Psychiatric Rehabilitation Journal 2015, Vol. 38, No. 2, 135–141
© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000131
Modeling Stigma, Help-Seeking Attitudes, and Intentions to Seek Behavioral Healthcare in a Clinical Military Sample Nathaniel G. Wade and David L. Vogel
Patrick Armistead-Jehle and Scott S. Meit
Iowa State University
Munson Army Health Center, Fort Leavenworth, Kansas
Patrick J. Heath and Haley A. Strass This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Iowa State University Objective: This study examined the relationship between public and self-stigma of seeking behavioral health services, and help-seeking attitudes and intent in a sample of active duty military personnel currently being assessed for traumatic brain injuries in a military health center. Although it has been suggested that many military personnel in need of care do not seek services due to concerns with stigma it is not fully clear what role different types of stigma play in the process. Method: Using previously collected data from a clinical sample of 97 military personnel, we conducted path analyses to test the mediation effects of self-stigma on the relationship between public stigma and attitudes toward and intentions to seek behavioral health care. Results: In contrast to a model of military stigma but in line with research with civilian samples, results from this study indicate that self-stigma fully mediates the relationship between public stigma and help-seeking attitudes and intentions. Conclusions and Implications for Practice: These results indicate that programming aimed at increasing mental health care use in the military might best focus on reducing self-stigma associated with seeking mental health services. Keywords: public stigma, self-stigma, help seeking, attitudes, military
the stigma associated with using BH services (see Corrigan, 2004; Skopp et al., 2012).
Military personnel who have been deployed, and particularly those have suffered physical injuries, are at increased risk for a variety of mental health concerns, including depression and posttraumatic stress disorder (PTSD; e.g., Schwarzbold et al., 2008; Thomas et al., 2010). Prolonged exposure to dangerous environments and associated injuries or risk of injury or death has been found to take a psychological toll on military personnel (Mental Health Advisory Team Six, 2009). This psychological toll has been linked to serious problems including reductions in quality of life, decreased retention, loss of productivity, lower organizational efficiency, family disruption (Westphal, 2007), and increased risk for suicide (Kuehn, 2009). Despite the need for behavioral health (BH) services to address these concerns, there is ample evidence that those most in need of care are often unlikely to seek care (Gould et al., 2010; Kim, Thomas, Wilk, Castro, & Hoge, 2010). Epidemiological studies report that the percentage of military personnel experiencing mental health concerns who utilize BH services could be as low as 23% (Hoge et al., 2004). One proposed barrier to accessing services is
Stigma and Help-Seeking in the Military The history of military endorsement of seeking BH services has been a fluid one. Nash, Silva, and Litz (2009) note that conceptualizations of mental disorders as being “emblematic of personal weakness” (p. 790) fuel military stigma and social prejudices. This has not always been the case. For example, when BH was “medicalized” in the military just after the Civil War, many service members were diagnosed with disorders like “shellshock” (Nash et al., 2009). However, leading psychiatrists and neurologists around the time of WWI concluded that “impairment following exposure to a traumatic stressor could only occur in an individual with ‘hysteria,’ a preexisting personality weakness” (p. 791). Consequently, the label shellshock was banned from use in the military. Subsequent wartime psychiatric evacuations dropped precipitously to 10% in WWII, 3.7% in the Korean War, and 1.2% during the Vietnam conflict (Nash, 2007). Current views of treatment seeking in the military seem to be mixed. Contemporary messages from military leadership encourage treatment seeking (e.g., indicating use of BH care is a sign of strength). Alternatively, unique aspects of the military mission potentially increase perceptions of stigma through stated policies that set limits to the privacy of patients. As an example, The Office of the Surgeon General/Medical Command Policy Memo 12– 015 details situations in which a BH provider is obligated to notify command that a service member is receiving care, such as when a service member might be at “harm to mission.” Military personnel are generally aware of such limitations and these mixed messages
This article was published Online First March 30, 2015. Nathaniel G. Wade and David L. Vogel, Department of Psychology, Iowa State University; Patrick Armistead-Jehle and Scott S. Meit, Department of Behavioral Health, Munson Army Health Center, Fort Leavenworth, Kansas; Patrick J. Heath and Haley A. Strass, Department of Psychology, Iowa State University. Correspondence concerning this article should be addressed to Nathaniel G. Wade, Department of Psychology, w112 Lagomarcino Hall, Ames, IA 50011. E-mail: [email protected] 135
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could impact how they see treatment and the stigma they may feel if they were to consider seeking treatment.
