Tucker, J. R., Hammer, J. H., Vogel, D. L., Bitman, R. L., Wade, N. G., & Maier, E. (2013). Disentangling stigmas: Are mental-illness and help-seeking stigmas distinct? Journal of Counseling Psychology, 60, 520-531. pdf
Two established but disparate lines of research exist: studies examining the self-stigma associated with
mental illness and studies examining the self-stigma associated with seeking psychological help. Whereas
some researchers have implicitly treated these 2 constructs as synonymous, others have made the
argument that they are theoretically and empirically distinct. To help clarify this debate, we examined in
the present investigation the overlap and uniqueness of the self-stigmas associated with mental illness and
with seeking psychological help. Data were collected from a sample of college undergraduates experi-
encing clinical levels of psychological distress (N 217) and a second sample of community members
with a self-reported history of mental illness (N 324). Confirmatory factor analyses provide strong
evidence for the factorial independence of the 2 types of self-stigma. Additionally, results of regression
analyses in both samples suggest that the 2 self-stigmas uniquely predict variations in stigma-related
constructs (i.e., shame, self-blame, and social inadequacy) and attitudes and intentions to seek help.
Implications for researchers and clinicians interested in understanding stigma and enhancing mental
health service utilization are discussed.
Vogel, D. L., Armstrong, P. I., Tsai, P-C., Wade, N. G., Hammer, J., Efstathiou, G., Holtham, E., Kouvaraki, E., Liao, H-Y., Shechtmn, & Topkaya, N. (in press). Cross-cultural validity of the Self-Stigma of Seeking Help (SSOSH) scale: Examination across six nations. Journal of Counseling Psychology. pdf
Researchers have found that the stigma associated with seeking therapy—particularly self-stigma—can inhibit the use of psychological services. Yet, most of the research on self-stigma has been conducted in the United States. This is a considerable limitation, as the role of self-stigma in the help-seeking process may vary across cultural groups. However, to examine cross-cultural variations, researchers must first develop culturally valid scales. Therefore, this study examined scale validity and reliability of the widely used Self-Stigma of Seeking Help scale (SSOSH; Vogel, Wade, & Haake, 2006) across samples from 6 different countries (England, Greece, Israel, Taiwan, Turkey, and the United States). Specifically, we used a confirmatory factor analysis framework to conduct measurement invariance analysis and latent mean comparisons of the SSOSH across the 6 sampled countries. Overall, the results suggested that the SSOSH has a similar univariate structure across countries and is sufficiently invariant across countries to be used to explore cultural differences in the way that self-stigma relates to help-seeking behavior.
Vogel, D. L., Bitman, R. L., Hammer, J. H., & Wade, N. G. (in press). Is stigma internalized? The lognitudinal impact of public stigma on self-stigma. Journal of Counseling Psychology. pdf
Stigma is considered an important barrier to seeking mental health services. Two types of stigma exist: public stigma and self-stigma. Theoretically, it has been argued that public stigma leads to the development of self-stigma. However, the empirical support for this assertion is limited to cross-sectional data. Therefore, the goal of this research was to examine the relationship between public stigma and self-stigma over time. Perceptions of public and self-stigma were measured at Time 1 (T1) and then again 3 months later at Time 2 (T2). Using structural equation modeling, we conducted a cross-lag analysis of public stigma and self-stigma among a sample of 448 college students. Consistent with assertions that public stigma leads to the development of self-stigma, we found that public stigma at T1 predicted self-stigma at T2, whereas the converse was not true. These findings suggest that if self-stigma develops from public stigma, interventions could be developed to interrupt this process at the individual level and reduce or eliminate self-stigma despite perceptions of public stigma.
