Journal of Counseling Psychology

Journal of Counseling Psychology Does Self-Stigma Reduce the Probability of Seeking Mental Health Information? Daniel G. Lannin, David L. Vogel, Rachel E. Brenner, W. Todd Abraham, and Patrick J. Heath Online First Publication, August 31, 2015. http://dx.doi.org/10.1037/cou0000108 CITATION Lannin, D. G., Vogel, D. L., Brenner, R. E., Abraham, W. T., & Heath, P. J. (2015, August 31). Does Self-Stigma Reduce the Probability of Seeking Mental Health Information?. Journal of Counseling Psychology. Advance online publication. http://dx.doi.org/10.1037/cou0000108

Journal of Counseling Psychology 2015 American Psychological Association 2015, Vol. 62, No. 4, 000 0022-0167/15/$12.00 http://dx.doi.org/10.1037/cou0000108 BRIEF REPORT Does Self-Stigma Reduce the Probability of Seeking Mental Health Information? Daniel G. Lannin, David L. Vogel, Rachel E. Brenner, W. Todd Abraham, and Patrick J. Heath Iowa State University An important first step in seeking counseling may involve obtaining information about mental health concerns and treatment options. Researchers have suggested that some people may avoid such information because it is too threatening due to self-stigma and negative attitudes, but the link to actual help-seeking decisions has not been tested. Therefore, the purpose of the present study was to examine whether self-stigma and attitudes negatively impact decisions to seek information about mental health concerns and counseling. Probit regression models with 370 undergraduates showed that self-stigma negatively predicted decisions to seek both mental health and counseling information, with attitudes toward counseling mediating self-stigma s influence on these decisions. Among individuals experiencing higher levels of distress, the predicted probabilities 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% and 15.0%, respectively). This suggests that self-stigma may hinder initial decisions to seek mental health and counseling information, and implies the need for the development of early interventions designed to reduce help-seeking barriers. Keywords: self-stigma, attitudes, counseling, help seeking, mental health Gathering information related to mental health concerns and counseling may constitute an important first step in seeking counseling (Oh, Jorm, & Wright, 2009; Rogers, 2008). Individuals may want to know if their symptoms warrant seeking help (i.e., severe enough; diagnosable), and what treatment options are available before making a decision. Compared to those who do not seek counseling, those who eventually seek counseling are more likely to have first sought out information (Ybarra & Eaton, 2005). Unfortunately, many people may still avoid or delay accessing mental health and counseling information when they need it the most because of concerns about self-stigma (Lannin, Guyll, Vogel, & Madon, 2013; Vogel, Wade, & Haake, 2006) and negative attitudes toward counseling (Vogel, Wade, & Hackler, 2007). To better develop interventions that empower people to gather the necessary information to make informed decisions about seeking counseling, it is important to examine a theoretical model that explains why people avoid taking these first steps in the helpseeking process (i.e., obtaining relevant information). Therefore, the purpose of the present study was to examine the effects of self-stigma and attitudes toward counseling on peoples decisions to seek mental health and counseling information. Daniel G. Lannin, David L. Vogel, Rachel E. Brenner, W. Todd Abraham, and Patrick J. Heath, Department of Psychology, Iowa State University. Correspondence concerning this article should be addressed to Daniel G. Lannin, W112 Lagomarcino Hall, Department of Psychology, Iowa State University, Ames, IA 50011-3180. E-mail: dglannin@iastate.edu Self-Stigma Heightens the Threat Associated With Seeking Counseling Self-stigma corresponds to the negative self-perceptions and demoralization that occur when societal stigma regarding mental health and counseling is internalized and applied to the self (Corrigan, 2004; Kranke, Floersch, Townsend, & Munson, 2010; Manos, Rüsch, Kanter, & Clifford, 2009; Vogel, Bitman, Hammer, & Wade, 2013; Vogel et al., 2006). Self-stigma threatens positive self-conceptions that individuals are strongly motivated to protect (Lannin et al., 2013; Vogel et al., 2013). For example, self-stigmatizing labels associated with seeking counseling include insecure, inadequate, inferior, weak, and disturbed (King, Newton, Osterlund, & Baber, 1973; Sibicky & Dovidio, 1986), which contradict positive labels such as competent, adequate, and stable (Sherman & Cohen, 2006). As such, people may avoid counseling (Fisher, Nadler, & Whitcher-Alagna, 1982; Lannin, Vogel, Brenner, & Tucker, 2015; Wade, Post, Cornish, Vogel, & Tucker, 2011) and counseling-related information to reduce the threat associated with self-stigma and protect positive self-conceptions (Lannin et al., 2013). When counseling is viewed as threatening, individuals are likely to perceive it more negatively (Bayer & Peay, 1997; Codd & Cohen, 2003; Hammer & Vogel, 2013; Mo & Mak, 2009; Schomerus, Matschinger, & Angermeyer, 2009; Vogel et al., 2006). Self-stigma has been linked to more negative attitudes toward individual counseling (e.g., Vogel et al., 2006), career counseling (Ludwikowski, Vogel, & Armstrong, 2009), and group counseling (Shechtman, Vogel, & Maman, 2010). In addition, self-stigma has been linked to decreased intentions and willingness to seek counseling (Hammer & Vogel, 2013; Lannin et al., 2015; Wade et al., 2011). Previous 1

