Journal of Applied Social Psychology 2016, 46, pp. 470–482
The stigma of seeking help for mental health issues: mediating roles of support and coping and the moderating role of symptom profile Miki Talebi1, Kimberly Matheson2,3, Hymie Anisman2 1Department
of Psychology, Carleton University
2Department
of Neuroscience, Carleton University
3Department
of Health Sciences, Carleton University
Correspondence concerning this article should be addressed to Miki Talebi, Department of Psychology, Carleton University, B550 Loeb Building, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6 Canada. E-mail:
[email protected] This research was supported by the Canadian Institutes of Health Research (CIHR) doi: 10.1111/jasp.12376
Abstract A key factor to the prevalence of mental illness might be the disinclination to seek help, perhaps owing to the stigma of mental illness. In two studies, the contribution of severity of depressive symptoms, social support, and unsupport, coping strategies, and salience of psychological versus biological features of depression in relation to perceived self- and other-stigma of help-seeking for mental health issues were examined. Participants were first year students experiencing a transitional stressor, namely entry to university. Together, the findings point to the contribution of social support and unsupportive interactions, and coping methods to the prediction of perceived stigma of seeking help, but that the framing of mental illness can limit or strengthen these relations.
Prevalence rates of mental illness continue to be on the rise, particularly among adolescents and young adults (Hunt & Eisenberg, 2010). Unfortunately, an underwhelmingly small proportion seek treatment (Andrews, Issakidis, & Carter, 2001). A key factor in the disinclination to seek help concerns the stigma of mental illness (Hinshaw & Stier, 2008), which is compounded by perceptions that help-seeking in itself is an admission that the individual is contending with problems beyond his or her control (Biddle, Donovan, Sharp, & Gunnel, 2007). This concern might be particularly profound among young people, as they struggle to achieve a balance between continued dependence on others for support, and the need to assert themselves as autonomous and competent adults. In this regard, the transition from high school to university can be a highly stressful period, and students frequently experience greater strain and distress symptoms in their first semester of university compared to either preuniversity levels (Bewick, Koutsopoulou, Miles, Slaa, & Barkham, 2010) or to young people who do not attend university (Stewart-Brown et al., 2000). Remarkably, despite the ready availability of on-campus resources, up to 70–85% of students who experience symptoms of depression and anxiety are reluctant to turn to these resources (Eisenberg, Golberstein, & Gollust, 2007; Zivin, Eisenberg, Gollust, & Golberstein, 2009). C 2016 Wiley Periodicals, Inc V
The present investigation assessed psychosocial factors that contribute to the perceived stigma of seeking help for mental health problems among students as they transition into university. It was proposed that severity of depressive symptoms might contribute to diminished perceptions of the availability or utility of social support. Because social support is a critical resource for effectively coping with stressors, it was suggested that depressed students would be more likely to adopt coping strategies that exacerbated rather than alleviated the perceived stigma of help-seeking. Finally, as stigma is more likely to be associated with psychological rather than physical illnesses, we evaluated the possibility that helpseeking stigma could be reduced by making the biological, rather than affective features of depression most salient, and whether as a result of this framing, coping strategies to contend with the depressive symptoms might be more effectively implemented.
Depressive symptoms and help-seeking stigma For many mental health disorders, including depression, first onset of symptoms frequently emerges in late adolescence and early adulthood (Kessler et al., 2005). Transitional stressors, such as starting college or university, might be especially Journal of Applied Social Psychology 2016, 46, pp. 470–482
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likely to trigger symptoms of mood disorders (Royal College of Psychiatrists, 2011). Indeed, approximately 15% of students entering postsecondary educational institutions have undiagnosed or untreated mental illnesses (Midtgaard, Ekeberg, Vaglum, & Tyssen, 2008), and some have suggested that the frequency of depressive disorders or subsyndromal symptoms is even higher (National College Health Assessment, 2012). It has been estimated that only one in four students diagnosed with a depressive disorder receives treatment (American College Health Association, 2008), and the median delay to seek treatment is as long as 11 years from first onset (Kessler et al., 2005). The under-treatment of depression may be due to a number of factors, including failure to recognize symptoms, underestimating severity of symptoms, lack of access to healthcare, and noncompliance with treatment (Hirschfeld et al., 1997). The stigma of mental illness contributes to the reluctance to seek help (Barney, Griffiths, & Banfield, 2011; Corrigan, 2004; Hirschfeld et al., 1997), and this reluctance is furthered by the stigma associated with help-seeking itself. It should be noted, however, that these two constructs (stigma of mental illness and stigma associated with seeking help) are conceptually distinct (Tucker et al., 2013). Although the stigma of mental illness might be a factor in the decision to seek help, given that it requires an admission of illness, help-seeking in itself can be viewed unfavorably in a society that places great value on self-reliance (Vogel, Wade, & Ascheman, 2009). Recognizing the impediments that emanate uniquely from the stigma associated with seeking help is important to understanding the help-seeking process, and discerning potentially more effective and targeted interventions.