Vogel, D. L., Wester, S. R., Hammer, J., H., & Downing-Matibag, T. M. (in press). Referring men to seek help:
The influence of gender role conflict and stigma. Psychology of Men and Masculinity. pdf
Why do men tend to underutilize mental health services? One reason may be that men are less frequently referred to seek such services. Indeed, male friends and family members may be particularly unlikely to refer men to seek mental health services, as it means going against the traditional male gender role proscription of talking to other men about emotional issues. This study is the first to explore how men’s experiences of gender role conflict may be associated with an increased endorsement of stigmatization around mental health concerns and, subsequently, a decreased willingness to refer friends and family members experiencing a mental health concern to seek help. Results based on structural equation modeling with data from 216 male collegians indicated that men who endorsed greater restricted emotionality were less willing to refer friends and family members experiencing a mental health concern to seek treatment. In turn, men who endorsed greater Restricted affectionate behavior between men also endorsed greater stigma, which then led to a decreased willingness to refer friends and family members to seek help.
Cheng, H-L., Kwan, K-L., & Sevig, T. (2013). Racial and ethnic minority college students’ stigma associated with seeking psychological help: Examining psychocultural correlates. Journal of Counseling Psychology, 60, 98-111. pdf
Many college students underuse professional psychological help for mental health difficulties. The stigma associated with seeking such help appears to be one of the reasons for this underuse. Levels of psychological distress and past use of counseling/psychotherapy have been found to be important correlates of stigma associated with seeking psychological help (Obasi & Leong, 2009; Vogel, Wade, & Haake, 2006). For racial and ethnic minorities, the hindering effects of self-stigma and perceived stigmatization by others on treatment seeking may further be compounded by their relationships with their own ethnic groups, with other ethnic groups, and with the dominant society. This study used structural equation modeling (SEM) to test a model that explored the effects of psychological distress and psychocultural variables (i.e., ethnic identity, other-group orientation, perceived discrimination) on perceived stigmatization by others and self-stigma for seeking psychological help, controlling for past use of counseling/psychotherapy. The sample consisted of 260 African American, 166 Asian American, and 183 Latino American students. SEM multigroup analyses indicated measurement invariance, but partial structural invariance, across racial/ethnic groups. Across all 3 groups, higher levels of psychological distress and perceived racial/ethnic discrimination, respectively, predicted higher levels of perceived stigmatization by others for seeking psychological help, which, in turn, predicted greater self-stigma for seeking psychological help. Higher levels of other-group orientation predicted lower levels of self-stigma of seeking psychological help across groups. Higher levels of ethnic identity predicted lower levels of self-stigma of seeking psychological help only for African Americans. Implications for research and practice are discussed.
Hammer, J., Vogel, D. L., & Heimerdinger-Edwards (2013). Men’s Help-Seeking: Examination of differences across community size, eduction, and income. Psychology of Men and Masculinity, 14, 65-75. doi: 10.1037/a0026813 pdf
The present study examined the relationships between traditional Western masculine norms, self-stigma, and attitudes toward counseling among 4,748 men from different community sizes, and different education and income levels. Structural equation modeling (SEM) analyses suggest that, across all male subgroups, masculine norms were linked to self-stigma and, in turn, attitudes toward counseling. However, several clear differences in the strengths of the relationships between model variables were found, including a relationship between masculine norms and self-stigma that was twice as strong for rural men than for other men. The importance of attending to the varying relationships among masculine norm conformity, self-stigma, and help-seeking attitudes for men from these diverse demographic backgrounds—in the context of clinical practice, prevention, and future research—is discussed.