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Public and Self-Stigma Consistent with this, a theoretical model of mental health stigma (Corrigan, 2004) has been applied to the military. This model emphasizes the importance of two types of stigma, public and self-stigma, which could impact seeking help among military personnel (see Greene-Shortridge et al., 2007). When applied to help seeking, public stigma is the perception that people in society would believe that an individual who seeks psychological help is undesirable or socially unacceptable (Corrigan, 2004; Vogel, Wade, & Haake, 2006). In contrast, self-stigma of seeking psychological help refers to the perception held by the individual that he or she is undesirable or socially unacceptable for seeking psychological help (Corrigan, 2004; Vogel et al., 2006). Studies examining the perceived barriers to accessing BH care have found evidence of the existence of both public and selfstigma in military settings. For example, public stigma has been identified in a number of studies. Military personnel have expressed concerns that others in the military will stigmatize people who seek BH care and that seeking help would affect military promotions, prevent them from going on future deployments, or hinder later job opportunities (Cornish, Thill, Wade, & Vogel, 2012). Service members also feared that others would perceive them as being weak or see them as malingering (Zinzow et al., 2013). Military personnel may experience even greater public stigma than civilians because their military records are less private, the BH professionals they work with are often employed by the military, and a history of treatment could negatively impact possible job options and advancement (Gould et al., 2010; Warner, Appenzeller, Mullen, Warner, & Grieger, 2008; Hoge et al., 2004). Evidence of self-stigma toward seeking out BH care also exists in the military. For example, seeking out BH services has often been described as a symbol of weakness in military culture (Stecker, Fortney, Hamilton, & Ajzen, 2007). Cornish et al. (2012) found that veterans explicitly believed negative things would be true of them if they sought BH treatment (e.g., feeling ashamed if they sought help). As a result of this tendency, there have been some efforts to combat stigma in the military by reframing helpseeking as a sign of courage and strength. The Real Warriors campaign (www.realwarriors.net) encourages the use of mental health services by highlighting military values that might be used to seek psychological help (e.g., value of mutual support, bravery). The research noted above supports the theoretical model of military mental health stigma proposed by Greene-Shortridge and colleagues (2007). In particular, their identification of two separate types of stigma, public and self-stigma, seems to be important. However, their model indicates that the public and self-stigma associated with seeking BH services act independently of one another. This is in contrast to models tested on civilian samples, which indicate that self-stigma fully mediates the relationship between public stigma and help seeking attitudes and intentions (Vogel, Wade, & Hackler, 2007). Because self-stigma is thought to occur when individuals apply the stigmatizing labels to themselves following an awareness of public stigma (Corrigan, 2004), the self-stigma associated with seeking BH services may be the more
proximal predictor of outcomes such as attitudes about and intentions to seek BH care. Empirical evidence with the general population supports these assertions. A recent cross-panel longitudinal study provided evidence that the public stigma of seeking psychological help was internalized as self-stigma over time (Vogel, Bitman, Hammer, & Wade, 2013). Several cross sectional studies support mediation models wherein the self-stigma of seeking psychological help fully mediates the effects of public stigma of mental illness (Vogel, Shechtman, & Wade, 2010; Vogel et al., 2007) and the effects of public stigma of seeking psychological help on attitudes and intentions toward seeking different types of therapy (Ludwikowski, Vogel, & Armstrong, 2009). Overall, both public and self-stigma have been identified as important variables in military samples and linked to more negative attitudes and decreased intentions toward seeking BH care (see Greene-Shortridge et al., 2007; Skopp et al., 2012; Zinzow et al., 2013). However, unlike in civilian samples, the relative contribution of each is not well understood, as most empirical studies in the military have focused on public stigma and not self-stigma. Furthermore, the few studies that have focused on both types of stigma have tended to use samples of military personnel generally and not focused on clinical samples. As such, we do not know if the same mediated pathways exist as have been found in nonmilitary samples.
The Current Study In order to further understand the role of both public and self-stigma within military personnel, the current study applies the multiple mediation model described by Vogel et al. (2007) to a sample of military personnel who were evaluated for a history of possible traumatic brain injury (see Figure 1). Although some models postulate that public and self-stigma act independently on a service member’s decision to seek help for BH problems (Greene-Shortridge et al., 2007), we hypothesize that self-stigma will fully mediate the relationship between public stigma and attitudes toward BH care. In turn, we hypothesized that attitudes would then fully mediate the relationships between self-stigma and intentions to seek help for interpersonal concerns and drug use concerns. Finally, we hypothesized that attitudes would fully mediate the relationship between public-stigma and intentions to seek help for interpersonal concerns and drug use concerns while controlling for the mediating effects of self-stigma (see Figure 1).
Method Participants The study included 97 active duty service members evaluated in an outpatient neuropsychology clinic located in a U.S. Army Health Center between October 2010 and March 2012. Study participants were referred for neuropsychological evaluation from either primary care or BH. The average age of the sample was 35.2 years (SD ⫽ 7.7), with an average education of 15.2 years (SD ⫽ 2.4). The sample was 92.8% male. The majority of the sample was European American (78.4%), with 13.4% of African American, 5.2% of Hispanic, 2.1% of Asian, and 1% of Pacific Island descents. Most of the sample was active duty Army (86.6%), with
HELP-SEEKING STIGMA IN THE MILITARY
.50***
Public Stigma
.44***
Self-Stigma
-.67***
PIC
Attitudes Toward Seeking Help
.36***
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DUC
Figure 1. Final multiple mediation model (N ⫽ 97). PIC ⫽ Psychological and Interpersonal Concerns subscale of Intent to Seek Counseling Inventory; DUC ⫽ Drug Use Concerns subscale of Intent to Seek Counseling Inventory. Numbers are standardized parameter estimates. ⴱⴱⴱ p ⬍ .001.
a minority of Army Reservists (9.3%), Active Duty Marines (3.1%) and Active Duty Navy (1%). The majority of the sample (77.3%) consisted of people with a remote history of at least one mild traumatic brain injury as defined by the American Congress of Rehabilitation Medicine (1993) criteria. One individual had a remote history of a penetrating brain injury. Other participants were either deemed to not have sustained a concussion (9.3%) or were diagnosed with a primary psychiatric (5.2%) or another neurologic (5.2%) condition. Nonmutually exclusive psychiatric diagnoses consisted of PTSD (18.6%), other anxiety disorder (39.2%), unipolar depressive disorder (12.4%), adjustment disorder (2.1%), and attention deficit hyperactivity disorder (2.1%). There were seven participants (7.2%) with a dual diagnosis of PTSD and depressive disorder and 12 (12.4%) who did not have any psychiatric diagnosis. Many participants had received BH care (n ⫽ 69, 71.1%), with 15 currently under care of a psychiatrist, 16 currently in psychotherapy, 15 in both psychiatry and psychotherapy, and 23 with a history of BH care.
