power analysis

was computed to determine the statistical power of the sample size and was reported a

power at .97 with an alpha at .05 (see Appendix E).

The online informed consent document was embedded within the online survey

provided to participants. By taking the survey, the participants were made aware they

gave their permission for the data collected to be reported in this research (see Appendix

C). Black women who responded to the survey were provided a randomized respondent

number via Survey Monkey settings. All participation in the study was voluntary, and at

any time, participants were given the ability to cancel the survey responses. Participants

were also given the ability to skip answers and the questions were not obligatory due to

the informed consent protocols. Before any final submission of the survey, the participant

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had an opportunity to review, delete, or change their responses. Once data collection

closed, all data was transferred to IBM SPSS (versions 24).

After transferring data points to IBM SPSS (version 24) and completing listwise

deletion of missing data, all randomly assigned participant numbers were removed from

the downloaded Excel file. This deletion made it so that even the assigned number was no

longer accessible when computing the data analysis charts in IBM SPSS (version 24) and

no participants could be traced. After all data was cleaned, descriptive statistics were

computed. The following descriptive statistics will detail the demographic data collected

from the 153 Black women participants.

The sample consisted of 153 Black/African American females ranging from 18-64

years of age. Half of the sample (50.3%, n = 77) was 25-34 years of age; 29.4% (n = 45)

were 35-44; and 9.8% (n = 15) were 45-54 years of age. Age group is provided in Table

Table 3.

Age Group

Age n % Cumulative %

18-24 14 9.2 9.2

25-34 77 50.3 59.5

35-44 45 29.4 88.9

45-54 15 9.8 98.7

55-64 2 1.3 100.0

Total 153 100.0

Most females (56.9%, n = 87) were either single or divorced. The remaining

43.1% (n = 66) were either married or in a relationship. Marital status is presented in

Table 4.

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Table 4.

Marital Status

Marital Status n %

Single 69 45.1

Married 48 31.4

Divorced 18 11.8

In a relationship 18 11.8

Total 153 100.0

The sample was highly educated. Most of the participants (88.2%, n = 135) had a

college degree, which ranged from an associate degree to a graduate degree. More than

half (60.8%, n = 93) had graduate degrees. Females with only a high school diploma or

equivalent were in the educational minority (3.9%, n = 6). Level of education for the

sample is presented in Table 5.

Table 5.

Education Level

Education n % Cumulative %

High school or equivalent 6 3.9 3.9

Some college, no degree 12 7.8 11.8

Associate degree 6 3.9 15.7

Bachelor’s degree 36 23.5 39.2

Graduate degree 93 60.8 100.0

Total 153 100.0

Slightly more than half of the respondents (53.6%, n = 82) reported household

incomes of $50,000 or higher. The top 15.7% (n = 24) had household incomes of

$100,000 or more. Household income is presented in Table 6.

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Table 6.

Household Income

Income n % Cumulative %

$0-$24,999 18 11.8 11.8

$25,000-$49,999 53 34.6 46.4

$50,000-$74,999 38 24.8 71.2

$75,000-$99,999 20 13.1 84.3

$100,000-$124,999 8 5.2 89.5

$125,000-$149,999 5 3.3 92.8

$150,000-$174,999 5 3.3 96.1

$175,000-$199,999 4 2.6 98.7

$200,000 and up 2 1.3 100.0

Total 153 100.0

Descriptive Statistics

Scores for the variables of interest were computed by calculating the mean

responses for the items corresponding to the variable or subscale. Responses for the

Strong Black Woman Attitudes Scale are measured on a Likert scale, ranging from 0

(Never) to 4 (Almost always). Higher scores indicate greater identification with this

coping style. Therefore, the possible range of scores was 0 to 4. For the sample, scores

ranged from 1.67 to 3.87 (M = 2.71, SD = 0.49). Responses on the Inventory of Attitudes

Toward Seeking Mental Health Services range from 0 (“Somewhat Disagree”) to 4

(“Agree”). Therefore, the possible range of scores was also 0 to 4. For attitudes toward

help-seeking, for instance, scores ranged from 0.79 to 3.38 (M = 1.79, SD = 0.37).

Descriptive statistics are presented in Table 7.

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Table 7.

Descriptive Statistics

Variable Minimum Maximum M SD

Internalization of the Strong Black Woman Schema 1.67 3.87 2.71 0.49

Attitudes Toward Help-Seeking 0.79 3.38 1.79 0.37

Psychological Openness 0.38 4.00 1.53 0.58

Help-Seeking Propensity 0.13 3.00 2.15 0.63

Indifference to Stigma 0.13 3.13 1.71 0.43

As aforementioned, both surveys had Likert type items ranging from 0 to 4.

According to the Inventory of Attitudes Toward Mental Health Help-Seeking higher

scores indicate more positive attitudes while lower scores indicate less positive attitudes

(Mackenzie et al, 2004). Additionally, higher scores on the Strong Black Woman

Attitudes Scale indicate greater internalization while lower scores indicate lower

internalization (Green, 2012).

The minimum score for internalization of the Strong Black Woman schema was

46 while the maximum was 82. Figure 1 shows that the participants of this study

generally indicated greater internalization of the Strong Black Woman schema. For this

sample the mean score for internalization of the Strong Black Woman schema was 59.92.