2 LANNIN, VOGEL, BRENNER, ABRAHAM, AND HEATH research has found that one s attitudes toward counseling mediates the relationship between self-stigma and intentions to seek counseling (Pederson & Vogel, 2007; Vogel et al., 2007). In other words, selfstigma may reduce a person s intentions to seek counseling because self-stigma may erode positive attitudes toward counseling. However, one limitation of previous research is that it has often relied on self-reported outcome variables while not examining actual helpseeking decisions. Therefore, the present study examines decisions to seek mental health and counseling information. Current Study In the current study, we investigated whether the relationships between self-stigma and attitudes toward counseling apply to actual decisions to seek mental health and counseling information. Selfstigma represents a threat to positive self-perceptions that may be activated when considering whether or not to seek mental health and counseling information. Therefore, we first hypothesized that people with higher self-stigma would be less likely to seek information about mental health concerns and counseling (Figure 1A). It is also likely that self-stigma s negative impact on decisions to seek information A B Distress Self- gma Distress Self- gma Gender - + may be mediated by attitudes toward counseling, a possibility supported by previous research (Pederson & Vogel, 2007; Vogel et al., 2007). Consequently, we also hypothesized that attitudes pertaining to psychological counseling would mediate the negative association due to self-stigma (see Figure 1B) on decisions to seek mental health and counseling information. Specifically, we predicted that self-stigma s negative associations with decisions to seek mental health and counseling information would be due to its negative association with attitudes toward counseling. Finally, previous studies have found that being female and having greater levels of distress are associated with an increased likelihood of seeking treatment (e.g., Lannin et al., 2015; Addis & Mahalik, 2003). Therefore, we controlled for the influence of these variables in our models. Method Participants A total of 370 undergraduates from a large Midwestern university were recruited to participate in the study through announce- - - tudes + C Info MH Info C Info + Gender MH Info Figure 1. Conceptual direct effect model (A) and fully mediated model (B). Hypothesized paths are represented by dark lines with hypothesized directions of effects depicted by or. Covariates are represented by dotted lines. C Info Participants decision to obtain counseling information; MH Info participants decision to obtain mental health information. C Info and MH Info are dummy coded, such that 0 no and 1 yes. Gender is effects-coded, such that 1 female and 1 male.

SEEKING MENTAL HEALTH INFORMATION 3 ments in their psychology and communication studies classes (female 61%; age, M 19.4, SD 1.77, range 17 41). The sample included first-year students (56%), second-year students (24%), third-year students (11%), fourth-year students (7%), and other (2%). Participants were European American (82%), Asian American/Pacific Islander (7%), Latino/a (4%), African American (4%), multiracial (2%), and other (1%). Sexual orientations included heterosexual (94%), bisexual (3%), questioning (1%), selfidentifying (1%), gay (1%), and lesbian ( 1%). Procedures After voluntarily agreeing to participate and providing informed consent, participants completed an online survey using Qualtrics software in exchange for class credit. The survey included demographic questions, assessments of stigma (Self-Stigma of Seeking Help scale [SSOSH]; Vogel et al., 2006), help-seeking attitudes (Attitudes Toward Seeking Professional Psychological Help Scale [ATSPPHS]; Fischer & Farina, 1995), and psychological distress (K6 ; Kessler et al., 2002). After participants completed these survey items, two help-seeking decisions were obtained. Participants were first asked if they would like to be directed to the University Student Counseling Service website where they can learn more about seeking help from a psychologist. Affirmative responses opened a new tab in the web-browser that directed participants to the University s Counseling Service website. Regardless of whether or not they chose to seek counseling information, all participants were then asked if they would like to be directed to a website that provides more information about mental health concerns. Affirmative responses opened a new tab in the web-browser that directed participants to a mental health website designed for college students (The Jed Foundation). Thus, all participants could choose to seek information about counseling services, mental health concerns, both, or neither. University human subject approval was obtained for all study procedures prior to data collection. Measures Self-stigma. The SSOSH (Vogel et al., 2006) was used to measure participants self-stigma related to seeking professional counseling. The 10-item scale includes items such as If I went to a therapist, I would be less satisfied with myself (Vogel et al., 2006, p. 328). Items are rated on a 5-point scale from 1 (strongly disagree) to5(strongly agree). Five items are reverse-scored so that higher scores correspond to higher self-stigma related to seeking counseling. Previous support for the validity of the SSOSH scale has indicated positive associations with assessments of societal stigma of seeking counseling, anticipated risks of disclosing in therapy, and negative associations with assessments of attitudes toward seeking professional counseling and intentions to seek