Procedures All patients were tested by the third author (a board-certified clinical neuropsychologist) or a trained neuropsychology technician under the supervision of the third author. As part of a larger neuropsychological test battery patients were administered selfreport assessment measures that included the scales described below. The Institutional Review Board at Madigan Army Medical Center approved the retrospective analysis of this previously collected clinical data.
Measures Self-stigma. The Self-Stigma of Seeking Help scale (Vogel et al., 2006) was used to measure participants’ self-stigma related to seeking professional psychological help. 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 Likert scale where 1 ⫽ strongly disagree and 5 ⫽ strongly agree. Five items are reverse scored so that higher scores correspond to higher self-stigma related to seeking psychological help. Previous support for the validity of the Self-Stigma of Seeking Help scale has indicated positive relationships with the social
stigma of seeking psychological help, anticipated risks of disclosing in therapy, and negative relationships with attitudes toward seeking professional psychological help and intentions to seek counseling (Vogel et al., 2006). Previous Cronbach’s alpha scores have ranged from .86 to .90 in undergraduate samples (test–retest, .72; Vogel et al., 2006) and .89 in a military sample (Skopp et al., 2012). The Cronbach’s alpha score in this sample was .83. Public stigma. Participants’ perceptions of public stigma associated with seeking psychological help were measured using the Stigma Scale for Receiving Psychological Help (Komiya, Good, & Sherrod, 2000). This is a five-item scale measured on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). A sample item is, “People tend to like less those who are receiving professional psychological help.” Higher scores indicate higher levels of perceived public stigma associated with seeking psychological help. In a previous study, a Cronbach’s alpha of .72 was reported, and the measure was found to correlate with attitudes toward seeking psychological help (Komiya et al., 2000). The internal consistency of the scores obtained in the current sample was .82. Attitudes. The Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (Fischer & Farina, 1995) is a 10-item revision of the original 29-item measure (Fischer & Turner, 1970), consisting of items such as, “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.” Items are rated from 1 (disagree) to 4 (agree). Five items are reverse scored so that higher scores reflect more positive attitudes toward seeking mental health services. The revised and original scales are correlated .87, suggesting that they tap into a similar construct (Fischer & Farina, 1995). The revised scale also correlates with previous use of professional help for a problem. Estimates of the internal consistency (␣ ⫽ .84) have been reported for college student samples (Fisher & Farina, 1995), general community samples (␣ ⫽ .87; Hammer, Vogel, & Heimerdinger-Edwards, 2013), and military samples (␣ ⫽ .82; Kehle et al., 2010). The internal consistency of the scores obtained in the current sample was .82. Intentions. Participants’ level of intent to seek out BH care was measured using the Intentions to Seek Counseling Inventory (Cash, Begley, McCown, & Weise, 1975). The inventory consists of 17 items, with participants responding from 1 (very unlikely) to
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4 (very likely) to questions about how likely they would be to seek help if they were experiencing each of the specific problem listed (e.g., depression, conflict with family, excessive alcohol use, etc.). The inventory is broken into three subscales: Psychological and Interpersonal Concerns (PIC; 11 items), Academic Concerns (AC; four items), and Drug Use Concerns (DUC; two items). For the purpose of this study, only the PIC and DUC subscales were used. The internal consistency was .90 for each subscale.
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Data Analysis Path analysis, using LISREL 8.8 program, was used to examine the hypothesized model. We used the full information maximum likelihood estimation to address missing data, though there were very few missing data in the sample. Only one participant failed to complete the whole set of questionnaires, leaving items blank for the public stigma and attitudes toward counseling scales. To assess goodness of fit, the root mean square error of approximation (RMSEA; .06 or less), the Comparative Fit Index (CFI; .95 or greater; see Hu & Bentler, 1999; Martens, 2005), and standardized root mean residual (SRMR; .08 or less; Hu & Bentler, 1999) were used. We also compared the hypothesized full mediation model (see Figure 1) against an alternative partial mediation model to determine best fit (Holmbeck, 1997). MacKinnon et al. (2002) reported that the standard errors of the indirect effects reported by the LISREL program are not accurate. As a result, Shrout and Bolger (2002) suggested that a more accurate estimate of the standard error of the indirect effect could be calculated with a bootstrap procedure. The bootstrap procedure is an empirical method of determining the significance of statistical estimates (Efron & Tibshirani, 1993). Therefore, in the current study, we used a bootstrap procedure to test the statistical significance of the hypothesized indirect effects.
Results The means, standard deviations, and correlations for the scales are summarized in Table 1. First we examined the multivariate normality of the data. Results showed that the data were multivariate normal, 2(2, N ⫽ 97) ⫽ 5.75, p ⬎ .05. Results for the hypothesized path model (see Figure 1) indicated an excellent fit to the data, 2(5, N ⫽ 97) ⫽ 1.73, p ⫽ .89, RMSEA ⫽ .00 (95% confidence interval [CI] [.00, .07]), CFI ⫽ 1.0, SRMR ⫽ .02). Table 1 Means, Standard Deviations, and Correlations (N ⫽ 97) M 1. 2. 3. 4. 5.
