Received 02/13/16

Revised 01/11/17
Accepted 02/20/17
DOI: 10.1002/jcad.12178

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 approxi-
mately 50% of college-attending adults meeting diagnostic
criteria for a mental disorder (Zivin, Eisenberg, Gollust, &
Golberstein, 2009). However, help seeking among college stu-
dents 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 recogni-
tion, (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 influ-
ence (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. Spe-
cifically, we investigated mental health literacy, defined as
“knowledge and beliefs about mental disorders” (Jorm et
al., 1997, p. 182), and self-stigma of seeking psychologi-
cal 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 help-
seeking 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, Depart-
ment 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 94117 (e-mail: hcheng13@usfca.edu).

© 2018 by the American Counseling Association. All rights reserved.

64 Journal of Counseling & Development  ■  January 2018  ■  Volume 96
Attitudes Toward Seeking Psychological Help
and self-stigma (Vogel et al., 2006) separately, less atten-
tion 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 seek-
ing 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 (help-
seeking history, current depression and anxiety) correlates of
help-seeking attitudes.
Mental Health Literacy
Mental health literacy, by definition, encompasses the abil-
ity 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 individu-
als with higher levels of mental health literacy (e.g., abil-
ity 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 recogni-
tion 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 us-
ing 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 col-
lege 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 Af-
rican Americans in their college student sample were unable
Journal of Counseling & Development  ■  January 2018  ■  Volume 96
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 individu-
als 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 associ-
ated 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 self-
stigma 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

Gender, Race/Ethnicity,
Help-Seeking History, and
Psychological Distress as Correlates
Because of the diversity of college students, when examin-
ing 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 theoreti-
cal rationale for the inclusion of these important covariates.
Gender
Data based on community samples have consistently demon-
strated 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 open-
ness 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 stu-
dents 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 (Ma-
suda 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, includ-
ing mistrust of non-Hispanic White counselors because of
66 Journal of Counseling & Development  ■  January 2018  ■  Volume 96
Cheng, Wang, McDermott, Kridel, & Rislin
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 pro-
fessional 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 depres-
sion 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 psychologi-
cal 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 rec-
ognition, GAD recognition, depression attribution, and GAD
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 psycho-
logical 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 e-mail, 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 Ameri-
can, 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
Journal of Counseling & Development  ■  January 2018  ■  Volume 96
services. To monitor inattentive responding, we asked par-
ticipants 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 in-
strument 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, respon-
dents 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 Likert-
type 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 correla-
tions 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

Items are rated on a 5-point Likert scale ranging from 1
(strongly disagree) to 5 (strongly agree), with higher aver-
age 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 at-
tributions 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 Psychologi-
cal 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 di-
verse 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).
68 Journal of Counseling & Development  ■  January 2018  ■  Volume 96
Cheng, Wang, McDermott, Kridel, & Rislin
Results
As a preliminary step, we screened data for outliers, normality,
and multicollinearity before performing the primary regres-
sion 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 90–10 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 rec-
ognition 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 nor-
mality 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 partici-
pants’ 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 help-
seeking 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 < .01 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). Regard-
ing 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 <
.01 to p < .001). Table 1 presents the intercorrelations, means,
Attitudes Toward Seeking Psychological Help

TABLE 1
Intercorrelations, Means, and Standard Deviations Among Variables
Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 M SD
1. Help seeking — .00 .07* –.65* .23* –.17* –.17* .38* .39* –.26* .01 –.16* .04 .11* 2.85 0.57
2. Current DEP — .71* .16* –.01 .01 .01 .28* .17* –.04 .04 –.03 .04 –.01 0.60 0.54
3. Current anxiety — .10* .00 .01 .01 .28* .18* –.07* .01 –.08* .02 .10* 0.72 0.66
4. Self-stigma — –.17* .13* .10* –.21* –.27* .16* –.06* .13* –.03 –.61 2.46 0.78
5. Correct GADa — –.21* –.13* .10* .14 –.20* –.06 –.12 –.01 .14* 0.61 0.49
6. Stress GADa — .12* –.07* –.13* .22 .10* .11* .03 –.10* 0.48 0.50
7. Stress DEPa — –.06* –.10* .11* .06* .09 .03 –.12* 0.27 0.44
8. Past help-Aa — .41* –.91* .03 –.13* .02 .08* 0.28 0.45
9. Past help-Ba — –.06* .00 –.17* .04 .12* 0.40 0.49
10. Malea — –.05 .00 –.03 .04 0.36 0.48
11. African Ama — –.10* –.06* –.41* 0.54 0.23
12. Asian Ama — –.10* –.71* 0.15 0.35
13. Latino Ama — –.42* 0.06 0.23
14. Whitea — 0.74 0.44

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 self-
stigma predicted help-seeking attitudes after covariates had
been taken into account, we conducted a hierarchical regres-
sion 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 < .01) 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 help-
seeking 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 < .01)
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 self-
stigma and mental health literacy variables significantly and
uniquely explained help-seeking attitudes above and beyond
demographic (gender, race/ethnicity) and psychological (help-
seeking 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

Journal of Counseling & Development  ■  January 2018  ■  Volume 96 69

 Cheng, Wang, McDermott, Kridel, & Rislin

TABLE 2
Summary of Hierarchical Regression Analyses Predicting Help-Seeking Attitudes
Variable B SE B b Adjusted R2 DR2
Step 1 .28***
Past help-Aa .35 .03 .28***
Past help-Ba .31 .03 .27***
Current DEP –.16 .03 –.16**
Current anxiety .03 .03 .03
Malea –.26 .03 –.22***
African American –.04 .06 –.04
Asian American –.13 .04 –.08*
Latino American .05 .05 .02
Non-Hispanic White b
Step 2 .54*** .19***
Self-stigma –.30 .01 –.53***
Correct GADa .07 .02 .06**
Stress GADa –.05 .02 –.05*
Stress DEPa –.09 .02 –.07***
Step 3 .54*** .03***
Self-Stigma × Correct GAD .04 .02 .05
Self-Stigma × Stress GAD .10 .02 .01
Self-Stigma × Stress DEP –.03 .02 .03
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. bReference group.
*p < .05. **p < .01. ***p < .001.

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 ac-
count. 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-stigma—we found no
significant interaction. However, to our knowledge, no pre-
vious 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 self-
stigma and mental health literacy variables. We found that
several demographic and psychological variables had signifi-
cant 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 clari-
fying the contributions of primary variables of interest (e.g.,
self-stigma, mental health literacy) in help-seeking processes.
Several additional prominent findings related to demo-
graphic 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 depres-
sion 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 Journal of Counseling & Development  ■  January 2018  ■  Volume 96

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 identi-
fication 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 signifi-
cance. 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 limi-
tation 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. Relat-
edly, 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
Journal of Counseling & Development  ■  January 2018  ■  Volume 96
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 at-
tributed 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 condi-
tions 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 out-
reach 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

It is important for counselors to demystify the counseling
process (Thomas et al., 2014) and frame help-seeking en-
gagement 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. Increased
availability of racial/ethnic minority counselors and demonstra-
tion of multicultural knowledge concerning the unique mental
health needs of diverse students may be an effective way to
reach groups of underserved students (Turner et al., 2016).
Conclusion
A striking majority of college students do not seek psycholog-
ical help when needed, and further confounding this problem,
many college students hold high levels of self-stigma and low
mental health literacy concerning psychological problems and
professional services. Our findings highlight the importance
of concurrent consideration of both decreasing self-stigma
and enhancing mental health literacy to facilitate positive
attitudes toward seeking professional psychological help,
particularly among underserved, minority college students.
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