However, none of the participants reported very low or very high internalization of the

schema.

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Figure 1. Internalization of the strong Black woman schema.

Regarding overall attitudes toward mental health help-seeking the minimum score

reported was 17 while the maximum score reported was 83. Figure 2 shows that

participants reported generally positive attitudes toward seeking mental health help. The

mean score reported was 42.59. However, none of the participants were classified as

having very low or very highly positive attitudes toward mental health help-seeking.

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Figure 2. Black/African American females’ attitudes toward mental health help-seeking.

Regarding psychological openness, the distribution of scores were varied. The

lowest reported score was 3 while the highest reported score was 32. The mean reported

score was 12.24. The complete distribution of scores are presented in Figure 3.

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Figure 3. The psychological openness of Black/African American females.

Participants reported varying degrees of help-seeking propensity. The minimum

reported score was 1 while the maximum reported score was 24. The mean score was

17.12. None of the respondents indicated possessing very high help-seeking propensity.

See Figure 4.

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Figure 4. The help-seeking propensity of Black/African American females.

Like help-seeking propensity, participants reported varying degrees of

indifference to stigma. The minimum reported score was 3 while the maximum reported

score was 27. The mean score was 13.24. None of the respondents indicated very high

indifference as illustrated in Figure 5.

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Figure 5. The indifference to stigma of Black/African American females.

Data Analysis Procedures

All data analyzed were aligned with the research questions posed in this study. To

report accurate correlations, research supported the use of a guideline for interpreting the

correlation coefficients present within findings (Fitzgerald, Rumrill, & Schenker, 2004).

Data collected from the demographics, Strong Black Woman Attitudes Scale, and the

Inventory of Attitudes Toward Mental Health Services were used for analysis. Analysis

using Pearson’s correlational coefficient requires the researcher to make three

assumptions. The first assumption is that the variables have a continuous measurement

level. The second assumption is that the variables are normally distributed. The third

assumption is that there is a linear correlation between variable (Green & Salkind, 2008).

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However, if data does not meet these assumptions then an alternative analysis must be

used.

First, the continuous data, not the categorical data, were screened for normality

with the Shapiro-Wilk Test of Normality, histograms, and box and whisker plots as

warranted. The Shapiro-Wilk Test of Normality is the most powerful normality test

(Razali & Wah, 2011). When p < .05 for the Shapiro-Wilk Test of Normality, the data are

not normally distributed. The distribution was normal for the internalization of the strong

Black woman schema, p = .104. However, the distributions were not normal for the other

variables of interest. The Shapiro Wilk Test of Normality results are presented in Table 8.

Table 8.

Shapiro-Wilk Normality Test Results

Variables Statistic df p

Internalization of the Strong Black Woman Schema .985 153 .104

Attitude Toward Mental Health Help Seeking .965 153 .001

Psychological Openness .928 153 .000

Help-Seeking Propensity .936 153 .000

Indifference to Stigma .968 153 .001

A graphical representation of the distribution for the internalization of the strong

Black woman schema illustrated that the distribution approximated normality. See Figure

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Figure 6. Normal histogram for internalization of the strong Black woman schema.

The distribution for attitude toward mental health help seeking was not normal

according to the Shapiro-Wilk Test of Normality, p = .001. However, a visual inspection

of the histogram appeared to be normal. See Figure 7.

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Figure 7. Histogram for attitude toward mental health help-seeking.

There appeared to be outliers in the distribution for attitude toward mental health

help-seeking. This was confirmed by generating a box and whisker plot for the data.

Three statistical outliers were observed; one ≤ 0.79 and two ≥ 3.08. See Figure 8.

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Figure 8. Box and whisker plot for attitude toward mental health help-seeking.

The distribution for psychological openness was not normal according to the

Shapiro-Wilk Test of Normality, p < .001. A visual inspection of the histogram suggested

that the distribution was slightly skewed to the right, which means that it had a positive

skew. The histogram for psychological openness is presented in Figure 9.

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Figure 9. Histogram for psychological openness.

There appeared to be outliers in the distribution for psychological openness. Four

statistical outliers were observed; ≥ 3.3. A box and whisker plot for psychological

openness is illustrated in Figure 10.

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Figure 10. Box and whisker plot for psychological openness.

The distribution for help-seeking propensity was not normal according to the

Shapiro-Wilk Test of Normality, p < .001. A visual inspection of the histogram suggested

that the distribution was skewed to the left, which means that it had a negative skew. The

histogram for psychological openness is presented in Figure 11.

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Figure 11. Histogram for help-seeking propensity.

There appeared to an outlier in the distribution for help-seeking propensity. One

statistical outlier was confirmed; ≤ 0.1. A box and whisker plot for help-seeking

propensity is illustrated in Figure 12.

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Figure 12. Box and whisker plot for help-seeking propensity.

The distribution for indifference to stigma was not normal according to the

Shapiro-Wilk Test of Normality, p = .001. However, a visual inspection of the histogram

appeared to be normal. See Figure 13.

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Figure 13. Histogram for indifference to stigma.

There appeared to be outliers on both ends of the distribution for indifference to

stigma. Fourteen statistical outliers were confirmed; six ≤ 0.88 and eight ≥ 2.50. A box

and whisker plot for indifference to stigma is illustrated in Figure 14.

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Figure 14. Box and whisker plot for indifference to stigma.

