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How and why people seek help after a traumatic event remains an area ripe for study. We know that trauma symptoms can be a potential barrier to seeking psychological help though in some cases they may serve to facilitate help seeking. Lack of access to health insurance and financial stresses also serve as barriers. Stigma about seeking mental health, particularly for populations that have been historically oppressed, can play a more complex role serving as either a barrier or a facilitator to engagement with care (Alvidrez, Snowden, & Kaiser, 2008; Alvidrez, Snowden, & Patel, 2010). Given the burden of racism in the US, Black men often feel these barriers most potently. In addition, Black men are more likely to suffer violent injury and death. Because we know that trauma and violence have the potential to feed the cycle of violence either by disrupting key supports and buffers or by activating social pressures to keep oneself safe, understanding pathways to psychological help-seeking is imperative (Rich & Grey, 2005).

Our prior qualitative study of black male victims of trauma explored perceptions of psychological symptoms after injury and the factors guiding their decision to seek professional mental health help (Jacoby, Rich, Webster, & Richmond, 2018). Themes which emerged from that study included that injury related psychological distress was a facilitator of psychological help seeking. Barriers to help seeking included financial constraints, limited access to mental health care services and fear that mental health professionals would judge these victims based on their injuries. We also found that for some men the decision not to seek psychological help hinged on their perception that they did not need such support or that they had enough support among their existing social networks to deal with any challenges.

Based on these results, our next step was to consider each of these men as a case where we could understand how these various factors might combine in unique ways to compel them to seek psychological help. A case study approach would allow us to meld together qualitative findings and the results of quantitative scales that were collected as part of the overall research project. This approach was guided by understanding that the decision to seek psychological help for black men is complex. At the same time, despite sharing a self-identified racial identity and a gender, black men are not monolithic and therefore likely have multiple different pathways toward psychological help seeking which can best be discerned by using a configurational case study method.

Our paper Pathways to Help-Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis, used a unique method called qualitative comparative analysis (QCA), a set theory-based configurational method designed to study complex causation (Ragin, 1999). QCA asks the question “which combination of the presence or absence of factors, called causal conditions is most consistently a subset of the outcome?” In this case the outcome was defined as psychological help seeking. For our study, the outcome psychological help seeking was derived from the qualitative data, and the causal factors - PTSD symptoms, depression symptoms, financial worry and stigma/discrimination - were derived from scales in the quantitative data.

Our paper looked at 32 black men hospitalized for either intentional or unintentional injury at the University of Pennsylvania trauma center in an effort to understand how various factors, some typically constructed as facilitators and others constructed as barriers, combined to compel them to seek psychological help. Using QCA, our study found three distinct pathways toward seeking psychological help among these trauma survivors. Two pathways showed that severe trauma symptoms in the absence of financial worry was sufficient for seeking help. A third showed that the combination of financial worry and discrimination, in the absence of trauma symptoms, was sufficient for psychological help-seeking. In other words, trauma symptoms can serve as a driver for seeking psychological help in the absence of social factors. Social factors, however, can also facilitate psychological help seeking in the absence of PTSD symptoms or depression symptoms.

Newer configurational methods are specifically designed to assess causal complexity in cases where the combination of the presence or absence of important factors can be understood, while correlational methods can be useful in isolating net effects of variables like PTSD symptoms, depression symptoms and social factors such as discrimination, stigma and financial worry (Ragin & Fiss, 2017). We believe that QCA is especially important in research that looks at racial inequalities. Our study focused exclusively on men who self-identified as Black. We know however that race itself lacks meaning except for the extent to which it is a proxy for other factors like racism or related conditions that are associated with historical oppression and racism such as poverty, lack of opportunity, internalized racism and stigma, just to name a few. All too often research on black men presents them as monolithic and brings a deficit lens to their motivations and associated resources. Our study, using QCA to analyze qualitative and quantitative data on cases, allows us to identify different pathways to psychological help-seeking within the group of black men who are trauma survivors rather than presuming that all black men are motivated toward help seeking in the same ways.

Our hope is that our results and our approach will inform future research aimed at untangling the complex interactions between trauma symptoms, social factors and historical oppression on how particular groups seek help for psychological distress. We also hope to stimulate a discussion about how multiple methods and data sources can combine to produce new insights.


Alvidrez, J., Snowden, L. R., & Kaiser, D. M. (2008). The experience of stigma among Black mental health consumers. Journal of Health Care for the Poor and Underserved, 19(3), 874-893. doi:https://doi.org/10.1353/hpu.0.0058

Alvidrez, J., Snowden, L. R., & Patel, S. G. (2010). The relationship between stigma and other treatment concerns and subsequent treatment engagement among Black mental health clients. Issues in Mental Health Nursing, 31(4), 257-264. doi:10.3109/01612840903342266

Jacoby, S. F., Rich, J. A., Webster, J. L., & Richmond, T. S. (2018). ‘Sharing things with people that I don’t even know’: help-seeking for psychological symptoms in injured Black men in Philadelphia. Ethnicity & health, 1-19.
Ragin, C. C. (1999). Using qualitative comparative analysis to study causal complexity. Health Services Research, 34(5), 1225-1239.

Ragin, C. C., & Fiss, P. C. (2017). Intersectional inequality: Race, class, test scores, and poverty: University of Chicago Press.

Rich, J. A., & Grey, C. M. (2005). Pathways to recurrent trauma among young Black men: traumatic stress, substance use, and the "code of the street". Am J Public Health, 95(5), 816-824. doi:10.2105/AJPH.2004.044560

Reference Article:

Rich, J.A., Corbin, T.J., Jacoby, S.F., Webster, J.L. and Richmond, T.S. (2020), Pathways to Help‐Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis. Journal of Traumatic Stress. doi:10.1002/jts.22517

Questions for Discussion:

  1. Our research looked at individual level conditions and how they combine to lead to psychological help-seeking. How might future research add to our understanding of how structural racism and racial trauma affect how Black men seek help after trauma?

About the Author:

John Rich is a primary care internal medicine physician and professor of Health Management and Policy at the Dornsife School of Public Health at Drexel University in Philadelphia, PA. He also serves as Co-Director of the Drexel Center for Nonviolence and Social Justice.