counseling (Vogel et al., 2006). The SSOSH has shown high internal consistency (.86.90) and 2-month test retest reliability (.72) in undergraduate samples (Vogel et al., 2006), with similar internal consistency in this sample (.87). Attitudes toward counseling. Attitudes were assessed using the short form of the ATSPPHS (ATSPPHS-SF; Fischer & Farina, 1995). This scale has 10 items that are answered on a 4-point scale with responses ranging from 0 (disagree) to3(agree), and includes items such as I might want to have psychological counseling in the future. Five items are reverse-scored so that higher scores indicate more positive attitudes. Previous findings support the validity of the scale, with scores on the ATSPPHS-SF being negatively associated with assessments of self-stigma and positively associated with assessments of help-seeking intentions (e.g., Vogel et al., 2007). Internal consistency of this scale has ranged from.79 to.82 in undergraduate samples (Fischer & Farina, 1995; Pederson & Vogel, 2007), with similar internal consistency in this sample (.81). Psychological distress. The Self-Administered K6 (Kessler et al., 2002) was used to assess psychological distress. This 6-item measure of psychological distress was developed for use in the U.S. National Health Interview Survey. Participants read the sentence stem, during the past 30 days, about how often did you feel... and rate items such as nervous and hopeless on a 5-point Likert scale from 1 (all the time) to5(none of the time). A distress score is calculated by converting the scale items such that 0 none of the time and 4 all of the time, and then summing all converted items. Epidemiological research has found that scores above 5 indicate moderate psychological distress, appropriate for seeking help, and scores above 13 suggest the likely presence of a serious mental illness, defined as a DSM IV disorder occurring in the last 12 months (Prochaska, Sung, Max, Shi, & Ong, 2012). Previous research has provided support for the validity of the K6 due to its ability to discriminate between clinical and nonclinical populations, as well as internal consistency ranging from.89 to.92 (Kessler et al., 2002), with similar internal consistency in this sample (.84). Results Descriptive and Preliminary Analyses First, missing data were examined and found to range from 0% to 1.9% across all items. Of the 370 participants who began the survey, 98% completed all measures. Descriptive statistics and bivariate intercorrelations were calculated for all study variables and are displayed in Table 1. In the present sample, the mean distress score was equal to 7.51 (SD 4.65), indicative of moderate psychological distress (Prochaska et al., 2012). Self-Stigma s Influence on Decisions to Seek Information The relationship of self-stigma and decisions to acquire information was explored by using a robust weighted least squares approach (i.e., WLSMV estimator in Mplus 6), an approach that functions well with sample sizes of 200 or larger (Brown, 2006; Muthén, du Toit, & Spisic, 1997). Self-stigma was specified as a predictor variable, distress and gender specified as covariates, and counseling information and mental health information as categorical outcome variables. To aid interpretation of results, all continuous predictor variables were standardized. Effects coding for gender (1 male, 1 female) causes the effect associated with being male versus female to equal twice the reported coefficient, but also allows for averaging across genders (i.e., when gender is specified as

4 LANNIN, VOGEL, BRENNER, ABRAHAM, AND HEATH Table 1 Intercorrelation Matrix of All Study Variables (N 370) Variables 1 2 3 4 5 6 Predictor variables 1. Distress.08.10.05.15.23 2. Gender.08.08.19.01.00 3. Self-Stigma.12.07.56.08.11 4. Attitudes.03.17.60.16.17 Outcome variables 5. C Info.20.01.08.15.42 6. MH Info.26.00.11.16.42 M (SD) 7.51 (4.65) Female 61% 2.75 (.68) 1.61 (.52) Yes 7.3% Yes 7.0% Note. Pearson s product-moment correlation coefficients (parametric) are shown below the diagonal; Spearman s rank-order correlation coefficients (nonparametric) are shown above the diagonal. Distress K6 ; Self-Stigma Self-Stigma of Seeking Psychological Help scale; Attitudes short form of the Attitudes Toward Seeking Professional Psychological Help Scale; C info participants decision to obtain counseling information; MH Info participants decision to obtain mental health information. C Info and MH Info are dummy coded, such that 0 no and 1 yes. Gender is effects-coded, such that 1 female and 1 male. p.05. p.01. p.001. 0). The two outcome variables mental health information and counseling information were each dummy coded such that 0 no and 1 yes. Estimation of path coefficients to categorical outcome variables under WLSMV estimation in Mplus uses a probit function, which is based on a cumulative normal probability distribution of z-scores. In the present models, the values of path coefficients represent the increase/decrease of a z-score, which in turn corresponds to the probability of seeking information. For standardized variables, the values of 1 and 0 are particularly meaningful. For the current results, standardized variables allow the reader to interpret path coefficients to representing the change in z-score for a person who scores 1 SD above the mean on the self-stigma measure compared to that of a person who scores at the mean of the self-stigma measure. As shown in Figure 2, the model testing the direct effects of stigma on decisions to seek information demonstrated good fit to the data, 2 (0, N 370) 0.00, p.00; comparative fit index (CFI) 1.000; Tucker-Lewis index (TLI) 1.000; root mean square error of approximation (RMSEA).000, 90% confidence interval (CI).000,.000], which is expected because this model estimates all the associations among the measures. Results supported the hypothesis that people with higher self-stigma would be less likely to seek information about both mental health concerns and counseling. As shown in Figure 2, self-stigma was a significant predictor of decisions to seek mental health information ( 0.33, SE 0.15, p.029, 95% CI for 0.63, 0.03) and approached significance as a predictor of counseling information ( 0.23, SE 0.14, p.097, 95% CI for 0.51, 0.04). Controlling for gender and distress, a calculation of predicted probabilities from predicted z-scores indicated that among individuals with low self-stigma ( 1 SD), 8.7% of individuals sought mental health information and 9.0% sought counseling information, but among individuals with high self-stigma ( 1 SD) only 2.2% sought mental health information and 3.5% sought counseling information. Distress was also a significant predictor of decisions to seek mental health information ( 0.55, SE 0.14, p.001, 95% CI for 0.29, 0.82) and counseling information ( 0.39, SE 0.11, p.001, 95% CI for 0.18, 0.59). Gender was not predictive of either decision to seek information, both ps.47. Self-stigma s indirect effects. To examine the potential mediating role of attitudes we reran the above model with attitudes included as a mediator. Namely, we specified a model in which self-stigma predicted attitudes, and attitudes then predicted both outcome variables mental health information and counseling information (see Figure 3). Distress and gender were specified as covariates, predicting attitudes, and both outcome variables. A test of the hypothesized structural model resulted in a good fit to the data, 2 (2, N 370) 1.23, p.54; CFI 1.000; TLI 1.017; RMSEA.000, 90% CI.000,.089. In line with recommendations to examine alternative models against the hypothesized model (Martens, 2005), we compared the hypothesized model against two alternative models. First, to rule out the possi- Distress Self-S gma Gender + C Info R 2 =.15 MH Info R 2 =.26 0.68 *** Figure 2. Direct effects of stigma on decisions to seek information. Hypothesized paths are represented by dark lines. Covariates are represented by dotted lines. Distress K6 ; Self-Stigma Self-Stigma of Seeking Help scale; C info Participants decision to obtain counseling information. MH Info Participants decision to obtain mental health information. C Info and MH Info are dummy coded, such that 0 no and 1 yes. Gender is effects-coded, such that 1 female and 1 male..05 p.10. p.05. p.001.

SEEKING MENTAL HEALTH INFORMATION 5 Distress C Info R 2 =.18-0.60*** A tudes Self-S gma 0.62*** R 2 =.39 Gender MH Info R 2 =.29 Figure 3. Fully mediated model. Hypothesized paths are represented by dark lines. Covariates are represented by dotted lines. Distress K6 ; Self-Stigma Self-Stigma of Seeking Help scale; Attitudes short form of the Attitudes Toward Seeking Professional Psychological Help Scale; C Info Participants decision to obtain counseling information; MH Info participants decision to obtain mental health information. C Info and MH Info are dummy coded, such that 0 no and 1 yes. Gender is effects-coded, such that 1 female and 1 male. p.05. p.01. p.001. bility that self-stigma mediated the effects of attitudes on both outcome variables, we tested a model identical to the hypothesized model, except that self-stigma now mediated the effects of attitudes on both outcome variables. Although it is impossible to compare this model to the hypothesized model via a chi-square difference test because both models contain the same degrees of freedom, this alternative structural model fit the data worse than the hypothesized model, with the TLI below the cutoff point of.95 and RMSEA exceeding the critical cutoff point of.06 (Hu & Bentler, 1999), 2 (2, N 370) 4.86, p.09; CFI 0.989; TLI 0.935; RMSEA.062, 90% CI.000,.135. Therefore, we retained the hypothesized model. Next, to rule out the possibility that attitudes may be a partial mediator, we compared the hypothesized full mediation model against a partial mediation model that contained two additional paths over the fully mediated model: one from self-stigma to mental health information and one from self-stigma to counseling information. The direct paths from self-stigma to both outcome variables were not significant (ps.35), and a chi-square difference test of the hypothesized full mediation versus partial mediation model indicated that the two models were not significantly different from one another 2 (2, N 370) 1.57, p.46. Therefore, for parsimony we retained the hypothesized full mediation model. 1 Results provided support for the hypothesis that self-stigma s negative association with decisions to seek mental health and counseling information would be due to its negative association with attitudes toward counseling. Self-stigma was a significant predictor of more negative attitudes ( 0.60, SE 0.04, p.001, 95% CI for [ 0.68, 0.52]). Attitudes toward counseling, in turn, was a significant predictor of decisions to seek mental health information ( 0.35, SE 0.13, p.007, 95% CI for [0.09, 0.61]) and counseling information ( 0.29, SE 0.10, p.004, 95% CI for [0.09, 0.48]). Furthermore, there were statistically significant indirect effects of self-stigma through attitudes on both mental health information ( 0.21, SE 0.08, p.004, 95% CI for [ 0.37, 0.06]) and on counseling information ( 0.17, SE 0.06, p.008, 95% CI for [ 0.29, 0.06]). This finding is consistent with the interpretation that self-stigma