Various methods to exclude statistical outliers were conducted. It was not possible

to exclude every statistical outlier because that would have left only two cases. Moreover,

most (4 out of 5) of the variables originated from one instrument, the IASMHS.

Therefore, excluding some outliers for one variable caused others to have outliers. In

addition, two of the variables; psychological openness and indifference to stigma had

unacceptable reliability. After tests of normality were conducted it was determined that

the data did not meet the assumptions to utilize Pearson’s correlation. As a result,

utilizing Spearman’s rho was necessary for the analyses to proceed as planned.

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Instrument Reliability for the Sample

Instrument reliability for the sample was tested with Cronbach’s alpha. For the

internalization of the Strong Black Woman schema, the reliability was good (α = .88),

which was higher than what was reported by the original author Thompson (2003), who

reported an alpha of .74. However, for attitudes toward help seeking, the reliability was

poor (α = .59) for the current study based on generally accepted criteria (DeVellis, 2012).

For the subscales on the Inventory of Attitudes Toward Seeking Mental Health Services

(IASMHS) scale, the internal consistency ranged from .09 for indifference to stigma to

.76 for help-seeking propensity. Internal consistency coefficients for the Inventory of

Attitudes Toward Seeking Mental Health Services subscales were reported to be good

with Cronbach’s alphas of .82 (psychological openness), .76 (help-seeking propensity)

and .79 (indifference to stigma) with an overall internal consistency of .87 (Mackenzie et

al., 2004). Thus, for help-seeking propensity, the reliability for the sample (α = .76) was

consistent with what was reported in the literature (α = .76). Reliability coefficients for

the variables of interest are presented in Table 9.

Table 9.

Reliability Coefficients

Variable Cronbach’s alpha for

Sample

Interpretation for

Sample

Value Reported in

Literature

Internalization of the Strong Black

Woman Schema

.875 Good .74 (Thompson,

2003)

Attitudes Toward Help-Seeking .587 Poor .87 (Mackenzie et

al., 2004)

Psychological Openness .372 Unacceptable .82 (Mackenzie et

al., 2004)

Help-Seeking Propensity .756 Acceptable .76 (Mackenzie et

al., 2004)

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Indifference to Stigma .094 Unacceptable .79 (Mackenzie et

al., 2004)

After screening for normality and determining reliability coefficients, the analyses

proceeded as planned. Bivariate correlations using Spearman’s rho were used to explore

correlations between the study variables of internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking. The correlation coefficient that

demonstrated either a strong, weak or no relationship and those associations found

between variables are reported in the results section of Chapter 4. The p-value was

reported to determine the strength of the relationship against the population surveyed at

0.05 which will be shown further in the findings section of Chapter 4. The findings in this

study will report those levels of measurement, when noted.

With the correlation level of internalization of the Strong Black Woman schema

as measured by the mean score on the Strong Black Woman Attitudes Scale along with

the mean score of attitudes toward mental health help-seeking as measured by the mean

score on the Inventory of Attitude Toward Seeking Mental Health Services, the first

research question was addressed:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes towards mental health help-seeking?

With the correlation level of internalization of the Strong Black Woman schema

as measured by the mean score on the Strong Black Woman Attitudes Scale along with

the mean score of psychological openness as measured by the mean score of questions

1,4,7,9,12,14,18, and 21 on the Inventory of Attitude Toward Seeking Mental Health

Services, the second research question was addressed:

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RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

With the correlation level of internalization of the Strong Black Woman schema

as measured by the mean score on the Strong Black Woman Attitudes Scale along with

the mean score of help-seeking propensity as measured by the mean score of questions 2,

5,8,10,13,15,19, and 22 on the Inventory of Attitude Toward Seeking Mental Health

Services, the third research question was addressed:

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

Several pieces of data were utilized to address research question four. First, the

correlation level of internalization of the Strong Black Woman schema as measured by

the mean score on the Strong Black Woman Attitudes Scale was used. In addition to the

correlation level of internalization of the Strong Black Woman schema the mean score of

indifference to stigma as measured by the mean score of questions 3,6,11,16,17,20,23,

and 24 on the Inventory of Attitude Toward Seeking Mental Health Services was used.

As a result, the fourth research question was addressed:

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

All data analysis procedures were conducted based on the alignment of the

research questions posed in this study and strictly adhered to the protocols set forth in

Chapter 3. To ensure that data analysis was carried out under the ethical considerations

established in this study, the following steps were followed: the proposal was approved

through the Academic Quality Review process and an application package was submitted

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to the Institutional Review Board. Once approval was received and documented (see

Appendix B), recruitment for participation in the study began. In Chapter 3, a G*Power

analysis determined the minimum sample recommendation for a correlational study of 84

participants (see Appendix E).

Using a sample size calculator of the minimum participants for the a priori power

analysis, the power was reported at 80%. However, after receiving 153 total respondents

for this research, an additional G*Power analysis had to be conducted to compute the

post hoc statistical analysis (see Appendix E). Recruitment of the sample size was

collected from Black women, ages 18-65 who reside in the Southern region of the United

States. The Spearman’s rho test in IBM SPSS (version 24) visually represented the data

collected to describe the relationships present between variables of internalization of the

Strong Black Woman schema and attitudes toward mental health help-seeking.

