Self-Stigma, Mental Health Literacy, and Attitudes Toward Seeking Psychological Help

Transcription

1 Received 02/13/16 Revised 01/11/17 Accepted 02/20/17 DOI: /jcad Self-Stigma, Mental Health Literacy, and Attitudes Toward Seeking Psychological Help Hsiu-Lan Cheng, Cixin Wang, Ryon C. McDermott, Matthew Kridel, and Jamey Leeanne Rislin This study examined self-stigma of seeking psychological help and mental health literacy as predictors of college students (N = 1,535) help-seeking attitudes, with additional attention to psychological and demographic correlates. Results indicated that mental health literacy predicted help-seeking attitudes above and beyond self-stigma. Asian American race/ethnicity, male gender, current psychological distress, and help-seeking history were also significant predictors. Implications for addressing mental health literacy and self-stigma while attending to demographic and psychological variations in help seeking are discussed. Keywords: self-stigma, mental health literacy, help-seeking attitudes, college students, race/ethnicity Mental health problems are prevalent on college campuses (American College Health Association, 2015), with approximately 50% of college-attending adults meeting diagnostic criteria for a mental disorder (Zivin, Eisenberg, Gollust, & Golberstein, 2009). However, help seeking among college students is alarmingly low. For example, researchers have found that approximately 64% of college students with a mental health problem have not sought professional help in the past year (Eisenberg, Hunt, Speer, & Zivin, 2011). In addition, racial/ethnic minority students are even less likely than non- Hispanic White students to seek psychological help for mental health difficulties, possibly because of a lack of culturally sensitive services (Masuda et al., 2009). The increased risk for mental health concerns in college students coupled with a general reluctance to seek psychological help, particularly among minority students, makes identifying contributing factors to positive attitudes toward help seeking in college an important area of inquiry. A particularly useful framework for understanding diverse college students help-seeking attitudes is Cauce et al. s (2002) Model for Mental Health Help Seeking, which describes three interconnected aspects of help seeking: (a) problem recognition, (b) decision to seek help, and (c) service selection. A key assumption of this model is that cultural worldviews, including those shaped by race/ethnicity and gender, are integral in the help-seeking process and influence all three domains of the model. For example, race/ethnicity may influence (a) whether certain problems are perceived as mental health related, (b) decisions to seek help, and (c) what types of services are acceptable to the person (e.g., informational supports vs. psychotherapy). Guided by Cauce et al. s (2002) model, the present study examined help seeking related variables with a racially/ ethnically diverse sample of college men and women. Specifically, we investigated mental health literacy, defined as knowledge and beliefs about mental disorders (Jorm et al., 1997, p. 182), and self-stigma of seeking psychological help, defined as viewing psychological help as a threat to personal self-worth (Vogel, Wade, & Haake, 2006). As articulated by Cauce et al., problem recognition is the first step to help seeking, and mental health literacy aids in this initial step (Jorm et al., 1997). Levels of self-stigma, on the other hand, may influence the decision-making and service selection stages (Cauce et al., 2002) by either facilitating or discouraging these processes. We focused on these two variables because of their pertinence in informing helpseeking interventions. Moreover, although researchers have examined mental health literacy (Coles & Coleman, 2010) Hsiu-Lan Cheng, Department of Counseling Psychology, University of San Francisco; Cixin Wang, Department of Counseling, Higher Education, and Special Education, University of Maryland, College Park; Ryon C. McDermott and Matthew Kridel, Department of Counseling and Instructional Sciences, University of South Alabama; Jamey Leeanne Rislin, Department of Counseling and Educational Psychology, New Mexico State University. Correspondence concerning this article should be addressed to Hsiu-Lan Cheng, Department of Counseling Psychology, University of San Francisco, School of Education, 2130 Fulton Street, San Francisco, CA ( hcheng13@usfca.edu) by the American Counseling Association. All rights reserved.