The role of support and unsupport A perception that important others are willing to provide social support is often viewed as an significant factor that contributes to well-being (Cohen & Wills, 1985), and might be a key element to encouraging help-seeking during difficult times. Unfortunately, it is often those individuals who are experiencing the greatest distress, particularly if it is a symptom of more chronic depression, who lack an effective social support network (Kaniasty & Norris, 2008), and who are least likely to seek social support (Matheson & Anisman, 2003). The symptoms of depression, which include negative self-statements, self-pity, seeking excessive reassurance, unsolicited self-disclosures, and social withdrawal, have been implicated in undermining perceptions of support availability and the acquisition of effective social support (Coyne et al., 1987; Stice, Rhode, Gau, & Ochner, 2011). Even more devastating than believing that one has no one to turn to is for the individual to discover that when she or he does turn to trusted others, they receive a response that is unhelpful or unsupportive (Figueiredo, Fries, & Ingram, 2004). These C 2016 Wiley Periodicals, Inc V
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unsupportive interactions might take the form of blaming the individual or minimizing the seriousness of his or her problems, or social distancing from the individual (Ingram, Betz, Mindes, Schmitt, & Smith, 2001). This unsupport does not simply reflect an absence of support, but rather is about not receiving support when it was sought and when it was reasonably expected. Unfortunately, when individuals are in a chronic depressive state, they may be more likely to elicit such responses from those around them (Coyne et al., 1987). In the absence of perceiving a supportive social network, or if unsupportive interactions are encountered, the depressed individual may be especially sensitive to stigmatizing attitudes regarding their need for help. The endorsement of negative stereotypes of individuals who need help to contend with depression (other-stigma) might result in the distressed individual internalizing these attitudes, resulting in diminished self-esteem and feelings of inferiority (selfstigma) (Corrigan, 2004). Predictably, stigma has also been linked to attitudes and decisions associated with the reluctance to seek professional help for mental health problems (Vogel, Wade, & Hackler, 2007). Studies have demonstrated a strong link between depressive symptoms and perceptions of social support. In particular, social selection theory posits that individuals who are experiencing psychological distress may be at a diminished capacity to reach out for and acquire effective social support (Coyne et al., 1987; Kaniasty & Norris, 2008). It has been suggested that these individuals’ diminished capacity to cope with stressors shapes their social context, consequently resulting in eroding support resources and less support (Johnson, 1991). As social support, in turn, has been found to modify perceptions of stigma (Mueller et al., 2006), it is conceivable to consider that one who perceives diminished (or ineffective) support might also report greater self- and perceived other-stigma when there is a need to engage in help-seeking for mental health concerns. Although previous research has not directly examined, the mediating role of perceived support in the relation between depressive symptoms and the stigma associated with seeking help, such associations might be anticipated based on the findings of research predicting help-seeking intentions. For example, in line with social selection theory, social support was found to mediate the relation between suicidal ideation (a key indicator of severe depression) and intention to seek help (Yakunina, Rogers, Waehler, & Werth, 2010). In this sense, perceiving a limited support network can have a profound influence on the decision to seek help, particularly for those who are in the most distress. The authors suggest the lack of perceived support might reduce help-seeking intentions due to individuals’ fears regarding how others might stigmatize them for seeking help, as well as their own self-stigmatizing attitudes (Yakunina et al., 2010). Thus, it was the goal of the present study Journal of Applied Social Psychology, 2016, 46, pp. 470–482
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to assess the role of support perceptions on such stigmatizing attitudes to help-seeking.