Shepherd, C. B., Rickard, K. M. (2012). Drive for muscularity and help-seeking: The mediational role of gender role conflict, self-stigma, and attitudes. Psychology of Men & Masculinity, 13, 379-392. pdf
Men with greater gender role conflict (GRC) tend to exhibit a variety of body image concerns, including a drive for muscularity (DM). In accordance with the theory of planned behavior (TPB), men with higher levels of GRC also report negative attitudes and a lack of intentions to seek help for problems. Additionally, prior research regarding other individual and contextual help-seeking related variables has shown that men with higher GRC report increased stigma of both seeking help and having mental health problems, as well as greater concrete barriers to help-seeking. In this study, 176 undergraduate men were assessed for GRC, DM, and help-seeking-related variables including attitudes, intention to seek help, self-stigma of seeking help, self-stigma regarding mental health problems, and concrete barriers to seeking help. Results indicate that GRC is positively correlated with DM and negatively correlated with help-seeking variables. Mediation analyses suggest a relationship between DM, GRC, and help-seeking. Specifically, results demonstrate that GRC mediates the relationship between DM and intentions to seek help, thus explaining why men with body image concerns may be less likely to utilize treatment. In addition, self-stigma of seeking help and attitudes toward seeking help emerged as mediating factors between GRC and intentions to seek help. Intervention strategies aimed at increasing help-seeking behavior for men who suffer from body image concerns, and disordered eating and exercise behaviors, may benefit from targeting stigmatization and attitudes toward seeking help.
Kaplan, S., Vogel, D. L., Gentile, D., Wade, N. G. (2012). Increasing positive perceptions of counseling: The importance of repeated exposures. The Counseling Psychologist, 40, 409-442. doi: 10.1177/0011000011414211 pdf
This study assesses the effectiveness of repeated exposures to a video intervention based on the Elaboration Likelihood Model. The video was designed to increase help-seeking attitudes and perceptions of peer norms and to decrease the stigma associated with seeking counseling. Participants were 290 undergraduates who were randomly assigned to a repeated-exposure video intervention, a single-exposure video intervention, or a control video condition. Participants completed measures pre- and post-intervention and at a 3-week follow-up. Those in the repeated-exposure intervention improved significantly more than the single-exposure and control groups on help-seeking attitudes and perception of peer norms but not for stigma. The effect of repeated exposures on attitudes and peer norms showed both immediate and longer-term effects. Effective, empirically supported interventions capable of reaching large numbers of people are necessary to improve utilization rates of counseling services. This study offers support for the use of repeated video interventions in changing attitudes and perceptions of counseling.
Skopp, N., A., Bush, N. E., Vogel, D. L., Wade, N. G., Sirotin, A. P., McCann, R. A., Metzger-Abamukong, M. J. (2012). Development and initial testing of a measure of public and self-stigma in the military. Journal of Clinical Psychology, 68, 1036-1047. doi:10.1002/jclp.21889 pdf
This research developed and tested the Military Stigma Scale (MSS), a 26-item scale, designed to measure public and self-stigma, two theorized core components of mental health stigma. Method: The sample comprised 1,038 active duty soldiers recruited from a large Army installation. Soldiers’ mean age was 26.7 (standard deviation = 5.9) years, and 93.6% were male. The sample was randomly split into a scale development group (n = 520) and a confirmatory group (n = 518). Results: Factor analysis conducted with the scale development group resulted in the adoption of two factors, named public and self-stigma, accounting for 52.1% of the variance. Confirmatory factor analysis conducted with the confirmatory group indicated good fit for the two-factor model. Both factors were components of a higher order stigma factor. The public and self-stigma scales for the exploratory and confirmatory groups demonstrated good internal consistency (α = .94 and .89; α = .95 and .87, respectively). Demographic differences in stigma were consistent with theory and previous empirical research: Soldiers who had seen a mental health provider scored lower in self-stigma than those who had not. Conclusions: The MSS comprises two internally consistent dimensions that appear to capture the constructs of public and self-stigma. The overall results indicate that public and self-stigma are dimensions of stigma that are relevant to active duty soldiers and suggest the need to assess these dimensions in future military stigma research. ⃝C 2012 Wiley Periodicals, Inc. J. Clin. Psychol. 68:1036–1047, 2012.