Computing the strength of the correlation from the correlational models by the reporting

of the rs coefficient, with the significance of the correlation measured by the p-value,

correlations between variables were found and will be further addressed in the Results

section of Chapter 4.

Results

The researcher of this study recruited 200 Black females for voluntary

participation in this research study. From the 200 recruited women, responses from 47 of

the women contained missing data. Those 47 respondents were removed from the study

using listwise deletion due to missing data points. Listwise deletion is found to be a

common method to employ in statistics when analyzing data that contains missing points

(Sang Kyu & Jong Hae, 2017). After removal of missing data, a sample size of 153 Black

126

women participants was determined by the researcher. After the final sample size was

determined, tests for normality were conducted utilizing SPSS (Version 24).

The four research questions and hypotheses were tested using Spearman’s rho. A

correlation matrix for the variables of interest is presented in Table 10.

Table 10.

Correlation Matrix

Variable Strong Black

Woman

Schema

Attitudes Toward

Mental Health Help

Seeking

Psychological

Openness

Help-Seeking

Propensity

Indifference to

Stigma

Strong Black Woman

Schema _ .230** -.085 .281** .151

Attitudes Toward

Mental Health Help

Seeking

_ .514* .739** .653**

Psychological

Openness _ .019 .179

Help-Seeking

Propensity _ .287**

Indifference to Stigma _

Note. **p < .01; *p < .05. N = 153 two-tailed.

Research question one/hypothesis one. Is there a correlation between

internalization of the Strong Black Woman schema and attitudes toward mental health

help-seeking? There was a significant correlation between internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking, rs (153) =.230, p

= .005, two-tailed.

H01 stated that there is not a statistically significant correlation between

internalization of the Strong Black Woman schema and attitudes toward mental health

help-seeking. There was a significant correlation between internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking, rs (153) = .230, p

= .005, two-tailed. Therefore, the null hypothesis was rejected.

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Research question two/hypothesis two. Is there a correlation between the

internalization of the Strong Black Woman schema and psychological openness? There

was no significant correlation between the internalization of the Strong Black Woman

schema and psychological openness, rs (153) = -.085, p = .301, two-tailed.

H02 stated that there is not a statistically significant correlation between

internalization of the Strong Black Woman schema and psychological openness. There

was no significant correlation between the internalization of the Strong Black Woman

schema and psychological openness, rs (153) = -.085, p = .301, two-tailed. Therefore, the

results failed to reject the null hypothesis.

Research question three/hypothesis three. Is there a correlation between the

internalization of the Strong Black Woman schema and help-seeking propensity? There

was a significant correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity, rs (153) = .281, p = .001; two-tailed.

H03 stated that there is not a statistically significant correlation between

internalization of the Strong Black Woman schema and help-seeking propensity. There

was a significant correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity, rs (153) = .281, p = .001; two-tailed . Therefore, the

null hypothesis was rejected.

Research Question Four/Hypothesis Four. Is there a correlation between

internalization of the Strong Black Woman schema and indifference to stigma? There

was no significant correlation between internalization of the Strong Black Woman

schema and indifference to stigma, rs (153) =.151, p = .065; two-tailed.

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H04 stated that there is not a statistically significant correlation between the

internalization of the Strong Black Woman schema and indifference to stigma. There was

no significant correlation between internalization of the Strong Black Woman schema

and indifference to stigma, rs (153) = .151, p = .065; two-tailed. Therefore, the results

failed to reject the null hypothesis.

Summary

Four research questions and related hypotheses were tested in this study. It was

determined that there was a significant correlation between internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking. There was no

significant correlation between the internalization of the Strong Black Woman schema

and psychological openness. There was a significant correlation between the

internalization of the Strong Black Woman schema and help-seeking propensity.

Additionally, there was no significant correlation between internalization of the Strong

Black Woman schema and indifference to stigma.

The internal consistency of the IASMHS was acceptable for help-seeking

propensity and good for the internalization of the strong Black woman schema. But, the

internal consistency was poor for attitudes toward help-seeking (composite score) and

unacceptable for psychological openness and indifference to stigma. Due to the lack of

reliability coefficients caution should be exercised when generalizing the results of this

study. However, no significant results were observed for any constructs that were

determined to be unreliable. Implications and recommendations will be discussed in

Chapter Five.

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Chapter 5: Summary, Conclusions, and Recommendations

Introduction and Summary of Study

The premise of this research study was to determine if, or to what extent, there

were statistically significant correlations between internalization of the Strong Black

Woman schema and attitudes toward mental health help-seeking. This research addressed

how internalization of the Strong Black Woman schema correlated with the factors of

psychological openness, help seeking propensity, and indifference to stigma. As outlined

in Chapter 1 and reiterated throughout, the research was supported by an extensive

literature review and the further recommendations by researchers in the field.

There were multiple gaps that substantiated the investigation of this problem, and

those gaps will be further explored in Chapter 5 to show how these findings add to the

body of knowledge on the Strong Black Woman schema (Abrams et al., 2014; Nelson et

al., 2016; Watson & Hunter, 2015). What is known about the effects of internalization of

the Strong Black schema were addressed in Chapter 2 of this study. This study identified

the connections between the internalization of the Strong Black Woman schema and

attitudes toward mental health help-seeking that have not been explored previously, with

the underpinnings of gender schema theory as the basis for the theoretical framework

guiding this research.