is associated with decreased attitudes toward counseling, which then leads to decreased likelihood of seeking mental health and counseling information. Next, we were interested in examining how the indirect effect of self-stigma through attitudes was associated with the predicted probability of seeking mental health and counseling information for individuals most at risk (i.e., those with high levels of distress). For ease of interpretation, to calculate scores for individuals with high distress we substituted distress scores of 1 SD into the mediation model shown in Figure 3. In the present sample, individuals 1 SD above the mean on distress scored 12.16 on the K6, which places them above the clinical cutoff for moderate distress (scores of 5 and above) and approaching the clinical cutoff for severe distress (scores of 13 and above) that has been identified in an epidemiological validation study (Prochaska et al., 2012). To calculate indirect effects of self-stigma we multiplied the path from self-stigma to attitudes by the path from attitudes to the relevant outcome variable (mental health information and counseling information), then multiplied the indirect effect by either the coefficient 1or 1 to refer to high self-stigma ( 1 SD) orlow self-stigma ( 1 SD), respectively (MacKinnon & Dwyer, 1993). Among individuals experiencing higher levels of distress, the predicted probability of seeking mental health information for people with high self-stigma was 8.5% whereas the probability for those with low self-stigma was 17.1%. Results for counseling information were of a similar direction and magnitude. Among individuals experiencing higher levels of distress, the probability of seeking counseling information for people for people with high self-stigma was 8.4% whereas the probability for those with low self-stigma was 15.0%. Discussion Building on previous work that has often relied on self-report outcomes, the present study examined the harmful effects of selfstigma on early help-seeking decisions. We hypothesized that people with higher self-stigma would be less likely to decide to 1 Some participants sought both mental health and counseling information (participants seeking counseling information only 4.1%; participants seeking mental health information only 3.8%; participants seeking both types of information 3.2%). Therefore, we also examined a model wherein the two outcome variables were collapsed into a single variable, coded such that 0 sought no information and 1 sought either or both types of information. This model also fit the data well, but fit indices were slightly worse than the hypothesized model, 2 (1, N 370) 1.60, p.21; CFI 0.997; TLI 0.982; RMSEA.040, 90% CI.000,.151. The direction and statistical significance of both the direct and indirect effects were not meaningfully different from the hypothesized model. However, we retained the hypothesized model because less than half of information-seekers sought both types of information, and previous research has suggested that seeking mental health information may be differently stigmatizing than seeking counseling information (e.g., Lannin, Vogel, Brenner, & Tucker, 2015).

6 LANNIN, VOGEL, BRENNER, ABRAHAM, AND HEATH seek mental health and counseling information. Results supported this hypothesis, indicating that self-stigma was significantly associated with the decreased probability of seeking online mental health information and marginally significantly associated with the decreased probability of seeking counseling information. This supports the notion that people may avoid information that highlights their mental health concerns in order to reduce threats associated with self-stigma (Lannin et al., 2013). The use of observable outcome measures decisions to seek information provides validation to and extends the findings of previous studies that have examined the impact of self-stigma on self-reported help-seeking outcomes (e.g., Vogel et al., 2006; Lannin et al., 2015). This suggests that self-stigma is a threat with observable consequences reducing the likelihood that an individual will seek materials that are relevant to directly addressing their mental health concerns. We also hypothesized that attitudes toward counseling would mediate the effects of self-stigma on decisions to engage with online information. Results also supported this hypothesis. The present study s mediation model provides initial evidence that self-stigma influences decisions to seek mental health and counseling information through its negative association with attitudes toward counseling. Overall, these findings add to the literature by investigating the psychological processes that impact an important initial step in the help-seeking process seeking relevant information. The present results bolster the notion that self-stigma associated with seeking counseling represents a threat that erodes positive attitudes toward counseling, and suggest that this psychological process hinders the probability of engaging in important help-seeking behaviors. Specifically, in the present study, individuals with high self-stigma were less likely to seek both mental health and counseling information than those with low self-stigma. Importantly, this relationship was also present for those most at risk (i.e., highest in distress). Not surprisingly, greater distress was strongly associated with greater probability of seeking both mental health and counseling information. This supports the notion that distress motivates decisions to obtain help-seeking information. In addition, in line with Addis and Mahalik (2003), being male was associated