Vogel, D. L., Heimerdinger-Edwards, S. R., Hammer, J. H., & Hubbard, A. (2011). “Boys don’t cry”: Examination of the links between masculine norms and help-seeking attitudes for men from diverse cultural backgrounds. Journal of Counseling Psychology, 58, 368-382. doi: 10.1037/a0023688 pdf
The role of conformity to dominant U.S. masculine norms as an antecedent to help-seeking attitudes in men has been established using convenience samples made up largely of college-age and European American males. However, the role of conformity to masculine norms on help-seeking attitudes for noncollege-age men or for men from diverse backgrounds is not well understood. To fill this gap in the literature, the present study examined the cross-cultural relevance of a mediational model of the relationships between conformity to dominant U.S. masculine norms and attitudes toward counseling through the mediator of self-stigma of seeking counseling for 4,773 men from both majority and nonmajority populations (race/ethnicity and sexual orientation). Structural equation modeling results showed that the model established using college males from majority groups (European American, heterosexual) may be applicable to a community sample of males from differing racial/ethnic groups and sexual orientations. However, some important differences in the presence and strengths of the relation- ships between conformity to dominant masculine norms and the other variables in the model were present across different racial/ethnic groups and sexual orientations. These findings suggest the need to pay specific theoretical and clinical attention to how conformity to dominant masculine norms and self- stigma are linked to unfavorable attitudes toward help seeking for these men, in order to encourage underserved men’s help-seeking behavior.
Wade, N. G., Post, B., Cornish, M., Vogel, D. L., & Tucker, J. (2011). Predictors of the change in self-stigma following a single session of group counseling. Journal of Counseling Psychology, 58, 170-182. doi: 10.1037/a0022630 pdf
One of the major obstacles to seeking psychological help is the stigma associated with counseling and therapy. Self-stigma, the fear of losing self-respect or self-esteem as a result of seeking help, is an important factor in the help-seeking process. In the present study, college students meeting a clinical cutoff for psychological symptoms participated in 1 session of group counseling that either contained therapist self-disclosure or did not. In general, participants reported significantly less self-stigma following the session. Working alliance–bond and session depth significantly predicted the change in self-stigma. Furthermore, self-stigma (as well as bond, depth, psychological symptoms, and being female) predicted the intention to seek help following the session. Self-stigma and session depth also predicted interest in continuing with counseling. The therapist self-disclosure condition, however, had no effect on the change in self-stigma, intentions to seek help, or interest in continuing with group counseling.
Hammer, J. H., & Vogel, D. L. (2010). Men’s help seeking for depression: Efficacy of a male-sensitive brochure about counseling. The Counseling Psychologist, 38, 296-313. doi: 10.1177/0011000009351937 pdf
Although depression among men is becoming better understood, men still underuse counseling services. Hence, there is an important need for improved ways to reach out to depressed men.This study examined the efficacy of a male-sensitive brochure aimed toward improving attitudes about seeking counseling and reducing the self-stigma of seeking counseling among 1,397 depressed men who had not previously sought help for their depression. Results indicate that the male-sensitive brochure, which incorporated current knowledge from the psychology of men and masculinity and mental health marketing, improved participants’ attitudes and reduced their self- stigma toward counseling. Furthermore, the new brochure improved attitudes and reduced stigma to a greater degree than previously developed brochures. Implications for mental health marketing, practice, and research are discussed.
The study examined public and self-stigma and their association with attitudes and intentions to seek psychological help in regard to both individual and group treatment as well as to various subgroups, including gender, ethnicity, educational orientation, level of religion, and age. Undergraduate students (N=307) in three universities in Israel participated in the study. Results partly confirmed the model for both individual and group therapy: Self-stigma was related to attitudes and intentions to seek help. However, public stigma was not related to self-stigma. Importantly, some differences were also found among the various subgroups, and the model, which takes into account the different subgroups, looks somewhat different for individual and group therapy.
Vogel, D. L., Shechtman, Z., & Wade, N. G. (2010). The role of public and self-stigma in predicting attitudes toward group counseling. The Counseling Psychologist, 38, 904-922. doi: 10.1177/0011000010368297 pdf
Public and self-stigmas have been implicated as factors in the underutilization of individual counseling. However, group counseling is also underutilized, and yet scholars know very little about the role of different types of stigma on attitudes toward seeking group counseling. Therefore, the current study examined the relationships between public and self-stigma and attitudes toward group counseling among a sample of 491 U.S. college students. Results of structural equation modeling analyses indicated that public stigma is internalized as self-stigma and self-stigma is then negatively related to attitudes toward group counseling. Furthermore, public stigma and self- stigma explained 52% of the variance in attitudes toward seeking help.