Public Stigma Self-Stigma Attitudes PIC DUC
10.78 24.21 29.22 29.55 6.44
SD
1
2
3
4
5
2.85 — .44ⴱⴱⴱ ⫺.33ⴱⴱ ⫺.15 ⫺.16 7.07 — ⫺.67ⴱⴱⴱ ⫺.36ⴱⴱⴱ ⫺.24ⴱ 5.23 — ⫺.49ⴱⴱⴱ ⫺.35ⴱⴱ 7.19 — .43ⴱⴱⴱ 1.76 —
Note. Public Stigma ⫽ Stigma Scale for Receiving Psychological Help; Self-Stigma ⫽ Self-Stigma of Seeking Help Scale; Attitudes ⫽ Attitudes Towards Seeking Professional Psychological Help Scale; PIC ⫽ Psychological and Interpersonal Concerns subscale of Intent to Seek Counseling Inventory; DUC ⫽ Drug Use Concern subscale of the Intent to Seek Counseling Inventory. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
Public stigma predicted self-stigma ( ⫽ .44), which predicted attitudes toward BH care ( ⫽ ⫺.67). In turn, attitudes toward BH care then predicted intentions to seek BH care for interpersonal concerns ( ⫽ .50) and for drug concerns ( ⫽ .36). The hypothesized multiple mediation model assumed full mediation. However, there still could be direct effects between public stigma and attitudes, and between public stigma and intentions to seek care for interpersonal concerns and drug concerns. In addition, there could be direct effects between self-stigma and intentions to seek care for interpersonal and drug concerns. Therefore, an alternative partially mediated model was tested which examined the addition of these five direct effects. This model had all paths accounted for and so provided a perfect fit to the data; however, the additional five direct pathways were each nonsignificant (absolute value of all betas at or below .11, ps ⬎ .05). Consistent with this, a 2 difference test between the two nested models showed no significant difference, 2diff ⫽ 1.73, p ⫽ .89, indicating the additional paths did not add significantly to the hypothesized model.
Bootstrapping To conduct the bootstrap procedure we created 1,000 bootstrap samples from the original dataset and saved 1,000 estimates of the path coefficients in the LISREL program. We calculated the indirect effect of public stigma on attitudes (mean indirect effect⫽ ⫺.29; 95% CI [⫺.41, ⫺.17]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes. We calculated the indirect effect of public stigma on intent to seek BH care for interpersonal concerns through self-stigma and attitudes (mean indirect effect ⫽ ⫺.14; 95% CI [⫺.23, ⫺.07]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes and with the 1,000 path coefficients from attitudes to intent to seek BH care for interpersonal concerns. We calculated the indirect effect of public stigma on intent to seek help for drug concerns through self-stigma and attitudes (mean indirect effect ⫽ ⫺.11; 95% CI [⫺.20, ⫺.04]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes and with the 1,000 path coefficients from attitudes to intent to seek BH care for drug concerns. We also calculated the indirect effect of just self-stigma on intent to seek BH care for interpersonal concerns through attitudes (mean indirect effect ⫽ ⫺.33; 95% CI [⫺.47, ⫺.20]) by multiplying the 1,000 path coefficients from self-stigma to attitudes with the 1,000 path coefficients from attitudes to intent. Finally we calculated the indirect effect of just self-stigma on intent to seek BH care for drug concerns through attitudes (mean indirect effect ⫽ ⫺.24; 95% CI [⫺.40, ⫺.10]) by multiplying the 1,000 path coefficients from self-stigma to attitudes with the 1,000 path coefficients from attitudes to intent to seek BH care for drug concerns. The indirect effect is statistically significant at the .05 level if the 95% CI for these estimates does not include zero (see Shrout & Bolger, 2002). The 95% CI for all indirect effects did not include zero, and therefore were significant at p ⬍ .05.
Discussion The results support our hypothesis that self-stigma fully mediates the relationship between public stigma and help seeking
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attitudes and intent to seek BH care. These results suggest that the relationships between public stigma, self-stigma, and help-seeking attitudes and intentions observed in civilian samples (e.g., Vogel et al., 2007) may operate in a very similar way for those in the military, particularly those presenting at a concussion clinic. The present analyses were conducted with the same measures used in civilians samples and the strength of the relationship among the variables in the present study match very closely with a previous study of university students, where the direct effects between public stigma and self-stigma and self-stigma and attitudes were .26 and ⫺.76, respectively (Vogel et al., 2007). Although previous models of military mental health stigma indicated that both public and self-stigma may act independently of one another to influence a service members’ decision to seek BH care (Greene-Shortridge et al., 2007), the results from this study indicate that self-stigma appears to be a more proximal predictor of attitudes about and intentions to seek professional BH services. In contrast to some findings in the past, however, public stigma was not directly related to intentions to seek counseling in the present sample. Despite this nonsignificant direct effect, self-stigma and attitudes toward counseling appeared to link public stigma with intentions. This indirect multiple mediation despite a direct effect might be the effect of public stigma being positively related to variables that have opposite relationships with intentions. For example, from our study, we know that public stigma is positively related to self-stigma, which is negatively related to intentions. However, past research has indicated that public stigma is also positively related to psychological distress, which in contrast to self-stigma is positively related to intentions. As a result, important mediating variables may have opposing relationships with the two variables to be mediated, resulting in a nonsignificant direct effect. As such a result of these findings, this study reveals important new details about the relationship between stigma and BH help seeking in the military. Considering the sample consisted largely of individuals who had experienced mild traumatic brain injuries and are at potentially increased risk for developing psychological disorders (Schwarzbold et al., 2008), these results have implications for future interventions. Estimates indicate the prevalence of BH problems like depression and PTSD in postdeployment military personnel ranges from 19% to 26% of returning service members (Hoge et al., 2004). Research also indicates that rates of mental illness like PTSD and depression persist, or even increase, even after returning from deployment (Thomas et al., 2010). Since military personnel utilize BH care at very low rates (Hoge et al., 2004), interventions aimed at decreasing the self-stigma associated with seeking help could lead to more individuals seeking out BH support. Recent work on interventions aimed at reducing self-stigma has advocated increasing self-esteem (Corrigan, Larson, & Rüsch, 2009; Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012), increasing self-affirmation (Lannin, Guyll, Vogel, & Madon, 2013), or utilizing cognitive restructuring (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008; Masuda et al., 2007) to decrease the effect of self-stigma on help-seeking attitudes. Online interventions have also recently been developed and have been found to be effective (Wade, Cornish, & Vogel, 2013).
