Many people who experience psychological and interpersonal concerns never pursue treatment (Corrigan, 2004). According to some estimates, within a given year, only 11% of those experiencing a diagnosable problem seek psychological services. In addition, fewer than 2% of those who struggle with problems that do not meet diagnosable criteria seek treatment (Andrews, Issakidis, & Carter, 2001). The most often cited reason for why people do not seek counseling and other mental health services is the stigma associated with mental illness and seeking treatment (Corrigan, 2004). Stigma can decrease the likelihood that an individual will seek services even when the potential consequences of not seeking counseling (e.g., increased suffering) are severe (Sibicky & Dovidio, 1986). In fact, in April 2002, during the launching of the New Freedom Commission on Mental Health (http://www.mentalhealthcommission.gov), the president declared that the stigma that surrounds mental illness is the major obstacle to Americans getting the quality mental health care they deserve. This is consistent with the 1999 surgeon general’s report on mental health (Satcher, 1999). The surgeon general’s report identified the fear of stigmatization as deterring individuals from (a) acknowledging their illness, (b) seeking help, and (c) remaining in treatment, thus creating unnecessary suffering. These commissions and reports stress the importance of better understanding the role of stigma in seeking care so that efforts to reduce stigma can be implemented.
Stigma Associated With Seeking Counseling
Stigma has been defined as a mark or flaw resulting from a personal or physical characteristic that is viewed as socially unacceptable (Blaine, 2000). The “stigma associated with seeking mental health services, therefore, is the perception that a person who seeks psychological treatment is undesirable or socially unacceptable” (Vogel, Wade, & Haake, 2006, p. 325). The existence of public stigma (i.e., negative views of the person by others) surrounding mental illness and the seeking of psychological services is clear. Past research has found that the public often describes people with a mental illness in negative terms (for a review, see Angermeyer & Dietrich, 2006). For example, survey research has shown that the majority of community respondents report negative attitudes toward people with an identified disorder (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000) and tend to avoid and perceive as dangerous those who are labeled as having been previously hospitalized (Link, Cullen, Frank, & Wozniak, 1987).
Whereas the stigma attached to being a mental health patient may not be the same as the stigma associated with being a counseling client, researchers have found that people tend to report more stigma surrounding counseling clients than nonclients. For example, people labeled as having used counseling services have been rated less favorably and treated more negatively than those who were not labeled (Sibicky & Dovidio, 1986). In scenario-based research, individuals described as seeking assistance for depression were rated as more emotionally unstable, less interesting, and less confident than those described as seeking help for back pain and than those described as not seeking help for depression (Ben-Porath, 2002). As a result, it seems that it is not just having a disorder but seeking psychological services that is stigmatized by the public.
Given the negative perceptions of those who seek psychological services, it is not surprising that individuals hide their psychological concerns and avoid treatment to limit the harmful consequences associated with being stigmatized (Corrigan & Matthews, 2003). Consistent with this, individuals are less likely to seek helpfor issues that are viewed negatively by others (Overbeck, 1977). In addition, surveys of undergraduate students have found that those who endorse stigmas of the mentally ill are less likely to seek psychological help (Cooper, Corrigan, & Watson, 2003). Researchers have also found that perceptions of counseling stigma predict attitudes toward seeking counseling (Deane & Todd, 1996; Komiya, Good, & Sherrod, 2000; Vogel, Wester, Wei, & Boysen, 2005) as well as willingness to seek counseling (Rochlen, Mohr, & Hargrove, 1999). Survey research with community samples has also found that the fear of being viewed as crazy is a common barrier to seeking professional help (Nelson & Barbaro, 1985) and that participants who do not seek therapy are more likely to report stigma as a treatment barrier than those who do (Stefl & Prosperi, 1985). Furthermore, the stigma associated with mental illness has been linked to the early termination of treatment (Sirey et al., 2001). In all, there is clear support that awareness of the stigma associated with seeking treatment has a negative influence on people’s attitudes toward seeking help and keeps many people from seeking help even when they have significant problems.