with worse attitudes toward counseling. However, gender was not a statistically significant predictor of decisions to seek information about mental health concerns or counseling. It is possible that the relatively anonymous and unthreatening context of seeking online information was responsible for allowing men with worse attitudes toward counseling to still seek mental health and counseling information. Examining the context in which help-seeking information is offered may be an important area for future research. The present study has important implications for psychoeducational efforts. Substantial resources have been allocated to develop programs to encourage people with mental health concerns to seek psychological counseling (e.g., American Psychological Association, 2012; The Jed Foundation; National Alliance on Mental Health, n.d.; National Institute of Mental Health, n.d.), and many of these efforts provide very useful information that could be helpful if accessed. However, our results suggest that even individuals in need (i.e., those experiencing distress) may be reluctant to access this information if they are experiencing higher levels of self-stigma. Thus, it is important to understand factors that impact how that information is sought (or avoided). If distressed individuals avoid engaging with relevant information about their mental health concerns and counseling options, making informed decisions regarding their recovery is difficult. Self-stigma is a salient factor that may prompt many to avoid seeking important information because it negatively influences their attitudes toward counseling. Therefore, when designing educational materials that cover mental health concerns and counseling, it may be important to consider how and why these materials might be threatening to individuals with self-stigma (e.g., they activate fears about stigma, reduced self-esteem, and the loss of important relationships; Corrigan, 2004). Although it is important to continue to develop psychoeducational interventions that can increase mental health literacy (Jorm, 2012), the present study suggests that it may also important to mitigate the threat of self-stigma to increase the likelihood that an individual accesses psychoeducational information. If self-stigma hinders engagement with educational materials, some of the effort in creating high-quality psychoeducational materials may be wasted. Therefore, it may be useful to consider theory-based approaches for mitigating self-stigma s negative impact on individuals decision to seek mental health and counseling information. Selfaffirmation theory offers one approach, predicting that a relatively brief intervention can reduce the threat evoked by self-stigma and can increase willingness to engage in help-seeking behaviors (Cohen & Sherman, 2014; Lannin et al., 2013; Steele, 1988). Selfaffirmation interventions highlight positive self-perceptions (e.g., I am generous) unrelated to the negative self-perceptions triggered by self-stigma (e.g., I am incompetent), which in turn buffer self-worth from threats elicited by subsequent mental health and counseling information. For example, Lannin et al. (2013) tested an intervention wherein participants wrote about an important personal value (i.e., self-affirmation) before reading an article that described what counseling is and its benefits, and found that self-affirmation reduced self-stigma and increased willingness to engage in help-seeking behaviors. Such approaches may be useful as direct attempts to change attitudes related to vulnerable aspects of identity can actually intensify anxiety and increase resistance to attitude change (Corrigan, 2004; Crocker & Park, 2004). Developing brief self-affirmation interventions that can occur online may constitute an important next step in mitigating self-stigma because growing proportions of adults (18%; Powell & Clarke, 2006) and college students (31%; Horgan & Sweeney, 2010) are browsing online resources to research their mental health concerns. For many, accessing online information may be an important first step that guides future decisions to seek in-person help (Oh et al., 2009; Rogers, 2008). In particular, brief online self-affirmation activities could be implemented on websites that (a) are commonly visited by identified at-risk populations and (b) offer links to additional mental health and treatment information (e.g., university webpages that provide orientation information for new students, webpages describing benefit information for veterans, and company webpages providing information about benefits and assistance programs for employees). In addition, outreach events such as those commonly implemented by University counseling centers could use self-affirmation-based interventions before presenting mental health and counseling information.