Due to the complex nature of attitudes toward mental health help-seeking,

additional theories were proposed to guide this research. The Theory of Planned Behavior

was utilized as a secondary theoretical model. The Theory of Planned Behavior was

included because the theory proposes that one of the main predictors of behavior are the

attitudes related to that behavior (Ajzen, 1991). This research advances scientific

130

knowledge in the field of psychology and counseling in that it has incorporated gender

schema theory as the foundational framework. Traditionally, gender schema theory has

not been used as a theoretical foundation for research involving diverse populations such

as people of color (Starr & Zurbriggen, 2017)

The following research questions and hypotheses were addressed in this

quantitative, correlational study:

RQ1: Is there a correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking?

H10: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

H1a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and attitudes toward mental health help-

seeking.

RQ2: Is there a correlation between the internalization of the Strong Black Woman

schema and psychological openness?

H20: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

H2a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and psychological openness.

RQ3: Is there a correlation between the internalization of the Strong Black Woman

schema and help-seeking propensity?

131

H30: There is not a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

H3a: There is a statistically significant correlation between internalization of the

Strong Black Woman schema and help-seeking propensity.

RQ4: Is there a correlation between internalization of the Strong Black Woman

schema and indifference to stigma?

H40: There is not a statistically significant correlation between the internalization of

the Strong Black Woman schema and indifference to stigma.

H4a: There is a statistically significant correlation between the internalization of the

Strong Black Woman schema and indifference to stigma.

A quantitative, correlational study was chosen for this research due to variables

being investigated to determine the significance of correlations present. Spearman’s rho

correlation was determined to be the most appropriate tests for the data collected on 153

Black women participants. Accordingly, correlational tests did not show statistically

significant correlation between the internalization of the Strong Black Woman schema

and attitudes toward mental health help-seeking.

The purpose of Chapter 5 will be to address the findings of this study and how

they extend current research in the field. Conclusions of this study are drawn from the

findings and will be presented in this chapter. Implications of this study will be addressed

and will show how the findings add to the current body of knowledge in the field of

psychology and counseling, as well as how these findings could help support dialogue on

cultural factors as potential predictors of mental health help-seeking. Recommendations

will also be discussed for further research to be conducted on Black women and the

132

Strong Black Woman schema. There is a need for researchers, educators, and providers to

understand factors regarding the Strong Black Woman schema, so this population will

access services and practices that promote their health (Woods-Giscombé, Robinson,

Carthon, Devane-Johnson, & Corbie-Smith, 2016).

A quantitative methodology with a correlational design measured what, if any,

statistically significant correlations existed between the internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking. The research

questions guided the study to add to the current body of knowledge of Black women and

their internalization of the Strong Black Woman schema, and the correlation of those

factors with attitudes toward mental health help-seeking. To test the hypotheses, the

Strong Black Woman Attitudes scale measured the variable of internalization of the

Strong Black Woman schema and the Inventory of Attitudes Toward Mental Health

Services measured the variable of attitudes toward mental health help-seeking.

Determining those statistically significant correlations or trends within the data

that existed internalization of the schema and attitudes toward mental health help-seeking

could be used to improve the utilization of mental health services. It has been stated that

African American adults generally do not seek professional mental health services to

manage psychological stress (Dean et al., 2017). Additionally, Jimenez et al. (2013)

suggested that even when barriers to accessing care are eliminated, mental health services

are still being underutilized in the Black community. Further, Donovan and West (2015)

found internalization of the Strong Black Woman schema to increase the correlation

between stress and depressive symptoms and suggested that future research regarding the

133

Strong Black Woman schema explore the correlation between the schema and health

compromising behaviors.

The findings of this study could be significant in that they may reveal how

internalization of cultural factors, such as the Strong Black Woman schema, influence

Black women’s attitudes toward mental health help-seeking. Incorporating gender

schema theory as well as the Theory of Planned Behavior with Black women broadens

the theoretical framework as a valued model for understanding the internalization of the

Strong Black Woman schema as it relates to mental health help-seeking. Additionally,

this research could create meaningful opportunities for mental health service providers to

become more sensitive to, and aware of, African American culture and the experiences

and perspectives of African American women to better serve these clients.

For the remainder of Chapter 5, for organizational purposes the discussion of the

findings and conclusions are by the research questions that guided the study. Previous

research from the literature review from Chapter 2 will be included in this chapter to

expound upon the findings and connect ideas found within this research to previous work

in the field of psychology. Implications are presented that will address the application of

this research to psychology and counseling, further study opportunities that could

springboard from this work, and the significance of this study within the field of

psychology and counseling.

Summary of Findings and Conclusion

The purpose of this correlational study was to determine if, and to what extent,

statistically significant correlations existed between the internalization of the Strong

Black Woman schema and attitudes toward mental health help-seeking. The organization

134

of this section will be outlined by the variables studied in this research and will provide

the findings and conclusions for all four research questions. Based on the Spearman’s rho

correlational coefficients of the variables presented results either failed to reject the null

hypothesis or rejected the null hypothesis. Previous research discussed at length in

Chapter 2 is included as it relates to each research question and the findings within this

study. The findings will also substantiate the significance of the study and provide future

direction for studies regarding the internalization of the Strong Black Woman schema.