2 Attitudes Toward Seeking Psychological Help and self-stigma (Vogel et al., 2006) separately, less attention has been focused on the investigation of their relative contributions and potential interactions in the prediction of help-seeking attitudes. Mental Health Literacy, Self-Stigma of Seeking Psychological Help, and Their Interplay Researchers have linked mental health literacy, self-stigma of seeking psychological help, and attitudes toward seeking psychological help (Coles & Coleman, 2010; Corrigan, 2004; Eisenberg, Downs, Golberstein, & Zivin, 2009; Milin et al., 2016; Wright, Jorm, Harris, & McGorry, 2007). In the following paragraphs, we review the literature on these three key variables and their associations. We also consider demographic (gender, race/ethnicity) and psychological (helpseeking history, current depression and anxiety) correlates of help-seeking attitudes. Mental Health Literacy Mental health literacy, by definition, encompasses the ability to differentiate a mental health condition from general stress, attributions of mental disorders, and knowledge and beliefs about risk factors and available professional help (Jorm et al., 1997). Researchers have found that individuals with higher levels of mental health literacy (e.g., ability to recognize symptoms and correctly attribute them to mental illness) are more likely to seek psychological help for themselves and recommend professional help for others (Coles & Coleman, 2010; Wright et al., 2007). For example, after controlling for demographic characteristics (age, gender, parents occupation) and exposure to mental health problems, Wright et al. (2007) found that correct recognition or labeling of depression was a significant predictor for choosing appropriate help (e.g., from a mental health professional) and seeking timely treatment for depression among young people ages 12 to 25 years in Australia. By contrast, inaccurate attributions of mental illness (e.g., to recent stressors, environmental factors) were related to using non-evidence-based interventions instead of seeking professional help among U.S. college students (Coles & Coleman, 2010). Although the importance of mental health literacy is clearly indicated in the literature, to date, only a limited number of researchers have conducted studies that examined mental health literacy regarding depression and anxiety among college students in the United States (Coles & Coleman, 2010; J. E. Kim, Saw, & Zane; 2015; Stansbury, Wimsatt, Simpson, Martin, & Nelson, 2011), and their findings suggest relatively low levels of literacy in recognizing depression and anxiety. For example, Stansbury et al. (2011) found that 37% of African Americans in their college student sample were unable to identify depression in a series of case vignettes; instead, they attributed depression to stress or personal reasons (e.g., family conflict). Coles and Coleman (2010) found that more than 50% of the respondents in their racially/ethnically diverse college student sample labeled generalized anxiety disorder (GAD) inaccurately. Thus, it is possible that young adults may have challenges in accurately identifying depression and anxiety. Given that depression and anxiety are common mental health concerns in college (American College Health Association, 2015), assessing college students mental health literacy is imperative. Self-Stigma of Seeking Psychological Help In addition to mental health literacy, stigma has been identified as a major barrier to seeking help from mental health professionals (Corrigan, 2004). Although individuals who seek psychological help must overcome a variety of public stigmas (Barney, Griffiths, Jorm, & Christensen, 2006), self-stigma may play an even more critical and proximal role in explaining help seeking (Eisenberg et al., 2009; Vogel et al., 2006). Among college samples, racially/ethnically diverse college students with higher levels of self-stigma are less likely to seek help (Nam et al., 2013; Vogel, Wade, & Hackler, 2007). In addition, researchers have identified that college students may be more likely to experience anxiety and depression associated with self-stigma of seeking help (Cheng, McDermott, & Lopez, 2015). The Interplay Between Mental Health Literacy and Self-Stigma Compared with the increasing research on self-stigma of seeking psychological help (for reviews, see Clement et al., 2015; Nam et al., 2013), less empirical effort has been directed toward understanding mental health literacy among college students. Furthermore, it is unknown what relative roles mental health literacy and self-stigma play in the prediction of college students help-seeking attitudes. It is possible that mental health literacy and self-stigma interact with each other to inform college students help-seeking attitudes. For example, an attribution of GAD to stress may intensify (i.e., exacerbate) the negative link between selfstigma and the willingness to seek help. Similarly, although the ability to correctly recognize symptoms of depression (i.e., problem recognition) may be positively associated with favorable help-seeking attitudes, high levels of self-stigma may diminish this positive link. Milin et al. (2016) found that when mental health literacy is enhanced among high school students, stigmatic views about mental illness tend to decrease. However, to our knowledge, researchers have not examined the potential interactions between mental health literacy and self-stigma in association with help-seeking attitudes in college student populations. 65