Wester, S. R., Arndt, D., Arndt L., & Sedivy, S. K. (2010). Male Police Officers and Stigma Associated With Counseling: The Role of Anticipated Risks, Anticipated Benefits and Gender Role Conflict. Psychology of Men & Masculinity, 11, 4, 286–302. doi: 10.1037/a0019108
Using a sample of 178 male law enforcement officers, we tested a mediation model in which the linkage between male gender role conflict (GRC) and the stigma associated with counseling could be accounted for by either the risks or the benefits associated with counseling. GRC predicted seeing fewer benefits and greater risks associated with coun- seling, and all three of these variables were associated with the stigma assigned to counseling. However, mediation was demonstrated only in regards to the relationship between GRC, anticipated risk, and stigma. Anticipated benefit did not mediate the relationship between GRC and stigma. The nature of the findings, as well as their implications, is discussed.
Ludwikowski, W., Vogel, D. L., & Armstrong, P. I. (2009). Attitudes towards career counseling: The role of public and self-stigma. Journal of Counseling Psychology, 56, 408-416. doi: 10.1037/a0016180 pdf [article reprinted in Italian in 2010 in GIPO Giornale Italiano Di Psicologia Dell’Orientamento, 11, 47-59.] pdf
Although many students struggle with career-related issues in college, comparatively few engage the career services offered by their academic institutions for help with their difficulties. In addition, there is little research on the factors influencing students’ decisions to engage in counseling for career-related issues, making it difficult to develop programs to enhance students’ use of career counseling services. The present study examines the relationships between the stigma associated with help seeking and attitudes toward engaging in career counseling. Participants were 509 college students who com- pleted measures of stigma and attitudes toward career counseling. Structural equation modeling results indicated that public and personal stigmas were linked to self-stigma, which in turn was linked to attitudes toward seeking career counseling. Sixty percent of the variance in self-stigma and 42% of the variance in attitudes was accounted for in the model.
Soheilian, S. S., & Inman, A. G. (2009). Middle Eastern Americans: The effects of stigma on attitudes toward counseling. Journal of Muslim Mental Health, 4, 139-158. doi: 10.1080/15564900903245766
The purpose of this study was to examine the mediating effect of self-stigma of mental illness on the relationship between perceived public stigma of mental illness and attitudes toward counseling. One hundred and two Middle Eastern Americans from universities across the United States participated in the study. Path analysis consisting of multiple regressions revealed that mediation was not met. However, results revealed that participants with greater levels of self-stigma exhibited more negative attitudes toward counseling. Implications for theory, practice, and research are discussed.
Vogel, D. L., & Wade, N. G. (2009). Stigma and seeking help: It’s not just about what others think. The Psychologist, 22, 20-23. pdf
The fear of being stigmatised by others often leads people to avoid professional help. This stigma can also be internalised, further reducing the likelihood of seeking help. Understanding these different forms of stigma can help psychologists target interventions at different levels to help people overcome the barriers to seeking help.