Correlation of internalization of the strong Black woman schema and

attitudes toward mental health help-seeking. The findings of this study indicated that

there was a significant correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking. Therefore, the null hypothesis

was rejected for the first research question. Spearman’s rho correlation showed there was

a statistically significant correlation between internalization of the Strong Black Woman

schema and attitudes toward mental health help-seeking, rs (153) = .230, p = .005; two-

tailed.

The sample of Black women included 153 participants with relatively high

degrees of schema internalization (M=59.92) but more positive attitudes toward mental

health help-seeking (M=42.59). As a result, these findings counter prior research that

found lack of help-seeking to be related to African American women’s internalization of

the Strong Black Woman schema (Nicolaidis et al., 2010). Additionally, this is opposition

to the findings of Watson and Hunter (2015) whose sample held less than favorable

attitudes toward mental health help-seeking. However, Black women, consistent with

their socialization as strong Black women, may present as composed and unaffected by

135

various stressors (Romero, 2000). Therefore, this composure may lead to indications of

more positive attitudes toward mental health help-seeking.

Correlation of internalization of the strong Black woman schema and

psychological openness. The findings of this study indicated that there was no

significant correlation between internalization of the Strong Black Woman schema and

psychological openness. Therefore, the results failed to reject the null hypothesis for the

second research question. Spearman’s rho correlation showed there was not a statistically

significant correlation between internalization of the Strong Black Woman schema and

psychological openness, rs (153) =-.085, p =.301; two-tailed. These results are counter to

previous research which has demonstrated that psychological openness was inversely

related to the Strong Black Woman schema (Watson & Hunter, 2015), such that Black

women who strongly internalized the schema felt less comfortable discussing emotional

concerns with a mental health professional.

Correlation of internalization of the strong Black woman schema and help-

seeking propensity. The findings of this study indicated that there was a significant

correlation between the internalization of the Strong Black Woman schema and help-

seeking propensity. Therefore, the null hypothesis was rejected for the third research

question. Spearman’s rho correlation showed there was a significant correlation between

internalization of the Strong Black Woman schema and help-seeking propensity, rs (153)

=.281, p =.001; two-tailed. These results are similar to the findings of Watson and Hunter

(2015) which suggested that internalization of the Strong Black Woman schema and

help-seeking propensity share statistical significance.

136

Correlation of internalization of the strong Black woman schema and

indifference to stigma. The findings of this study indicated that there was no significant

correlation between internalization of the Strong Black Woman schema and indifference

to stigma. Therefore, the results failed to reject the null hypothesis for the fourth research

question. Spearman’s rho correlation showed there was not a statistically significant

correlation between internalization of the Strong Black Woman schema and indifference

to stigma, rs (153) =.151, p =.065; two tailed. Although it has been concluded that stigma

related to seeking help for mental disorders may cause a service seeking delay (Pattyn et

al., 2014; Sickel et al., 2014; Turner et al., 2015), most participants in this study have a

high degree of indifference to stigma. These results are in opposition to the findings of

Watson and Hunter (2015) who reported that greater internalization of the Strong Black

Woman schema approached statistical significance when associated with indifference to

stigma.

The findings from this study help to build on the current research by correlating

the internalization of the Strong Black Woman schema and attitudes mental health help-

seeking. Further, this research provides additional support to explore the schema from a

quantitative perspective as opposed to qualitative which has been the primary basis for

research on the topic. While this study was not able to determine a statistically significant

correlation between internalization of the Strong Black Woman schema and attitudes

toward mental health help-seeking, this study did include women from a variety of

backgrounds to explore the relationship between the variables.

137

Implications

The results of this study have implications for potential positive social change on

the theoretical level, practical level, and in the future. A review of the academic literature

revealed a plethora of qualitative research on the Strong Black Woman schema. The

researcher noted the absence of quantitative studies on the Strong Black Woman schema.

As a result, additional quantitative research was needed to help scholars gain insight into

the potential correlation between internalization and mental health help-seeking. This

study answered a call in the literature to quantitatively explore the correlation between

the internalization of the Strong Black Woman schema and mental health help-seeking.

Implications from this research help mental health care providers piece together a more

complete framework for understanding how internalization of the schema may influence

help-seeking behaviors.

Theoretical implications. At the theoretical level this research may expand the

use of gender schema theory. Conventionally, gender schema theory is not utilized as a

theoretical foundation for research involving people of color (Starr & Zurbriggen, 2017).

However, this research has expanded the use of gender schema theory by utilizing it as

the theoretical framework in research with Black women. According to gender schema

theory, experiences and gender schemas interact to produce gendered perceptions of the

meanings of womanhood as well as behavioral guidelines and expectations for

circumstances (Bem, 1981). For women who internalize the Strong Black Woman

schema, expectations of self-reliance, caretaking, and affect regulation guide perceptions

of womanhood and dictate internalization of experiences and behavior. Data from this

study revealed that most of the women in this study had a high degree of internalization

138

of the Strong Black Woman schema and still possessed moderately positively attitudes

toward mental health help-seeking. This implies that the internalization of the schema

may not always have deleterious effects on attitudes regarding help-seeking behaviors.