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Limitations and Conclusions The relatively small sample size and preponderance of male participants limited our ability to examine potential moderating variables such as biological sex. Previous studies have indicated that stigma is internalized by men more than women (Vogel et al., 2007) and, therefore, could be a more salient barrier to seeking help for men than for women. In addition to gender, other factors that are specific to military personnel might influence the relationship between stigma and help-seeking attitudes and intentions. Factors such as rank in the military or number of deployments are unique to military personnel that could play a role in decisions to seek help. For example, personnel ranked more highly might not experience stigma as strongly due to their leadership role. Conversely, this group might experience stigma more strongly, as they might be expected to be stronger both physically and mentally. Further research is needed to address the potential moderating effects of these variables. The study was also limited by the nature of the sample, which was taken from a concussion clinic rather than a BH setting. While many of the service members in this sample had concurrent BH diagnoses, the precise role of concussion in their responses could not be determined. To this end, the external validity of the current study could be limited by the history of concussion in a number of these participants. Validation of the current results in a BH specific sample, especially in those without a history of BH treatment, would be a valuable extension to this line of research. Another limitation of the present study is the reliance solely on the Intentions to Seek Counseling scale without a measure of actual behaviors. This is one of the most important steps for researchers to take in the future. Although intentions are predictive of behaviors (Ajzen, 1991) and are often used as a proxy for behaviors in the literature, understanding the impact of public and self-stigma and attitudes on actual help-seeking behavior is paramount. Without information about the degree to which stigma relates to actually seeking psychological help, the information in this area is incomplete. In addition, sampling of military personnel who had followed through on an assessment referral is a third limitation. Therefore, the present results might not fully generalize to all military personnel, especially those who have psychological concerns but did not follow through after being referred or who were never referred. Our hypothesis would be that the relationship between public and self-stigma on the one hand and attitudes toward counseling and intentions to seek counseling on the other would actually be stronger in such a sample because these individuals are likely to see treatment more negatively. However, this might not be the case. In addition, the mediation effect of self-stigma might not be present either. These are research questions that will need to be addressed more fully in future research. Additionally, while this study helps clarify the relationship between public stigma, self-stigma, and help seeking in military personnel, it is cross sectional in design and is therefore limited in its ability to draw causal conclusions. Longitudinal analyses examining the relationship between stigma and help seeking attitudes over time would allow for causal conclusions to be made. Additional research on interventions targeting self-stigma would also be useful, as this study only addresses the relationship between stigma
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and help seeking attitudes. Assessing the impact of various selfstigma interventions (i.e., in person, online, etc.) within the context of the military is an important next step that must be taken.
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active duty and National Guard soldiers after combat. Psychiatric Services, 61, 582–588. http://dx.doi.org/10.1176/ps.2010.61.6.582 Komiya, N., Good, G. E., & Sherrod, N. B. (2000). Emotional openness as a predictor of college students’ attitudes toward seeking psychological help. Journal of Counseling Psychology, 47, 138 –143. Kuehn, B. M. (2009). Soldier suicide rates continue to rise: Military, scientists work to stem the tide. Journal of the American Medical Association, 301, 1111–1113. http://dx.doi.org/10.1001/jama.2009.342 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 Lannin, D. G., Vogel, D. L., Brenner, R. E., & Tucker, J. (in press). Predicting distress and intentions to seek psychological help: The internalized stigma model. The Counseling Psychologist. 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 Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., Bunting, K., & Rye, A. K. (2008). Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory, 16, 149 –165. http://dx.doi.org/10.1080/ 16066350701850295 MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A comparison of methods to test mediation and other intervening variable effects. Psychological Methods, 7, 83. Martens, M. P. (2005). Future directions of structural equation modeling in counseling psychology. The Counseling Psychologist, 33, 375–382. Masuda, A., Hayes, S. C., Fletcher, L. B., Seignourel, P. J., Bunting, K., Herbst, S. A., . . . Lillis, J. (2007). Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders. Behaviour Research and Therapy, 45, 2764 –2772. http://dx .doi.org/10.1016/j.brat.2007.05.008 Mental Health Advisory Team Six. (2009). Operation Iraqi Freedom 07– 09. Washington, DC: Office of the Surgeon, Multi-National CorpsIraq & Office of the Surgeon General, United States Army Medical Command. Mittal, D., Sullivan, G., Chekuri, L., Allee, E., & Corrigan, P. W. (2012). Empirical studies of self-stigma reduction strategies: A critical review of the literature. Psychiatric Services, 63, 974 –981. http://dx.doi.org/ 10.1176/appi.ps.201100459 Nash, W. P. (2007). Combat/operational stress adaptations and injuries. In C. F. Figley & W. P. Nash (Eds.), Combat stress injury: Theory, research, and management (pp. 70–102). New York, NY: Routledge. Nash, W. P., Silva, C., & Litz, B. (2009). The historic origins of military and veteran mental health stigma and the stress injury model as a means to reduce it. Psychiatric Annals, 39, 789 –794. http://dx.doi.org/10.3928/ 00485713-20090728-05 Schwarzbold, M., Diaz, A., Martins, E. T., Rufino, A., Amante, L. N., Thais, M. E., . . . Walz, R. (2008). Psychiatric disorders and traumatic brain injury. Neuropsychiatric Disease and Treatment, 4, 797– 816. Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychological Methods, 7, 422– 445. http://dx.doi.org/10.1037/1082-989X.7.4 .422 Skopp, N. A., Bush, N. E., Vogel, D. L., Wade, N. G., Sirotin, A. P., McCann, R. A., & Metzger-Abamukong, M. J. (2012). Development and initial testing of a measure of public and self-stigma in the military. Journal of Clinical Psychology, 68, 1036 –1047. http://dx.doi.org/ 10.1002/jclp.21889 Stecker, T., Fortney, J. C., Hamilton, F., & Ajzen, I. (2007). An assessment of beliefs about mental health care among veterans who served in Iraq.