3 Cheng, Wang, McDermott, Kridel, & Rislin Gender, Race/Ethnicity, Help-Seeking History, and Psychological Distress as Correlates Because of the diversity of college students, when examining the roles of mental health literacy, self-stigma, and their interaction, we considered potential variations in help-seeking attitudes due to gender and race/ethnicity. In addition, past help seeking and current levels of psychological distress (i.e., depression and anxiety symptoms) were also considered as correlates in the analyses. In the following paragraphs, we discuss the potential impact of gender, race/ethnicity, help-seeking history, and current psychological distress on help-seeking attitudes to provide an empirical and theoretical rationale for the inclusion of these important covariates. Gender Data based on community samples have consistently demonstrated that women have more positive attitudes toward help seeking (Gonzalez, Alegria, & Prihoda, 2005; Rüsch et al., 2014) and more favorable intentions to seek help from mental health professionals than do men (Mackenzie, Gekoski, & Knox, 2006). Theories addressing gender role characteristics (e.g., rigid masculinity) have been applied to explain gender differences in help seeking among adults in the community (Gonzalez et al., 2005) and college students (Good & Wood, 1995). In addition, psychological openness, defined as openness to acknowledge psychological difficulties and the need for help seeking, has been associated more with females and, thus, may explain gender differences in seeking mental health services (Mackenzie et al., 2006). Race/Ethnicity Researchers have generally found that racial/ethnic minority college students are less likely than their non-hispanic White peers to use mental health services (J. E. Kim & Zane, 2015). For example, only 18.9% of African American college students and 8.5% of Asian American college students sought help from a psychological professional (e.g., psychiatrist, psychologist, or counselor) for a personal problem compared with 50.4% of non-hispanic White college students (Masuda et al., 2009). In addition, African American and Asian American college students had less favorable help-seeking attitudes toward professional psychological services than did their non-hispanic White counterparts (Masuda et al., 2009). Similarly, results from one study showed that Asian American students used counseling or psychotherapy the least (only 18.8% had ever been in counseling) compared with African American (38.8%) and Latino American (48.6%) students (Cheng, Kwan, & Sevig, 2013). Various factors have been suggested to explain such racial/ethnic differences, including mistrust of non-hispanic White counselors because of historical oppression (David, 2010), cultural differences in problem recognition, racial/ethnic variations in perceived benefits of treatment, and the lack of culturally appropriate services (Cauce et al., 2002; J. E. Kim & Zane, 2015; Turner et al., 2016). Help-Seeking History Researchers have denoted a positive connection between past help seeking and current favorable intentions or attitudes toward seeking psychological help among college students (Fischer & Farina, 1995). Researchers have suggested that this positive association is related to increased knowledge about and openness toward mental health services among individuals with a help-seeking history (J. E. Kim et al., 2015). For example, college students who have sought professional psychological help in the past have been found to be more cognizant of symptoms indicative of potential depression and anxiety problems as well as more likely to recommend seeking professional help for those symptoms (J. E. Kim et al., 2015). Current Psychological Distress The findings on how current psychological distress affects help seeking have been mixed. Some researchers have found that college students with higher levels of psychological distress have more favorable attitudes toward seeking professional help (Vogel & Wei, 2005), possibly because of a higher perceived need for mental health services. However, results from a recent study showed that college students with moderate or serious psychological distress (i.e., depression and anxiety symptoms experienced in the past 30 days) were less likely to recommend seeking professional help for depression than were students with no or mild levels of distress (J. E. Kim et al., 2015). The results from this study also showed no association between levels of psychological distress and recommendations for seeking professional help for anxiety (J. E. Kim et al., 2015). Rüsch et al. (2014) suggested that adults (not specifically college students) may associate shame with their mental health problems and thus hold unenthusiastic attitudes toward seeking professional help. To account for the potentially complex relationship between psychological distress and help-seeking attitudes, we included psychological distress as a correlate of help-seeking attitudes. The Present Study The goals of the present study were to examine the roles of mental health literacy (i.e., recognition and attribution of depression and GAD) and self-stigma of seeking psychological help, as well as their interactions, in predicting attitudes toward seeking psychological help among a diverse sample of college students. We asked two important research questions: (a) Will mental health literacy variables (i.e., depression recognition, GAD recognition, depression attribution, and GAD 66