Additional implications relate to the secondary theoretical framework, the Theory

of Planned Behavior, chosen for the study. The Theory of Planned Behavior assumes that

human behavior is goal-directed, influenced by the social climate, and that individuals are

logical and rational in their decision making (Ajzen, 1991). However, this research

revealed that the Inventory of Attitudes Toward Seeking Mental Health Services was not

internally consistent for this sample of Black women. Women in this sample possessed

high internalization of the Strong Black Woman schema yet moderate degrees of

indifference to stigma. Consequently, this implies that the help-seeking behavior of Black

women may not be as influenced by their social climate.

Practical implications. At the practical level this research may have implications

for the fields of counseling and psychology. Black women, consistent with their

socialization as strong Black women, may present as composed and unaffected by

various stressors (Romero, 2000). However, this could lead Black women to underreport

symptoms of distress due to the core value of self-silence in the schema. As a result,

mental health service providers may need to gather a better understanding of the core

components of high internalization of the Strong Black Woman schema to better assess

and diagnosis potential mental health issues.

Similarly, to many non-dominant cultures, the stigma regarding mental health

issues is also powerful. However, many of the participants in this study reported low

indifference to stigma regarding seeking mental health services, yet mental health

139

services are still underutilized by Black people in the United States. As opposed to

pursuing therapy, many Black women may seek support and comfort from close friends,

family, and church. One implication of the findings of this study is that community-based

support and information regarding ways to seek mental health help might be

advantageous for the Black community. Also, it may be helpful to include information

about the Strong Black Woman schema into mental health provider education to improve

culturally relevant curriculum. When clinically appropriate, it would inform treatment

providers how to join with and provide the most relevant services to Black women.

Future implications. It is important to understand mental health help-seeking in

the Black community and the implications of this include improved psychological care

for Black women along with increased utilization of mental health care (Allen et al.,

2014). As a result of the Strong Black Woman schema being a complex, historically and

culturally embedded ethnic gender role with some adaptive value, it would not be

conceivable to fully unravel the schema. However, calling cognizance to its detrimental

effects might be successfully undertaken. One such approach might be to establish a

website with links to empirical research about the schema as well as resources for seeking

mental health help. The website may be able to generate discussions surrounding the

experiences of strong Black women and may stimulate increased cognizance of the

internalized schema factors. As a result of these discussions, some Black women may be

inspired to increase their mental health utilization.

Strengths and weaknesses of the study. The strength of this quantitative,

correlational research study was that it shed light on the correlation between the

internalization of the Strong Black Woman schema and mental health help-seeking

140

attitudes. Additionally, one alternate hypotheses was accepted for the research question

regarding the correlation between the internalization of the schema and help-seeking

propensity. There was a statistically significant correlation found between the variable of

internalization of the Strong Black Woman schema and help-seeking propensity.

Another strength of this study lies in the demographic profile of the sample. There

was a call from the scholarly community to explore the Strong Black Woman schema in

diverse ages, socioeconomic status, and educational backgrounds (Abrams et al., 2014;

Nelson et al., 2016; Watson & Hunter, 2015). This study included women who fell

between the ages of 18-64 with most them being between 25-44. Additionally, this

sample included both women who had been to college and those who had not been to

college which answers the call in the literature from West et al. (2016). Furthermore, this

research also included women from diverse socioeconomic background with participants

demonstrating a range of incomes.

Conversely, this study contained several limitations. One limitation of the study is

that it utilized a volunteer sample. Consequently, there is a large difference between the

educational level of the volunteer sample and the general population. Over 84% of the

Black women of the sample population hold bachelor’s degrees or higher. However, of

the overall population of female Black U.S citizens enrolled at post-secondary institutions

in 2014-2015, 37.4% of the Black females were awarded bachelor’s degrees or higher

(Ginder, Kelly-Reid, & Mann, 2016). As a result, these results may not be representative

of an entire population because it is likely that this method of recruitment resulted in a

sample of participants who were more aware of or interested in the Strong Black Woman

schema compared to Black women within the general population.

141

An additional limitation of this study is that it utilized a correlational design.

Because of the study’s correlational design, causality cannot be inferred from the results.

Also, the sample of this study consisted primarily of Black women living in the Southern

region of the United States which limits the understanding of this topic with Black

women in other regions. Another limitation of this study is that it utilized self-rated

surveys and as a result the researcher cannot guarantee the accuracy of the participant

responses.

Lastly, the low reliability coefficients for the Inventory of Attitudes Toward

Seeking Mental Health Services with this sample is a limitation of this study. According

to an EBSCOhost search, the Inventory of Attitudes Toward Seeking Mental Health

Services has been utilized in 130 studies. The Inventory of Attitudes Toward Seeking

Mental Health Services was selected over several other reliable help-seeking attitudes

instruments. The 29-item Attitudes Toward Seeking Professional Psychological Help

Scale (Fischer & Turner, 1970) has been used to measure attitudes in many, if not most,

of the previous studies on gender and help-seeking. Although the Attitudes Toward

seeking Professional Psychological Help Scale has been used widely as a measure of

attitudes toward mental health help-seeking, the instrument has not been used to examine

how attitudes toward mental health help-seeking may be related to masculine or feminine

gender norms (Yousaf et al., 2015). As a result, the researcher decided to utilize The

Inventory of Attitudes Toward Seeking Mental Health Services (Mackenzie et al., 2004)

which was designed as an alternative to the Attitudes Toward seeking Professional

Psychological Help Scale.