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HELP-SEEKING STIGMA IN THE MILITARY Psychiatric Services, 58, 1358 –1361. http://dx.doi.org/10.1176/ps.2007 .58.10.1358 Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67, 614 – 623. http://dx.doi.org/10.1001/archgenpsychiatry.2010.54 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., Shechtman, Z., & Wade, N. G. (2010). The role of public and self-stigma in predicting attitudes toward group counseling. The Counseling Psychologist, 38, 904 –922. http://dx.doi.org/10.1177/ 0011000010368297 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. http://dx.doi.org/10.1037/0022-0167.53.3.325 Vogel, D. L., Wade, N., & Hackler, S. (2007). Perceived public stigma and the willingness to seek counseling: The mediating role of self-stigma and
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attitudes toward counseling. Journal of Counseling Psychology, 54, 40 –50. http://dx.doi.org/10.1037/0022-0167.54.1.40 Wade, N. G., Cornish, M. A., & Vogel, D. L. (2013, August). Evaluation of an online help-seeking stigma-reduction intervention for military personnel. Poster presented at the Annual Convention for the American Psychological Association. Honolulu, HI. Warner, C. H., Appenzeller, G. N., Mullen, K., Warner, C. M., & Grieger, T. (2008). Soldier attitudes toward mental health screening and seeking care upon return from combat. Military Medicine, 173, 563–569. http:// dx.doi.org/10.7205/MILMED.173.6.563 Westphal, R. J. (2007). Fleet leaders’ attitudes about subordinates’ use of mental health services. Military Medicine, 172, 1138 –1143. Zinzow, H. M., Britt, T. W., Pury, C. I., Raymond, M. A., McFadden, A. C., & Burnette, C. M. (2013). Barriers and facilitators of mental health treatment seeking among active-duty army personnel. Military Psychology, 25, 514 –535. http://dx.doi.org/10.1037/mil0000015
Received March 28, 2014 Revision received December 15, 2014 Accepted January 26, 2015 䡲
© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000131
Modeling Stigma, Help-Seeking Attitudes, and Intentions to Seek Behavioral Healthcare in a Clinical Military Sample Nathaniel G. Wade and David L. Vogel
Patrick Armistead-Jehle and Scott S. Meit
Iowa State University
Munson Army Health Center, Fort Leavenworth, Kansas
Patrick J. Heath and Haley A. Strass This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Iowa State University Objective: This study examined the relationship between public and self-stigma of seeking behavioral health services, and help-seeking attitudes and intent in a sample of active duty military personnel currently being assessed for traumatic brain injuries in a military health center. Although it has been suggested that many military personnel in need of care do not seek services due to concerns with stigma it is not fully clear what role different types of stigma play in the process. Method: Using previously collected data from a clinical sample of 97 military personnel, we conducted path analyses to test the mediation effects of self-stigma on the relationship between public stigma and attitudes toward and intentions to seek behavioral health care. Results: In contrast to a model of military stigma but in line with research with civilian samples, results from this study indicate that self-stigma fully mediates the relationship between public stigma and help-seeking attitudes and intentions. Conclusions and Implications for Practice: These results indicate that programming aimed at increasing mental health care use in the military might best focus on reducing self-stigma associated with seeking mental health services. Keywords: public stigma, self-stigma, help seeking, attitudes, military
the stigma associated with using BH services (see Corrigan, 2004; Skopp et al., 2012).
Military personnel who have been deployed, and particularly those have suffered physical injuries, are at increased risk for a variety of mental health concerns, including depression and posttraumatic stress disorder (PTSD; e.g., Schwarzbold et al., 2008; Thomas et al., 2010). Prolonged exposure to dangerous environments and associated injuries or risk of injury or death has been found to take a psychological toll on military personnel (Mental Health Advisory Team Six, 2009). This psychological toll has been linked to serious problems including reductions in quality of life, decreased retention, loss of productivity, lower organizational efficiency, family disruption (Westphal, 2007), and increased risk for suicide (Kuehn, 2009). Despite the need for behavioral health (BH) services to address these concerns, there is ample evidence that those most in need of care are often unlikely to seek care (Gould et al., 2010; Kim, Thomas, Wilk, Castro, & Hoge, 2010). Epidemiological studies report that the percentage of military personnel experiencing mental health concerns who utilize BH services could be as low as 23% (Hoge et al., 2004). One proposed barrier to accessing services is
Stigma and Help-Seeking in the Military The history of military endorsement of seeking BH services has been a fluid one. Nash, Silva, and Litz (2009) note that conceptualizations of mental disorders as being “emblematic of personal weakness” (p. 790) fuel military stigma and social prejudices. This has not always been the case. For example, when BH was “medicalized” in the military just after the Civil War, many service members were diagnosed with disorders like “shellshock” (Nash et al., 2009). However, leading psychiatrists and neurologists around the time of WWI concluded that “impairment following exposure to a traumatic stressor could only occur in an individual with ‘hysteria,’ a preexisting personality weakness” (p. 791). Consequently, the label shellshock was banned from use in the military. Subsequent wartime psychiatric evacuations dropped precipitously to 10% in WWII, 3.7% in the Korean War, and 1.2% during the Vietnam conflict (Nash, 2007). Current views of treatment seeking in the military seem to be mixed. Contemporary messages from military leadership encourage treatment seeking (e.g., indicating use of BH care is a sign of strength). Alternatively, unique aspects of the military mission potentially increase perceptions of stigma through stated policies that set limits to the privacy of patients. As an example, The Office of the Surgeon General/Medical Command Policy Memo 12– 015 details situations in which a BH provider is obligated to notify command that a service member is receiving care, such as when a service member might be at “harm to mission.” Military personnel are generally aware of such limitations and these mixed messages
This article was published Online First March 30, 2015. Nathaniel G. Wade and David L. Vogel, Department of Psychology, Iowa State University; Patrick Armistead-Jehle and Scott S. Meit, Department of Behavioral Health, Munson Army Health Center, Fort Leavenworth, Kansas; Patrick J. Heath and Haley A. Strass, Department of Psychology, Iowa State University. Correspondence concerning this article should be addressed to Nathaniel G. Wade, Department of Psychology, w112 Lagomarcino Hall, Ames, IA 50011. E-mail: [email protected] 135
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could impact how they see treatment and the stigma they may feel if they were to consider seeking treatment.