4 Attitudes Toward Seeking Psychological Help attribution) and self-stigma of seeking psychological help significantly predict help-seeking attitudes after covariates (i.e., gender, race/ethnicity, help-seeking history, and current psychological distress) have been taken into account? and (b) Are there significant interaction effects between mental health literacy variables and self-stigma of seeking psychological help in predicting help-seeking attitudes, after the main effects of the predictors and the covariates have been taken into account? Method We used a cross-sectional design to investigate our research questions. Cross-sectional designs are a useful first step in uncovering potential causal relations among variables that may be further confirmed by experimental or longitudinal designs (Heppner, Wampold, & Kivlighan, 2008). In the following paragraphs, we describe our research procedures, sample characteristics, and measurement tools. Participants and Procedure We used an anonymous Internet-based survey to recruit participants from a large public university in the midwestern United States. Although a true response rate could not be calculated because of an inability to determine which students opened the targeted , a total of 1,873 college students (19%) participated in the survey. We used 1,535 participants for the present sample after excluding students who identified as international, other, or more than one race. The majority of the participants were non-hispanic White (77.5%, n = 1,190), followed by Asian American (8.6%, n = 132), Latino American (7.0%, n = 108), and African American (6.8%, n = 105). (Percentages do not total 100 because of rounding.) With consideration to the four primary racial/ethnic groups, the study sample was slightly different from the university demographics. At the time of data collection, the university s makeup was 74.4% non-hispanic White, 14.7% Asian American, 5.6% Latino American, and 5.4% African American. To adjust for these differences, we used sampling weights in the primary analyses. A post hoc power analysis (Balkin & Sheperis, 2011) conducted using G*Power (Version 3.1; Faul, Erdfelder, Buchner, & Lang, 2009) indicated that the current sample size had a statistical power of 1.00 to detect a small effect size of 0.15 based on the chosen Type I error probability rate (α =.05) and the number of predictors in the regression models. Participants ages ranged from 18 to 56 years (M = 23.71, SD = 6.29). Most participants identified as heterosexual (88.4%) and female (63.3%). Measures All participants completed a battery of five measures. In addition, we collected demographic information and data on participants history of utilizing professional mental health services. To monitor inattentive responding, we asked participants to respond to four randomly placed validity items (e.g., Please select Option 3 for this question ). Depression. Depression symptoms were measured using the Patient Health Questionnaire 9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a nine-item screening instrument that assesses the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) criteria for depression. Although the DSM-5 (APA, 2013) includes some changes (e.g., the bereavement exclusion was omitted in the DSM-5) from the DSM-IV-TR, the core criteria for diagnosing major depressive disorders have not changed between these versions. Because of the consistency in diagnostic criteria for major depressive disorders from the DSM-IV-TR to the DSM-5, we considered the PHQ-9 an appropriate screening measure for depression symptoms in our study. On the PHQ-9, respondents indicate the frequency with which they have experienced symptoms of depression (e.g., little interest or pleasure in doing most things ) in the past 2 weeks using a 4-point Likerttype scale ranging from 0 (not at all) to 3 (nearly every day). Higher scores indicate a greater endorsement of depression symptoms. Kroenke et al. (2001) first provided evidence for the predictive validity of the PHQ-9 in a sample of 6,000 medical patients. McAleavey et al. (2012) found support for the convergent validity of the PHQ-9 in a large college student sample and reported an internal consistency estimate of.86. In the present study, we averaged item responses to generate a scale score and obtained an adequate internal consistency coefficient (α =.86). Anxiety. Anxiety symptoms were measured using the Generalized Anxiety Disorder 7 (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006). The GAD-7 is a seven-item brief assessment of GAD. Respondents indicate the frequency of specific anxiety problems corresponding to the DSM-IV- TR (APA, 2000) criteria for GAD (e.g., feeling nervous, anxious or on an edge ) in the past 2 weeks using a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). Higher scores indicate a greater endorsement of GAD symptoms. Spitzer et al. (2006) provided initial evidence for the validity of the GAD-7 by identifying positive correlations with other anxiety screening instruments, as well as negative correlations with patient functioning. The GAD-7 demonstrated an internal consistency estimate of.92 (Spitzer et al., 2006). In the present study, we averaged item responses to generate a scale score and obtained an adequate internal consistency coefficient (α =.89). Self-stigma of seeking psychological help. Participants stigma of seeking psychological help was assessed with the Self-Stigma of Seeking Help Scale (SSOSH; Vogel et al., 2006). The SSOSH is a 10-item scale measuring internalized stigma of seeking psychological help (e.g., I would feel inadequate if I went to a therapist for psychological help ). 67