The role of coping According to the transactional model of stress and coping (Lazarus & Folkman, 1984), stress is comprised of two appraisal processes. When confronted with a potential stressor, the individual first engages in a primary appraisal process wherein the stressful experience is perceived as either a threat or challenge to the self. Following this, a secondary appraisal process occurs in which the individual determines if the necessary coping resources are available to contend with the stressor. This secondary appraisal is the basis for instigating particular coping strategies. In particular, problem-focused coping may be utilized when the individual perceives coping resources to be available, and thus aims to alter or end the source of stress by engaging in problem-solving or cognitive restructuring efforts. Alternatively, emotion-focused coping strategies might be employed if the stressful event is perceived to be uncontrollable; in this situation, efforts such as avoidance, rumination or emotional expression might be engaged to manage the emotional distress. A key resource for coping with stressful situations is the individual’s social support network. Support resources can provide information, tangible assistance, or emotional support, all of which might contribute to greater perceptions of having the capacity to contend more effectively with the situation. In effect, the responses encountered by one’s support network might inform the way in which the experience is dealt with. Greater levels of social support have been directly associated with an increase in the use of more beneficial coping strategies, such as problem-focused coping, and decreased use of maladaptive coping strategies, such as avoidance (Bigatti, Wagner, Lyndon-Lam, Steiner, & Miller, 2010). Common coping strategies endorsed by those experiencing mental illness have been identified, including secrecy, and avoidance/withdrawal. Such strategies have proven to be not only ineffective, but also more damaging than beneficial (Link, Mirotznik, & Cullen, 1991). In spite of attempts to examine coping methods and their relations to stigmatizing perceptions, the combined contribution of social support resources and coping strategies to attitudes towards the helpseeking process is scarce. Despite the considerable research pointing to stigma as a primary obstacle for seeking help for mental disorders (Eisenberg, Downs, Golberstein, & Zivin, 2009), there are no clearly effective strategies to reduce help-seeking stigma. Although the intrinsic features of depressive disorders might exacerbate the stigma associated with the need for help, individuals’ social networks might be essential in either furthering or diminishing stigma. It is proposed that mental illness symptoms, namely those associated with depression, will be C 2016 Wiley Periodicals, Inc V
The stigma of seeking help
related to reduced social support perceptions. Because social support may be a critical resource for effectively coping with life’s challenges, reduced perceptions of support were expected to increase the likelihood that individuals would adopt coping strategies that exacerbate (i.e., emotion-focused coping) rather than alleviate (i.e., problem-focused coping, such as information seeking) the perceived stigma of seeking help. Study 1 therefore examined whether social support facilitated coping strategies that were associated with lower perceived stigma of help-seeking for mental distress. It was further proposed that this sequence of events might depend on other factors, such as focusing on the emotional versus physical aspects of the phenomenology of depression. In this regard, Study 2 evaluated whether these psychosocial factors were more likely to be associated with lower stigma of helpseeking when the physical versus psychological features of depression were made salient.
Study 1 As encouraging effective coping strategies might be critical in facilitating help-seeking among depressed students, Study 1 examined the mediating role of problem- and emotionfocused coping strategies in the relations between perceptions of social support and perceived stigma associated with helpseeking for mental health challenges. It was hypothesized that: 1. Greater endorsement of problem-focused coping strategies would be associated with lower self- and otherstigma of help-seeking, whereas positive relations would be evident between emotion-focused strategies and stigma. 2. Individuals with mild levels of depressive symptoms would perceive greater social support from peers and fewer unsupportive interactions and these would, in turn, be associated with greater problem-focused coping, and lower emotion-focused coping efforts, which would subsequently be related to the stigma of seeking mental health help (i.e., sequential mediation).
Method Participants Students in their first year at Carleton University, Canada (female n 5 229; male n 5 99) ranging in age from 16 to 29 years (M 5 18.79, SD 5 1.74) participated in an online study. Participants’ ethnicity comprised Euro-Caucasian (71.3%, n 5 234), Asian (7.6%, n 5 25), South Asian (4.9%, n 5 16), Black (4.6%, n 5 15), Arab (3.0%, n 5 10), Latin American (1.5%, n 5 5), Aboriginal (1.5%, n 5 5), South East Asian (0.9%, n 5 3), and other (e.g., mixed ethnicity, 4.6%, Journal of Applied Social Psychology, 2016, 46, pp. 470–482
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n 5 15). Most participants reported that they had never received psychological therapy or counseling (87.8%, n 5 288), although some responded that they had, but were no longer being treated (8.8%, n 5 29), or that they were currently receiving counseling (3.4%, n 5 11). Procedure Following approval from the University’s ethics committee for psychological research, participants were recruited through the University’s online system from October 14th to November 27th, 2009. After providing informed consent, participants responded to the survey questions. Upon completion, they were debriefed and given the choice of course credit or a $10 gift certificate. As participation was online, steps were taken to ensure that responses were valid and consistent. Consistency of responses was assessed by considering whether the amount of time taken to complete the questionnaire exceeded the amount of time that was needed to read each question, and that highly similar reverse scored items were answered in the appropriate directions. Respondents who did not meet these criteria (less than 10%) were not included in the descriptives (including reported sample size) or analyses.