SEEKING MENTAL HEALTH INFORMATION 7 Limitations and Future Directions Even though this study has many strengths, including its focus on initial behavioral decisions in the help-seeking process, it also has some limitations. First, the majority of the sample was European American with some college education. Previous research indicates that the influence of stigma can differ depending on ethnicity, race, and other cultural factors (Brown et al., 2010; Vogel, Armstrong, et al., 2013; Vogel, Heimerdinger-Edwards, Hammer, & Hubbard, 2011). To generalize to other relevant adult populations, the results of the current study require replication with samples diverse in ethnicity, age, and educational background. Second, though we modeled the relationship between self-stigma and attitudes with subsequent decisions to seek information, evidence of causal relationships is not conclusive because there may be additional variables responsible for the observed correlations. Future studies may therefore consider longitudinal designs or experimental manipulations of self-stigma (or manipulating variables that approximate self-stigma) to examine self-stigma s causal influence on decisions to engage with information about mental health concerns and counseling. A third limitation is that participants were asked whether they would like to be redirected to websites about both mental health concerns and counseling, which constitutes a relatively benign and anonymous help-seeking decision. A help-seeking decision that required participants to disclose personal or identifying information (e.g., name or email) to obtain information would have been more threatening and could have resulted in stronger associations between self-stigma, attitudes, and decisions to seek mental health or counseling information. Nonetheless, the fact that the current study found statistically significant effects within a relatively benign context provides evidence for the robustness of the relationship between selfstigma, attitudes, and help-seeking decisions. Finally, though this study examined decisions to seek mental health and counseling information around the same point in time, it is possible that individuals may seek information more sequentially (i.e., mental health information before seeking information about counseling). Future research may benefit from examining how decisions to seek information about mental health concerns influence subsequent decisions to seek help for those concerns. Conclusion Results of the present study extend previous research, which has found links between self-stigma, negative attitudes toward counseling, and self-reported intentions to seek help. The present study identifies self-stigma as an important barrier to initial decisions to seek information about mental health concerns and counseling, even for individuals with higher levels of distress. The present study constitutes an initial step in understanding how psychological processes attenuate adaptive help seeking and has important implications for the development of early interventions designed to increase mental health literacy and help-seeking behaviors. References Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58, 5 14. http://dx.doi.org/10.1037/0003-066x.58.1.5 American Psychological Association. (2012, September 12). Psychotherapy: More than a quick fix (Episode 1). Retrieved from https://www.youtube.com/watch?v CvcOivVzCaI Bayer, J. K., & Peay, M. Y. (1997). Predicting intentions to seek help from professional mental health services. Australian and New Zealand Journal of Psychiatry, 31, 504 513. http://dx.doi.org/10.3109/ 00048679709065072 Brown, C., Conner, K. O., Copeland, V. C., Grote, N., Beach, S., Battista, D., & Reynolds, C. F., III. (2010). Depression stigma, race, and treatment seeking behavior and attitudes. Journal of Community Psychology, 38, 350 368. http://dx.doi.org/10.1002/jcop.20368 Brown, T. (2006). Confirmatory factor analysis for applied research. New York, NY: Guilford Press. Codd, R. T., & Cohen, B. N. (2003). Predicting college student intention to seek help for alcohol abuse. Journal of Social and Clinical Psychology, 22, 168 191. http://dx.doi.org/10.1521/jscp.22.2.168.22877 Cohen, G. L., & Sherman, D. K. (2014). The psychology of change: Self-affirmation and social psychological intervention. Annual Review of Psychology, 65, 333 371. http://dx.doi.org/10.1146/annurev-psych- 010213-115137 Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614 625. http://dx.doi.org/10.1037/0003-066x.59.7.614 Crocker, J., & Park, L. E. (2004). The costly pursuit of self-esteem. Psychological Bulletin, 130, 392 414. http://dx.doi.org/10.1037/0033-2909.130.3.392 Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36, 368 373. Fisher, J. D., Nadler, A., & Whitcher-Alagna, S. (1982). Recipient reactions to aid. Psychological Bulletin, 91, 27 54. http://dx.doi.org/10.1037/0033-2909.91.1.27 Hammer, J. H., & Vogel, D. L. (2013). Assessing the utility of the willingness/prototype model in predicting help-seeking decisions. Journal of Counseling Psychology, 60, 83 97. http://dx.doi.org/10.1037/ a0030449 Horgan, A., & Sweeney, J. (2010). Young students use of the Internet for mental health information and support. Journal of Psychiatric and Mental Health Nursing, 17, 117 123. http://dx.doi.org/10.1111/j.1365-2850.2009.01497.x Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1 55. http://dx.doi.org/10.1080/ 10705519909540118 The Jed Foundation. (n.d.). Half of us: The pain is real. Retrieved from http://www.halfofus.com Jorm, A. F. (2012). Mental health literacy: Empowering the community to take action for better mental health. American Psychologist, 67, 231 243. http://dx.doi.org/10.1037/a0025957 Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S. L.,... Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32, 959 976. http://dx.doi.org/10.1017/s0033291702006074 King, P. T., Newton, F., Osterlund, B., & Baber, B. (1973). A counseling center studies itself. Journal of College Student Personnel, 14, 338 344. Kranke, D., Floersch, J., Townsend, L., & Munson, M. (2010). Stigma experience among adolescents taking psychiatric medication. Children and Youth Services Review, 32, 496 505. http://dx.doi.org/10.1016/j.childyouth.2009.11.002 Lannin, D. G., Guyll, M., Vogel, D. L., & Madon, S. (2013). Reducing the stigma associated with seeking psychotherapy through self-affirmation. Journal of Counseling Psychology, 60, 508 519. http://dx.doi.org/10.1037/a0033789