5 Cheng, Wang, McDermott, Kridel, & Rislin Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher average scores indicating greater self-stigma. SSOSH scores are related to measures of general mental health stigma (Tucker et al., 2013) and attitudes toward seeking counseling (Vogel, Heimerdinger-Edwards, Hammer, & Hubbard, 2011). SSOH scores produced internal consistency estimates ranging from.86 to.90 in a sample of primarily non-hispanic White college students (Vogel et al., 2006), as well as internal consistency estimates within similar ranges in samples of racial/ethnic minority college students (Cheng et al., 2013). In the present study, we averaged item responses to generate a scale score and obtained an adequate internal consistency coefficient (α =.89). Mental health literacy. Mental health literacy was assessed using two vignettes developed by Coles and Coleman (2010); the vignettes are designed to portray the essential features of GAD and depression as defined by DSM-IV-TR (APA, 2000) criteria. Each vignette description was followed by questions assessing mental health literacy, such as problem recognition (e.g., What do you think is wrong with [name of person in vignette]? ) and perceptions of causality (e.g., What do you think is the primary cause of this problem? ). For the purpose of the current study, we focused only on participants ability to recognize anxiety or depression as well as their attributions of these symptoms to stress. Data were coded in a binary way such that 1 indicated recognition of a mental health problem (e.g., 1 = correct recognition of anxiety, 0 = inaccurate recognition of anxiety) or an attribution to stress (e.g., 1 = attribution of symptoms to stress, 0 = no attribution of symptoms to stress). Attitudes toward seeking psychological help. Participants attitudes toward seeking psychological help were assessed using the Attitudes Toward Seeking Professional Psychological Help Scale Short Form (ATSPPH-SF; Fischer & Farina, 1995). The ATSPPH-SF is a 10-item measure adapted from the original ATSPPH (Fischer & Turner, 1970), which assesses attitudes about using psychological services. Items are rated on a 4-point Likert-type scale ranging from 0 (disagree) to 3 (agree), with higher scores indicating more positive attitudes toward seeking psychological help. A sample item is I would want to get psychological help if I were worried or upset for a long period of time. Fischer and Farina (1995) reported that ATSPPH-SF scores highly correlated with the full-scale scores from the original measure, produced a good internal consistency coefficient (α =.84), and predicted past help seeking. The ATSPPH-SF has demonstrated good internal consistency coefficients in samples of racially/ethnically diverse community adults (Gloria, Castellanos, Segura-Herrera, & Mayorga, 2010) and college students (P. Y. Kim & Kendall, 2015). In the present study, we averaged item responses to generate a scale score and obtained an adequate internal consistency coefficient (α =.83). Results As a preliminary step, we screened data for outliers, normality, and multicollinearity before performing the primary regression analyses. No univariate outliers were found for all of the variables except for depression recognition. Specifically, there was an approximately 93 7 split between participants who correctly (92.9%) and incorrectly (7.1%) categorized the depression vignette. Researchers have suggested deletion of dichotomous variables with splits, or more, between categories because scores of the respondents in the small category can become excessively influential (Tabachnick & Fidell, 2007). Therefore, we did not include depression recognition as a predictor in our primary analyses. With regard to multivariate outliers, five cases (0.3% of the total sample of 1,535) had significant Mahalanobis distance scores (p <.001). However, some outliers are generally acceptable if they are less than 2% of the sample (Cohen, Cohen, West, & Aiken, 2003). In terms of normality, the covariate variables of depression and anxiety symptoms were moderately and positively skewed, whereas other continuous variables were normally distributed. Because a minor departure from normality usually does not influence the analysis substantially in large samples (Tabachnick & Fidell, 2007), we did not transform the anxiety and depression variables. In terms of multicollinearity, none of the variables tolerance statistics indicated signs of multicollinearity. In addition, we centered self-stigma (i.e., a continuous predictor variable) when testing its interaction with mental health literacy variables to avoid multicollinearity (Cohen et al., 2003). Descriptive Statistics Before describing our main analyses, we report the participants rates of help seeking and mental health literacy for descriptive purposes. Specifically, 29.5% of the sample had sought professional psychological help in the past 12 months, and 41.2% had sought this kind of help prior to the past 12 months. However, Asian Americans had the lowest helpseeking rates in the past 12 months (14.4%) and prior to the past 12 months (19.7%) compared with African Americans (34.3%, 40.4%), Latino Americans (31.5%, 47.2%), and non- Hispanic Whites (30.6%, 43.1%; p < to p <.001). In terms of mental health literacy, less than two thirds of the sample (61.8%) accurately categorized the GAD vignette. Asian Americans (47.0%) and African Americans (48.6%) had lower rates of GAD recognition compared with Latino Americans (58.3%) and non-hispanic Whites (64.9%; p <.001). Regarding attribution of symptoms to stress, 47.2% and 26.2% of the sample selected stress as the primary cause of symptoms in the GAD and depression vignettes, respectively. All minority groups were more likely than non-hispanic Whites to attribute stress to being the primary cause of GAD and depression (p < to p <.001). Table 1 presents the intercorrelations, means, 68