Measures Depressive symptoms The 13-item Beck Depression Inventory (BDI) (Beck & Beck, 1972) assessed depressive symptoms. For each item, participants selected one of four response options, which ranged from reflecting low to high depressive symptomatology (e.g., “I do not feel sad”; “I feel sad or blue”; “I am blue or sad all of the time and I can’t snap out of it”; “I am so sad or unhappy that I can’t stand it”). The total score for this scale was calculated by summing across all items (a 5 .84). Social support perceptions The 12-item Social Provisions Scale (Cutrona, 1989) for specific sources assessed the degree to which peers were perceived to provide social support. Participants responded to items (e.g., “are there friends you can depend on/can you depend on your partner if you really need it?”) on a threepoint scale (1 5 no, 2 5 not sure, 3 5 yes). It should be noted that support from peers was collapsed across two support scales, specifically support from friends (a 5 .82) and support from a partner when relevant (a 5 .90), as the correlation between them was high (r 5 .87, p < .001), and the correlations with the other variables of interest were highly similar. C 2016 Wiley Periodicals, Inc V
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Unsupportive interactions Perceptions of negative social interactions (unsupport) was measured using a shortened version of the Unsupportive Social Interactions Inventory (Ingram et al., 2001). Participants rated the extent to which they encountered each of eight behaviours from their peers (e.g., “my partner/close friend refused to provide the type of help or support I was looking for”) on a five-point scale ranging from 0 (never) to 4 (all the time). Scores were created by taking the average rating across all items (a 5 .92). Coping The Survey of Coping Profiles Endorsed (SCOPE, Matheson & Anisman, 2003) was used to assess participants’ coping styles. Responses to subscales of the SCOPE have been correlated with another frequently used coping scale (Carver, Scheier, & Weintraub, 1989). Furthermore, this scale has demonstrated validity in terms of discerning between various mood states (e.g., dysphoria, depression, anxiety; Matheson & Anisman, 2003), predicting stress responses to various situations (Taha, Matheson, & Anisman, 2013), and among a range of populations (e.g., Somali refugees, Matheson, Jorden, & Anisman, 2008). Participants rated how often they used each of 50 behaviors (e.g., “worried about your problem a lot”; “told jokes about your situation”; “exercised”) to cope with stressors in the past two weeks on a 5-point scale ranging from 0 (never) to 4 (almost always). These behaviors form 14 overarching strategies that were further reduced using a principal components analysis with varimax rotation. Based on the criteria that each factor account for at least 10% of variance, two factors were maintained. The first factor reflected the full range of emotion-focused coping strategies, including rumination, wishful thinking, emotional expression, emotional containment, self-blame, other-blame, passive resignation, and avoidance (a 5 .84). The second factor, problem-focused coping, comprised problem solving, cognitive restructuring, social support seeking, active distraction, and humor (a 5 .70). These factors were only mildly correlated with each other (r 5 .16, p 5 .004). Self-stigma of seeking help Participants completed this six-item measure (Vogel, Wade, & Haake, 2006) in reference to seeking help for mental health issues (e.g., “I would feel inadequate if I went to a mental health counselor for help”). Responses were on a seven-point scale ranging from 23 (strongly disagree) to 13 (strongly agree). Total scores were calculated by taking the mean across items assessing self-stigma for seeking help for mental health issues (a 5 .90). Journal of Applied Social Psychology, 2016, 46, pp. 470–482
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Other-stigma of seeking help
The stigma of seeking help
Path analysis
cance of the hypothesized indirect effects were also conducted (Hayes & Preacher, 2013). Where paths were significant, bootstrapping techniques for mediation, with 10,000 resamples and based on 95% confidence intervals (Preacher & Hayes, 2008) were used. Both gender and history of therapy were included as covariates in the path analysis. Examination of the fit indices indicated that the model depicted in Figure 1 yielded an acceptable fit to the data. The chi-square value was not significant, v2 (3) 5 7.26, ns, NNFI and CFI were above the minimum criteria of .90 (NNFI 5 .91, CFI 5 .99), and RMSEA did not exceed the cut-off criteria of .08 (RMSEA 5 .07, 90% CI{.00; .13}). Greater depressive symptoms were associated with lower perceptions of support and more unsupportive interactions with peers. Moreover, the diminished social support resources appeared to have consequences for how individuals coped with distress, in that perceptions of greater peer support were related to endorsement of more problem-focused coping strategies, and those who experienced more unsupportive responses from their peers were less likely to endorse problem-focused coping and more likely to engage in emotion-focused coping efforts. Finally, in line with expectations, emotion-focused coping was associated with greater self- and other-stigma of help-seeking, whereas problemfocused efforts were associated with lower stigma of helpseeking. To confirm the viability of the predictive model, several alternative models were explored, including (1) removing all paths associated with emotion- and problem-focused coping; (2) removing all paths related to unsupport and support from peers; and (3) altering the sequence of mediators by considering coping as the first mediator and support perceptions as the second mediator in relations between depressive symptoms and help-seeking stigma to test for alternative directionality. Chi-square difference tests consistently reaffirmed that the original hypothesized model yielded the best fit to the data.