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Public and Self-Stigma Consistent with this, a theoretical model of mental health stigma (Corrigan, 2004) has been applied to the military. This model emphasizes the importance of two types of stigma, public and self-stigma, which could impact seeking help among military personnel (see Greene-Shortridge et al., 2007). When applied to help seeking, public stigma is the perception that people in society would believe that an individual who seeks psychological help is undesirable or socially unacceptable (Corrigan, 2004; Vogel, Wade, & Haake, 2006). In contrast, self-stigma of seeking psychological help refers to the perception held by the individual that he or she is undesirable or socially unacceptable for seeking psychological help (Corrigan, 2004; Vogel et al., 2006). Studies examining the perceived barriers to accessing BH care have found evidence of the existence of both public and selfstigma in military settings. For example, public stigma has been identified in a number of studies. Military personnel have expressed concerns that others in the military will stigmatize people who seek BH care and that seeking help would affect military promotions, prevent them from going on future deployments, or hinder later job opportunities (Cornish, Thill, Wade, & Vogel, 2012). Service members also feared that others would perceive them as being weak or see them as malingering (Zinzow et al., 2013). Military personnel may experience even greater public stigma than civilians because their military records are less private, the BH professionals they work with are often employed by the military, and a history of treatment could negatively impact possible job options and advancement (Gould et al., 2010; Warner, Appenzeller, Mullen, Warner, & Grieger, 2008; Hoge et al., 2004). Evidence of self-stigma toward seeking out BH care also exists in the military. For example, seeking out BH services has often been described as a symbol of weakness in military culture (Stecker, Fortney, Hamilton, & Ajzen, 2007). Cornish et al. (2012) found that veterans explicitly believed negative things would be true of them if they sought BH treatment (e.g., feeling ashamed if they sought help). As a result of this tendency, there have been some efforts to combat stigma in the military by reframing helpseeking as a sign of courage and strength. The Real Warriors campaign (www.realwarriors.net) encourages the use of mental health services by highlighting military values that might be used to seek psychological help (e.g., value of mutual support, bravery). The research noted above supports the theoretical model of military mental health stigma proposed by Greene-Shortridge and colleagues (2007). In particular, their identification of two separate types of stigma, public and self-stigma, seems to be important. However, their model indicates that the public and self-stigma associated with seeking BH services act independently of one another. This is in contrast to models tested on civilian samples, which indicate that self-stigma fully mediates the relationship between public stigma and help seeking attitudes and intentions (Vogel, Wade, & Hackler, 2007). Because self-stigma is thought to occur when individuals apply the stigmatizing labels to themselves following an awareness of public stigma (Corrigan, 2004), the self-stigma associated with seeking BH services may be the more
proximal predictor of outcomes such as attitudes about and intentions to seek BH care. Empirical evidence with the general population supports these assertions. A recent cross-panel longitudinal study provided evidence that the public stigma of seeking psychological help was internalized as self-stigma over time (Vogel, Bitman, Hammer, & Wade, 2013). Several cross sectional studies support mediation models wherein the self-stigma of seeking psychological help fully mediates the effects of public stigma of mental illness (Vogel, Shechtman, & Wade, 2010; Vogel et al., 2007) and the effects of public stigma of seeking psychological help on attitudes and intentions toward seeking different types of therapy (Ludwikowski, Vogel, & Armstrong, 2009). Overall, both public and self-stigma have been identified as important variables in military samples and linked to more negative attitudes and decreased intentions toward seeking BH care (see Greene-Shortridge et al., 2007; Skopp et al., 2012; Zinzow et al., 2013). However, unlike in civilian samples, the relative contribution of each is not well understood, as most empirical studies in the military have focused on public stigma and not self-stigma. Furthermore, the few studies that have focused on both types of stigma have tended to use samples of military personnel generally and not focused on clinical samples. As such, we do not know if the same mediated pathways exist as have been found in nonmilitary samples.
The Current Study In order to further understand the role of both public and self-stigma within military personnel, the current study applies the multiple mediation model described by Vogel et al. (2007) to a sample of military personnel who were evaluated for a history of possible traumatic brain injury (see Figure 1). Although some models postulate that public and self-stigma act independently on a service member’s decision to seek help for BH problems (Greene-Shortridge et al., 2007), we hypothesize that self-stigma will fully mediate the relationship between public stigma and attitudes toward BH care. In turn, we hypothesized that attitudes would then fully mediate the relationships between self-stigma and intentions to seek help for interpersonal concerns and drug use concerns. Finally, we hypothesized that attitudes would fully mediate the relationship between public-stigma and intentions to seek help for interpersonal concerns and drug use concerns while controlling for the mediating effects of self-stigma (see Figure 1).