142

Recommendations

The current study represents an effort to explore how cultural factors, such as the

Strong Black Woman schema correlate with attitudes toward mental health help-seeking.

These findings extend the current literature regarding the role of the Strong Black

Woman schema and mental health help-seeking attitudes which may impact the

underutilization of mental health services. Although these findings address certain gaps in

the literature, additional research is needed to further understand, and hopefully address,

mental health help-seeking disparities.

Recommendations for future research. Most participants in the current study

reported a moderate degree of indifference to stigma. However, the strong Black woman

is expected to handle her problems independently, receiving mental health services may

be seen as an admission of weakness or failure (Harris, 1995; Littlefield, 2003; Thomas et

al., 2004). As a result, further qualitative and quantitative research is needed to

investigate the possible risks Black women may encounter when they possess attitudes

toward mental health and help-seeking behaviors that are not commonly accepted in the

culture.

Strength is a core aspect of the Strong Black Woman schema that has been

described as an obligation to resist being vulnerable and an unwillingness to ask for help

(Black & Woods-Giscombé, 2012; Woods-Giscombé, 2010). Conversely, participants in

this study reported low to moderate degrees of psychological openness. However, this

research did not inquire if specific events would increase of decrease a participant’s

attitudes toward mental health help-seeking. As a result, future research should

quantitatively explore whether trauma or other stressful life experiences correlate with

143

attitudes toward mental health help-seeking among Black women with varying degrees of

Strong Black Woman schema internalization. These findings would provide greater

insight into how the Strong Black Woman schema correlates with mental health help-

seeking attitudes particularly during times of amplified stress.

The sample of this study was highly educated. Most of the participants had a

college degree with over half of participants having graduate degrees. As a result of the

educational background, the women in this sample may have a higher socioeconomic

status than other women in the Southern region and Black women in general.

Consequently, Black women with higher socioeconomic status may have more ethnically

diverse social circles (Park, Denson, & Bowman, 2013). Experience with diverse ideals

of womanhood may decrease the internalization of the Strong Black Woman schema and

cause these women to be more accepting of seeking mental health help. Therefore, the

correlation between the internalization of the Strong Black Woman schema and mental

health help-seeking attitudes may be even stronger for low income women than for the

women in the current study’s sample. Additional quantitative research is needed to

determine if and to what extent a correlation between the Strong Black Woman schema

and attitudes toward mental health help-seeking is similar for Black women across

various levels of socioeconomic status.

Lastly, participation in this study was limited to Black women in the Southern

region of the United States. However, similar qualitative research on the internalization

of the Strong Black Woman has been conducted in England (Edge & MacKian, 2010)

and Canada (Jackson & Naidoo, 2013). As a result, quantitative studies in either other

144

regions or other countries may reveal different results regarding the Strong Black Woman

schema and attitudes toward mental health help-seeking.

Recommendations for future practice. Findings of this quantitative research

offer several recommendations for practice based on the findings of this study.

Information provided in this study may assist mental health professionals in building

strong relationships with their Black female clients by acknowledging the Strong Black

Woman schema and how it may contribute to Black women’s attitudes and behaviors

regarding mental health. Mental health professionals possessing knowledge about the

Strong Black Woman schema may make Black women feel understood and thus build

their confidence in seeking help from mental health professionals.

Results of this study found a significant, weak, negative relationship between the

internalization of the Strong Black Woman schema and help-seeking propensity. As a

result, mental health professionals should consider how identification with this schema

prevent Black women from seeking help. Therefore, it is it is important for mental health

professionals to consider culturally relevant strategies to connect with Black women.

‘‘Sister circles’’ have been suggested as a promising outlet for psychological support for

Black women experiencing mental health conditions (Neal-Barnett et al., 2011).

Accordingly, it may be advantageous to start mental health professional moderated social

media groups in which strong Black women can post about their experiences, provide

support and information for each other, and have access to a mental health professional.

Additionally, based on the finding of the relationship between internalization of

the schema and help-seeking propensity, Black women who strongly identify with the

Strong Black Woman schema may not feel comfortable discussing their challenges. As a

145

result, mental health professionals should consider providing group treatment offerings

particularly for Black women. A group setting may allow these women to see that they

are not alone in seeking help and increase their comfort in discussing their experiences

and challenges.

146

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Appendix A.

Site Authorization Letter

Site authorization is on file at Grand Canyon University.

180

Appendix B.

IRB Approval Letter

181

Appendix C.

Informed Consent

182

183

Appendix D.

Copy of Instruments and Permission Letters to Use the Instruments

184

185

186

Strong Black Woman Attitudes Scale

187

188

Appendix E.

Power Analyses for Sample Size Calculation

189

190

Appendix F.

Data Source Table

Correlation Matrix

Variable Strong Black

Woman

Schema

Attitudes Toward

Mental Health Help

Seeking

Psychological

Openness

Help-Seeking

Propensity

Indifference to

Stigma

Strong Black Woman

Schema _ .230** -.085 .281** .151

Attitudes Toward

Mental Health Help

Seeking

_ .514* .739** .653**

Psychological

Openness _ .019 .179

Help-Seeking

Propensity _ .287**

Indifference to Stigma _

Note. **p < .001; *p < .05. N = 153, two-tailed.