A path analysis assessed the hypothesized relations between the predictor (depressive symptoms), mediating variables (support, unsupport, coping), and outcome variables (selfand other-stigma for mental health help-seeking). Several fit indices were evaluated, including the Comparative Fit Index (CFI) and Non-Normative Fit Index (NNFI), for which values greater than .90 were considered acceptable (Pedhazur & Schmelkin, 1991), and the Root Mean Square Error of Approximation (RMSEA), for which values less than .08 were considered acceptable (Brown, 2006). Chi-square (v2) measures of fit have been known to be sensitive to sample size; however in order to compare alternative models against the hypothesized model, the Minimum Fit Function Chisquare was utilized. As the path analysis is limited to a descriptive function, inference tests to determine the signifi-
Testing indirect effects in relations between depressive symptoms and self-stigma. The confidence interval for tests of sequential mediation of social support and problem-focused coping did not overlap with zero (95% CI{.0006; .0068} SE 5 .002). Thus, it can be inferred that reduced support from peers and diminished problemfocused coping served as intervening variables in the relation between depressive symptoms and the heightened self-stigma of help-seeking. Specifically, those who perceived support and hence were inclined to endorse problem-solving techniques were less likely to regard help-seeking as negatively reflecting on their self-concept, and hence, might well have a greater propensity to actually seek help. Encountering unsupportive interactions and problemfocused coping did not appear to play a mediating role in the
The six-item scale (Vogel et al., 2009) measured the perceived stigma held by others associated with seeking help for mental health issues (e.g., “If you were to get help from a mental health counselor, to what degree do you believe that the people you interact with would: react negatively to you; think bad things of you”). Responses were made on a five-point scale ranging from 1 (not at all) to 5 (a great deal). Total scores were calculated by taking the mean across all items assessing other-stigma for seeking help for mental health issues (a 5 .92) and academic issues (a 5 .92), respectively.
Results and discussion Group differences Severity of depressive symptoms did not differ significantly between male and female students (Male: M 5 5.13, SD 5 4.95; Female: M 5 5.84, SD 5 4.68), t(326) 5 1.24, ns. Consistent with other research (Matheson & Anisman, 2003) females endorsed more emotion-focused coping strategies (M 5 2.00, SD 5 0.68) than did males (M 5 1.66, SD 5 0.61), t(326) 5 4.33, p < .001, but they did not differ in their endorsement of problem-focused strategies (Male: M 5 2.18, SD 5 0.64; Female: M 5 2.31, SD 5 0.60, t(326) 5 1.73, ns). No gender differences were observed for perceptions of unsupport, t(326) 5 20.56, ns, although females perceived more support from their peers (M 5 2.73, SD 5 0.28) than did males (M 5 2.66, SD 5 0.32), t(326) 5 2.04, p 5 .04). Males reported higher levels of self(Male: M 5 20.09, SD 5 1.48; Female: M 5 20.06, SD 5 1.61), t(326) 5 22.73, p 5 .01, and other-stigma (Male: M 5 1.86, SD 5 0.93; Female: M 5 1.62, SD 5 0.82), t(326) 5 22.23, p 5 .03, for seeking help for mental health concerns.
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Figure 1 Study 1 standardized beta (b) estimates of the predictive model linking depressive symptoms, unsupport, peer support, parental support (with relations to utcomes constrained), and self- and other-stigma for academic help-seeking as well as self- and other-stigma for mental health helpseeking. Dashed arrows indicate nonsignificant relations. * p