6 Attitudes Toward Seeking Psychological Help TABLE 1 Intercorrelations, Means, and Standard Deviations Among Variables Variable 1. Help seeking 2. Current DEP 3. Current anxiety 4. Self-stigma 5. Correct GAD a 6. Stress GAD a 7. Stress DEP a 8. Past help-a a 9. Past help-b a 10. Male a 11. African Am a 12. Asian Am a 13. Latino Am a 14. White a *.71*.65*.16*.10* M SD.23*.00.17*.17*.13*.21*.17*.10*.13*.12*.38*.28*.28*.21*.10*.07*.06*.39*.17*.18*.27*.14.13*.10*.41*.26*.07*.16*.20*.22.11*.91*.06*.06*.06.10*.06* *.08*.13*.12.11*.09.13*.17*.00.10*.06*.10*.11*.10*.61.14*.10*.12*.08*.12*.41*.71*.42* Note. N = 1,535. Help seeking = attitudes toward seeking professional psychological help; Current DEP = current depression; Self-stigma = self-stigma of seeking psychological help; Correct GAD = correct recognition of generalized anxiety disorder (GAD) symptoms in the vignette; Stress GAD = attribution of stress to being the primary cause of symptoms in the GAD vignette; Stress DEP = attribution of stress to being the primary cause of symptoms in the depression vignette; Past help-a = sought professional psychological help in the past 12 months; Past help-b = sought professional psychological help prior to the past 12 months; African Am = African American; Asian Am = Asian American; Latino Am = Latino American; White = non-hispanic White. a These variables were coded as 0 = no and 1 = yes. *p <.05. and standard deviations of the variables. As shown in Table 1, having a help-seeking history, higher levels of current GAD symptoms, and accurate recognition of GAD were associated with more favorable attitudes toward seeking psychological help. In contrast, higher levels of self-stigma and attribution of stress to being the primary cause of GAD or depression were associated with less favorable attitudes toward seeking psychological help. Primary Analyses To examine whether mental health literacy variables and selfstigma predicted help-seeking attitudes after covariates had been taken into account, we conducted a hierarchical regression analysis with the covariates entered in the first step and mental health literacy variables and self-stigma entered in the second step. Table 2 shows that in Step 1, male gender (B =.26, β =.22, p <.001), Asian American race/ethnicity (B =.13, β =.08, p <.05), and current levels of depression symptoms (B =.16, β =.16, p < ) significantly and negatively predicted attitudes toward seeking psychological help, whereas help seeking in the past 12 months (B =.35, β =.28, p <.001) and help seeking prior to the past 12 months (B =.31, β =.27, p <.001) positively predicted attitudes toward seeking professional help. In Step 2, self-stigma significantly and negatively (B =.30, β =.53, p <.001) predicted helpseeking attitudes, and so did attribution of stress to being the primary cause of GAD (B =.05, β =.05, p <.05) or depression (B =.09, β =.07, p <.001). On the other hand, accurate recognition of GAD (B =.07, β =.06, p < ) significantly and positively predicted help-seeking attitudes. To examine whether there was an interaction between the mental health literacy variables and self-stigma in predicting help-seeking attitudes, after the main effects of the predictors and the covariates had been taken into account, we entered the interaction terms in Step 3 of the hierarchical regression after entering Step 1 (covariates) and Step 2 (self-stigma, mental health literacy) variables. None of the interaction terms between the mental health literacy variables and self-stigma were statistically significant (see Table 2). Discussion Informed by Cauce et al. s (2002) help-seeking model, we examined our first research question to determine whether self-stigma and mental health literacy variables could explain help-seeking attitudes above and beyond covariates. Results of a hierarchical regression (Step 2 in Table 2) indicated that selfstigma and mental health literacy variables significantly and uniquely explained help-seeking attitudes above and beyond demographic (gender, race/ethnicity) and psychological (helpseeking history, current depression and anxiety) correlates. This finding supports the utility of concurrent consideration of the problem recognition (e.g., mental health literacy) and service selection (e.g., self-stigma of seeking professional psychological help) domains of Cauce et al. s model of help seeking in conceptualizing college students help-seeking attitudes. With regard to self-stigma, we found that college students with greater self-stigma were less likely to endorse favorable attitudes toward seeking professional psychological help, even after considering covariates variables. This finding 69

7 Cheng, Wang, McDermott, Kridel, & Rislin TABLE 2 Summary of Hierarchical Regression Analyses Predicting Help-Seeking Attitudes Variable Step 1 Past help-a a Past help-b a Current DEP Current anxiety Male a African American Asian American Latino American Non-Hispanic White b Step 2 Self-stigma Correct GAD a Stress GAD a Stress DEP a Step 3 Self-Stigma Correct GAD Self-Stigma Stress GAD Self-Stigma Stress DEP B SE B b Adjusted R 2 DR ***.27***.16**.22***.08*.53***.06**.05*.07*** Note. N = 1,535. Past help-a = sought professional psychological help in the past 12 months; Past help-b = sought professional psychological help prior to the past 12 months; Current DEP = current depression; Self-stigma = self-stigma of seeking psychological help; Correct GAD = correct recognition of generalized anxiety disorder (GAD) symptoms in the vignette; Stress GAD = attribution of stress to being the primary cause of symptoms in the GAD vignette; Stress DEP = attribution of stress to being the primary cause of symptoms in the depression vignette. a