8 LANNIN, VOGEL, BRENNER, ABRAHAM, AND HEATH Lannin, D. G., Vogel, D. L., Brenner, R. E., & Tucker, J. R. (2015). Predicting self-esteem and intentions to seek counseling: The Internalized Stigma Model. The Counseling Psychologist, 43, 64 93. http://dx.doi.org/10.1177/0011000014541550 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. http://dx.doi.org/10.1037/ a0016180 MacKinnon, D. P., & Dwyer, J. H. (1993). Estimating mediated effects in prevention studies. Evaluation Review, 17, 144 158. http://dx.doi.org/ 10.1177/0193841X9301700202 Manos, R. C., Rüsch, L. C., Kanter, J. W., & Clifford, L. M. (2009). Depression Self-Stigma as a Mediator of the Relationship Between Depression Severity and Avoidance. Journal of Social and Clinical Psychology, 28, 1128 1143. http://dx.doi.org/10.1521/jscp.2009.28.9.1128 Martens, M. P. (2005). The use of structural equation modeling in counseling psychology research. The Counseling Psychologist, 33, 269 298. http://dx.doi.org/10.1177/0011000004272260 Mo, P. K., & Mak, W. W. (2009). Help-seeking for mental health problems among Chinese: The application and extension of the theory of planned behavior. Social Psychiatry and Psychiatric Epidemiology, 44, 675 684. http://dx.doi.org/10.1007/s00127-008-0484-0 Muthén, B., du Toit, S. H. C., & Spisic, D. (1997). Robust inference using weighted least squares and quadratic estimating equations in latent variable modeling with categorical and continuous outcomes. Retrieved from http://www.statmodel.com/bmuthen/articles/article_075.pdf National Alliance on Mental Health. (n.d.). Find support. Retrieved from http://www.nami.org/find-support National Institute of Mental Health. (n.d.). Men and depression. Retrieved from http://www.nimh.nih.gov/health/topics/depression/men-anddepression/index.shtml Oh, E., Jorm, A. F., & Wright, A. (2009). Perceived helpfulness of websites for mental health information: A national survey of young Australians. Social Psychiatry and Psychiatric Epidemiology, 44, 293 299. http://dx.doi.org/10.1007/s00127-008-0443-9 Pederson, E. L., & Vogel, D. L. (2007). Male gender role conflict and willingness to seek counseling: Testing a mediation model on collegeaged men. Journal of Counseling Psychology, 54, 373 384. http://dx.doi.org/10.1037/0022-0167.54.4.373 Powell, J., & Clarke, A. (2006). Internet information-seeking in mental health: Population survey. The British Journal of Psychiatry, 189, 273 277. http://dx.doi.org/10.1192/bjp.bp.105.017319 Prochaska, J. J., Sung, H. Y., Max, W., Shi, Y., & Ong, M. (2012). Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization. International Journal of Methods in Psychiatric Research, 21, 88-97. http://dx.doi.org/10.1002/ mpr.1349 Rogers, V. (2008). Emotional self-disclosure: Differences between young adults who prefer face-to-face therapy and those who refer Internet therapy. Unpublished doctoral dissertation, Case Western Reserve University, Cleveland, OH Schomerus, G., Matschinger, H., & Angermeyer, M. C. (2009). Attitudes that determine willingness to seek psychiatric help for depression: A representative population survey applying the theory of planned behaviour. Psychological Medicine, 39, 1855 1865. http://dx.doi.org/10.1017/ S0033291709005832 Shechtman, Z., Vogel, D., & Maman, N. (2010). Seeking psychological help: A comparison of individual and group treatment. Psychotherapy Research, 20, 30 36. http://dx.doi.org/10.1080/10503300903307648 Sherman, D. K., & Cohen, G. L. (2006). The psychology of self-defense: Self-affirmation theory. Advances in Experimental Social Psychology, 38, 183 242. http://dx.doi.org/10.1016/s0065-2601(06)38004-5 Sibicky, M., & Dovidio, J. F. (1986). Stigma of psychological therapy: Stereotypes, interpersonal reactions, and the self-fulfilling prophecy. Journal of Counseling Psychology, 33, 148 154. http://dx.doi.org/10.1037/0022-0167.33.2.148 Steele, C. M. (1988). The psychology of self-affirmation: Sustaining the integrity of the self. In L. Berkowitz (Ed.), Advances in experimental social psychology (vol. 21, pp. 261 302). New York, NY: Academic Press. Vogel, D. L., Armstrong, P. I., Tsai, P. C., Wade, N. G., Hammer, J. H., Efstathiou, G.,... Topkaya, N. (2013). Cross-cultural validity of the Self-Stigma of Seeking Help (SSOSH) scale: Examination across six nations. Journal of Counseling Psychology, 60, 303 310. http://dx.doi.org/10.1037/a0032055 Vogel, D. L., Bitman, R. L., Hammer, J. H., & Wade, N. G. (2013). Is stigma internalized? The longitudinal impact of public stigma on selfstigma. Journal of Counseling Psychology, 60, 311 316. http://dx.doi.org/10.1037/a0031889 Vogel, D. L., Heimerdinger-Edwards, S. R., Hammer, J. H., & Hubbard, A. (2011). Boys don t cry : Examination of the links between endorsement of masculine norms, self-stigma, and help-seeking attitudes for men from diverse backgrounds. Journal of Counseling Psychology, 58, 368 382. http://dx.doi.org/10.1037/a0023688 Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53, 325 337. Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54, 40 50. http://dx.doi.org/10.1037/0022-0167.54.1.40 Wade, N. G., Post, B. C., Cornish, M. A., Vogel, D. L., & Tucker, J. R. (2011). Predictors of the change in self-stigma following a single session of group counseling. Journal of Counseling Psychology, 58, 170 182. http://dx.doi.org/10.1037/a0022630 Ybarra, M. L., & Eaton, W. W. (2005). Internet-based mental health interventions. Mental Health Services Research, 7, 75 87. http://dx.doi.org/10.1007/s11020-005-3779-8 Received April 24, 2015 Revision received July 14, 2015 Accepted July 14, 2015