The Role of Self-Stigma
Despite the awareness of the relationship between perceived public stigma and the decision to seek treatment, the complex role that stigma plays in this decision-making process is not fully known. Corrigan (1998, 2004) asserted that there are two separate types of stigma affecting an individual’s decision to seek treatment. The first, public stigma, is the perception held by others (i.e., by society) that an individual is socially unacceptable. The second, self-stigma, is the perception held by the individual that he or she is socially unacceptable, which can lead to a reduction in self-esteem or self-worth if the person seeks psychological help (Vogel et al., 2006). In other words, the negative images expressed by society toward those who seek psychological services may be internalized (Corrigan, 1998, 2004; Holmes & River, 1998) and lead people to perceive themselves as inferior, inadequate, or weak (Nadler & Fisher, 1986). As a result, people higher in self-stigma may decide to forego psychological services to maintain a positive image of themselves (Miller, 1985).
Whereas the direct relationship of perceived public stigma on one’s willingness to seek psychological services is well established, the role of self-stigma has only recently been addressed. Related research, however, has shown that people can internalize negative perceptions when dealing with mental health issues (Link, 1987; Link & Phelan, 2001) and that being labeled mentally ill can lead to lower self-esteem (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001). In addition, modified labeling theory asserts that societal devaluation and discrimination toward the mentally ill could directly lead to negative consequences for people’s self-esteem if they are labeled, by themselves or others, as having a mental illness or as being in need of psychological care (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). Consistent with this, perceptions of stigma surrounding mental illness are related to lower self-esteem for those suffering from a mental illness (Link et al., 1987). Research has also shown that individuals are less likely to ask for help from nonprofessional sources, such as friends, if they fear embarrassment (Mayer & Timms, 1970) or if asking for help would lead them to feel inferior or incompetent (Nadler, 1991).
Studies have showed that self-stigma is conceptually different from other, potentially related constructs, such as self-esteem and public stigma, suggesting that self-stigma is potentially unique in the conceptualization of help-seeking behavior. Similarly, self-stigma uniquely predicts attitudes toward seeking psychological help and willingness to seek counseling above previously identified factors. Furthermore, research suggests that self-stigma mediates the relationship between perceived public stigma and attitudes toward seeking help as well as willingness to seek help. This mediating relationship makes sense, as public stigma’s effect on one’s decision to seek help may have as much or more to do with the internalization of societal messages about what it means to be mentally ill (Link et al., 1989) or to seek psychological services. The internalization can lead to shame and loss of self-esteem (Link, 1987), and the attempt to avoid those feelings may have the most direct effect on an individual’s attitudes toward and willingness to seek counseling.
Researchers have also recently suggested that self-stigma should be assessed even among individuals who elect to seek psychotherapy (Wade, Post, Cornish, Vogel, & Tucker, 2011). For example, researchers have found that when individuals experiencing self-stigmatizing feeling do enter treatment, self-stigma may be associated with poor treatment adherence and dropout, if self-stigma reduction is not addressed (Sirey, Bruce, Alexopoulos, Perlick, Friedman et al., 2001; Sirey, Bruce, Alexopoulos, Perlick, Roue et al., 2001). Self-stigma has also been shown to produce lasting negative effects on well-being, even when mental health symptoms largely remit (Link et al., 1997). Over time, enduring harmful effects of self-stigma may even counteract or nullify positive treatment outcomes (Link et al., 1997) and negatively affect well-being (Rosenfield, 1997), whereas reductions in self-stigma are associated with enduring positive treatment effects and of quality of life (Rosenfield, 1997). Similarly, individuals who have a positive therapeutic experience that reduces self-stigma may experience more enduring treatment benefits (Link et al., 1997). Therefore, self-stigma could be important to address both before and during treatment.