These variables were coded as 0 = no and 1 = yes. b Reference group. *p <.05. **p <. ***p < ***.54***.54***.19*** *** is consistent with previous research indicating that self-stigma is a powerful factor that dissuades professional help seeking for mental health concerns (Nam et al., 2013; Vogel et al., 2006, 2007). In addition, we found that students who were able to correctly recognize GAD symptoms or did not attribute stress to being the primary cause of GAD or depression were more likely to hold positive views toward seeking professional psychological help, even after accounting for variations due to demographic and psychological factors. Also, in line with previous studies (Coles & Coleman, 2010), we found that college students who incorrectly attributed depression and GAD symptoms to stress reported less positive attitudes toward seeking professional psychological help. We examined our second research question to determine whether there would be significant interactions between mental health literacy variables and self-stigma after the main effects of the predictors and covariates had been taken into account. Although recent research data on high school students indicate that mental health stigma may decrease when mental health literacy increases (Milin et al., 2016)suggesting that there might be a potential interaction effect in which mental health literacy protects against self-stigmawe found no significant interaction. However, to our knowledge, no previous studies have examined the interaction between theses variables. Future research is needed to further examine this topic area before making firm conclusions. Although not a primary focus of our study, we also examined demographic and psychological correlates of help-seeking attitudes when testing the relevance of selfstigma and mental health literacy variables. We found that several demographic and psychological variables had significant associations with help-seeking attitudes. Specifically, we found that students who were male, were Asian American, had higher levels of current depression symptoms, or had no previous history of utilizing psychological services reported less favorable attitudes toward seeking psychological help. These findings are consistent with previous research (Cheng et al., 2013; Eisenberg et al., 2009; J. E. Kim et al., 2015; Masuda et al., 2009) and suggest the importance of including these demographic and psychological correlates when clarifying the contributions of primary variables of interest (e.g., self-stigma, mental health literacy) in help-seeking processes. Several additional prominent findings related to demographic variables were also observed. Specifically, although most participants (92.9% in the current sample) were able to recognize depression in the depression vignette, only 61.8% of the participants recognized anxiety in the GAD vignette. In addition, 47.2% and 26.2% of the sample, respectively, selected stress as the primary cause of symptoms in the GAD and depression vignettes. Although this finding is consistent with research data demonstrating that recognition of depression is generally higher than that of GAD among college students (Coles & Coleman, 2010), possibly because of increased mental health efforts raising depression awareness on college campuses (Field, Elliott, Korn, & Schuh, 2006), it indicates that mental health literacy in the areas of GAD 70

8 Attitudes Toward Seeking Psychological Help recognition and causal attribution of GAD and depression requires further empirical attention. Moreover, we found that racial/ethnic minority groups (i.e., African Americans, Asian Americans, and Latino Americans) were more likely than non-hispanic Whites to attribute stress to being the primary cause of GAD or depression. Although some research has compared health literacy (e.g., physical diseases) among U.S. racial/ethnic groups (Ickes & Cottrell, 2010), we were unable to locate any empirical studies that have compared mental health literacy (e.g., GAD or depression recognition or attribution) across the four major racial/ethnic groups in the United States. Thus, our preliminary findings point to the importance of considering cultural differences in the identification and attribution of mental health problems in future research and practice, which represents a significant gap in the help-seeking literature (Cauce et al., 2002). Limitations and Future Research Directions Several limitations should be acknowledged before discussing the implications of the current findings. First, our findings are based on the self-report data of a student sample recruited from one large public university in the midwestern United States and may not be generalizable to other geographic areas or other types of institutions. In addition, although our large sample size allowed for adequate statistical power to examine the hypothesized relationships, having a larger sample than necessary might have unwittingly inflated statistical significance. Second, cross-sectional data cannot confirm causality of relationships among variables or verify significant temporal links in the help-seeking process. Future researchers should replicate and extend our findings with longitudinal designs, including examining the possible causal interplay between mental health literacy and stigma (Coles & Coleman, 2010). For example, increases in mental health literacy may result in decreases in self-stigma that lead to favorable help-seeking outcomes. Gender, race/ethnicity, and help-seeking history may moderate such causal pathways. Another potential limitation of our study pertains to the measurement of problem recognition. Specifically, we