Vogel, D. L., Wade, N. G., & Ascheman, P. (2009). Measuring perceptions of stigmatization by others for seeking psychological help: Reliability and validity of a new stigma scale with college students. Journal of Counseling Psychology, 56, 301-308. doi: 10.1037/a0014903 pdf
Fear of being stigmatized is the most cited reason why individuals avoid psychotherapy. Conceptually, this fear should be strongest when individuals consider the reactions of those they interact with. Across 5 samples, the authors developed the Perceptions of Stigmatization by Others for Seeking Help (PSOSH) scale. In Sample 1 (N = 985), the 5 items of the PSOSH were selected (α = .91). In Sample 2 (N= 842), the unidimensional factor structure of the scale was examined across a diverse sample. In Sample 3 (N = 506), concurrent validity was supported through moderate associations with 3 different stigma measures (i.e., public stigma toward counseling, r = .31; public stigma toward mental illness, r = .20; and self-stigma, r = .37). In Sample 4 (N = 144), test–retest reliability across a 3-week period was calculated (.82). Finally, in Sample 5 (N = 130), reliability (α = .78) and validity were explored with a sample experiencing symptoms of psychological distress. Relationships between variables (i.e., public stigma toward counseling, r = .31, and self-stigma, r = .40) were similar to those in previous samples.
Television portrayals of psychologists may be contributing to an unfavorable perception of mental health services. The present study (N = 369) used structural equation modeling to examine the relationship between exposure to television programs, perceptions of therapy (i.e., perceived stigma, anticipated risks and benefits, and attitudes towards therapy), and intentions to seek therapy. The results demonstrated that (a) the relationship between television exposure and attitudes was fully mediated by stigma and anticipated benefits, and (b) the relationship between television exposure and intentions to seek therapy was fully mediated by attitudes, stigma, and anticipated benefits. Furthermore, 54% of the variance in attitudes and 47% of the variance in intentions was accounted for by the variables in the model.
Pederson, E. L., & Vogel, D. L. (2007). Men’s gender role conflict and their willingness to seek counseling: A mediation model. Journal of Counseling Psychology, 54, 373-384. doi: 10.1037/0022-0188.8.131.523 pdf
Men who experience negative consequences of their socialized gender roles—that is, have greater gender role conflict—report less positive attitudes and willingness to seeking counseling. Using structural equation modeling with data from 575 undergraduate men, the authors examined 3 mediators (self-stigma associated with seeking counseling, tendency to disclose distressing information, and attitudes toward seeking counseling) regarding the link between gender role conflict and willingness to seek counseling for psychological and interpersonal concerns. Results indicated that this link was partially mediated by these 3 factors. Men experiencing greater gender role conflict were more likely to self-stigmatize and less likely to self-disclose. High self-stigma and less disclosure then led to less positive attitudes and subsequently to less willingness to seek counseling.
Vogel, D. L., Wade, N. G., & Hackler, A. H.1 (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes towards counseling. Journal of Counseling Psychology, 54, 40-50. doi: 10.1037/0022-0184.108.40.206 pdf
This study examined the mediating effects of the self-stigma associated with seeking counseling and attitudes toward seeking counseling on the link between perceived public stigma and willingness to seek counseling for psychological and interpersonal concerns. Structural equation modeling of data from 676 undergraduates indicated that the link between perceived public stigma and willingness to seek counseling was fully mediated by self-stigma and attitudes. Perceptions of public stigma contributed to the experience of self-stigma, which, in turn, influenced help-seeking attitudes and eventually help-seeking willingness. Furthermore, 57% of the variance in attitudes toward counseling and 34% of the variance in willingness to seek counseling for psychological and interpersonal concerns were accounted for in the proposed model.
Vogel, D. L., Wade, N. G., & Haake, S.1 (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53, 325-337. doi: 10.1037/0022-0220.127.116.115 pdf
Self-stigma is an important factor in people’s decisions not to engage in therapy. To measure this construct, the authors developed the 10-item Self-Stigma of Seeking Help (SSOSH) scale. In Study 1 (n = 583), the SSOSH had a unidimensional factor structure and good reliability (.91) among participants. Study 2 (n = 470) confirmed the factor structure. Studies 2, 3 (n = 546), and 4 (n = 217) cross-validated the reliability (.86 to .90; test–retest, .72) and showed evidence of validity (construct, criterion, and predictive) across the study samples. The SSOSH uniquely predicted attitudes toward and intent to seek psychological help. Finally, in Study 5 (n = 655) the SSOSH differentiated those who sought psychological services from those who did not across a 2-month period.