asked participants, What do you think is wrong with [name of person in vignette]? as used in the original measure developed by Coles and Coleman (2010). The wording wrong with might unintentionally increase the likelihood for stigmatizing depression and anxiety. Future researchers may use questions such as What do you think is going on with [name of person in vignette]? instead. Relatedly, one challenge in our assessment of mental health literacy is the use of a measure that was developed based on Western epidemiological definitions of mental disorder symptoms rooted in the DSM paradigm. Symptoms typically seen as indicative of DSM disorders may be perceived or evaluated differently by other cultures. To our knowledge, no mental health literacy measures have been specifically developed for U.S. racial/ethnic minorities. Thus, an important area for future research is the development and cross-cultural validation of mental health literacy measures. Finally, our preliminary evidence suggests differential gender and racial/ ethnic patterns with regard to help-seeking history and mental health literacy. Thus, it is important that future researchers more thoroughly examine demographic differences to develop culturally syntonic help-seeking interventions. Implications for Professional Counseling Practice The findings in this study highlight the role of self-stigma and mental health literacy in college students attitudes toward seeking professional counseling. Increased knowledge about the factors that are associated with help seeking has valuable implications for professional counselors working with college students. Our study confirmed the utility of Cauce et al. s (2002) Model for Mental Health Help Seeking among diverse populations but also lent specificity to the model. Mental health literacy emerged as a factor that may be of particular importance in enhancing problem recognition and increasing positive attitudes toward help seeking among college students. We found that many college students in our sample attributed depression and anxiety to general stress. It is likely that students knowledge of counseling and their appraisals of the appropriateness of help seeking are based on inaccurate information gathered from media and other sources (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Jorm et al., 1997). Mental health literacy may be improved by having counselors on college campuses conduct outreach programs that provide information about the symptoms associated with mental health conditions, the differences between general stress and clinical syndromes, and the importance of help seeking. For example, professional counselors can inform college students about the early onset age (prior to 24 years) for most mental health conditions and the health benefits when these conditions are treated early on (Thomas, Caputi, & Wilson, 2014). Mental health service providers and counselors are called by professional organizations to contribute to the public good through information sharing and basing their techniques on scientific findings (American Counseling Association, 2014). Helping college students to increase their ability to detect symptoms associated with mental health conditions and garner an awareness of when professional help is warranted meets these two ethical imperatives. Given the fact that racial/ethnic minority students were more likely than their nonminority counterparts to dismiss psychological symptoms as stress, culturally responsive outreach programs that educate students about cultural concepts (e.g., saving face, strong Black woman syndrome, machismo) and how these might affect mental health and general stress attributions may facilitate greater mental health literacy. For example, minority students (e.g., Asian Americans) may be less comfortable with self-disclosure and equate the use of professional services with weakness (J. E. Kim et al., 2015). 71

9 Cheng, Wang, McDermott, Kridel, & Rislin It is important for counselors to demystify the counseling process (Thomas et al., 2014) and frame help-seeking engagement as a strength. We would also encourage counselor educators to address cultural barriers to help seeking in their curriculum in order to promote cultural competencies among new generations of professional counselors. In this study, higher self-stigma was associated with less favorable attitudes toward seeking counseling. According to social cognitive theory, people can acquire new attitudes and behaviors by simply observing competent models who are similar to them (Bandura, 1988). Therefore, college campaigns could normalize professional help seeking by bringing in speakers (e.g., college-age speakers, well-known athletes, popular icons) who can discuss the factors that facilitate or hinder help-seeking behavior. In line with past research, students may also benefit from college marketing campaigns that use videos in communal spaces (e.g., student unions) that identify elements of self-stigma (e.g., feeling weak because the student is considering seeking help) and promote the benefits of help seeking (Hernandez & Organista, 2013). Increased literacy about self-stigma may help students to recognize when self-stigma is impeding their ability to pursue professional help. Our findings portrayed a demographic and psychological profile of particular concern that may hold the least positive attitudes of seeking psychological help and may represent a difficult-to-reach population. This profile includes students who are Asian American, male, or psychologically distressed or who have no history of utilizing professional services. 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