Method Participants The study included 97 active duty service members evaluated in an outpatient neuropsychology clinic located in a U.S. Army Health Center between October 2010 and March 2012. Study participants were referred for neuropsychological evaluation from either primary care or BH. The average age of the sample was 35.2 years (SD ⫽ 7.7), with an average education of 15.2 years (SD ⫽ 2.4). The sample was 92.8% male. The majority of the sample was European American (78.4%), with 13.4% of African American, 5.2% of Hispanic, 2.1% of Asian, and 1% of Pacific Island descents. Most of the sample was active duty Army (86.6%), with
HELP-SEEKING STIGMA IN THE MILITARY
.50***
Public Stigma
.44***
Self-Stigma
-.67***
PIC
Attitudes Toward Seeking Help
.36***
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DUC
Figure 1. Final multiple mediation model (N ⫽ 97). PIC ⫽ Psychological and Interpersonal Concerns subscale of Intent to Seek Counseling Inventory; DUC ⫽ Drug Use Concerns subscale of Intent to Seek Counseling Inventory. Numbers are standardized parameter estimates. ⴱⴱⴱ p ⬍ .001.
a minority of Army Reservists (9.3%), Active Duty Marines (3.1%) and Active Duty Navy (1%). The majority of the sample (77.3%) consisted of people with a remote history of at least one mild traumatic brain injury as defined by the American Congress of Rehabilitation Medicine (1993) criteria. One individual had a remote history of a penetrating brain injury. Other participants were either deemed to not have sustained a concussion (9.3%) or were diagnosed with a primary psychiatric (5.2%) or another neurologic (5.2%) condition. Nonmutually exclusive psychiatric diagnoses consisted of PTSD (18.6%), other anxiety disorder (39.2%), unipolar depressive disorder (12.4%), adjustment disorder (2.1%), and attention deficit hyperactivity disorder (2.1%). There were seven participants (7.2%) with a dual diagnosis of PTSD and depressive disorder and 12 (12.4%) who did not have any psychiatric diagnosis. Many participants had received BH care (n ⫽ 69, 71.1%), with 15 currently under care of a psychiatrist, 16 currently in psychotherapy, 15 in both psychiatry and psychotherapy, and 23 with a history of BH care.
Procedures All patients were tested by the third author (a board-certified clinical neuropsychologist) or a trained neuropsychology technician under the supervision of the third author. As part of a larger neuropsychological test battery patients were administered selfreport assessment measures that included the scales described below. The Institutional Review Board at Madigan Army Medical Center approved the retrospective analysis of this previously collected clinical data.
Measures Self-stigma. The Self-Stigma of Seeking Help scale (Vogel et al., 2006) was used to measure participants’ self-stigma related to seeking professional psychological help. 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 Likert scale where 1 ⫽ strongly disagree and 5 ⫽ strongly agree. Five items are reverse scored so that higher scores correspond to higher self-stigma related to seeking psychological help. Previous support for the validity of the Self-Stigma of Seeking Help scale has indicated positive relationships with the social
stigma of seeking psychological help, anticipated risks of disclosing in therapy, and negative relationships with attitudes toward seeking professional psychological help and intentions to seek counseling (Vogel et al., 2006). Previous Cronbach’s alpha scores have ranged from .86 to .90 in undergraduate samples (test–retest, .72; Vogel et al., 2006) and .89 in a military sample (Skopp et al., 2012). The Cronbach’s alpha score in this sample was .83. Public stigma. Participants’ perceptions of public stigma associated with seeking psychological help were measured using the Stigma Scale for Receiving Psychological Help (Komiya, Good, & Sherrod, 2000). This is a five-item scale measured on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). A sample item is, “People tend to like less those who are receiving professional psychological help.” Higher scores indicate higher levels of perceived public stigma associated with seeking psychological help. In a previous study, a Cronbach’s alpha of .72 was reported, and the measure was found to correlate with attitudes toward seeking psychological help (Komiya et al., 2000). The internal consistency of the scores obtained in the current sample was .82. Attitudes. The Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (Fischer & Farina, 1995) is a 10-item revision of the original 29-item measure (Fischer & Turner, 1970), consisting of items such as, “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.” Items are rated from 1 (disagree) to 4 (agree). Five items are reverse scored so that higher scores reflect more positive attitudes toward seeking mental health services. The revised and original scales are correlated .87, suggesting that they tap into a similar construct (Fischer & Farina, 1995). The revised scale also correlates with previous use of professional help for a problem. Estimates of the internal consistency (␣ ⫽ .84) have been reported for college student samples (Fisher & Farina, 1995), general community samples (␣ ⫽ .87; Hammer, Vogel, & Heimerdinger-Edwards, 2013), and military samples (␣ ⫽ .82; Kehle et al., 2010). The internal consistency of the scores obtained in the current sample was .82. Intentions. Participants’ level of intent to seek out BH care was measured using the Intentions to Seek Counseling Inventory (Cash, Begley, McCown, & Weise, 1975). The inventory consists of 17 items, with participants responding from 1 (very unlikely) to
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4 (very likely) to questions about how likely they would be to seek help if they were experiencing each of the specific problem listed (e.g., depression, conflict with family, excessive alcohol use, etc.). The inventory is broken into three subscales: Psychological and Interpersonal Concerns (PIC; 11 items), Academic Concerns (AC; four items), and Drug Use Concerns (DUC; two items). For the purpose of this study, only the PIC and DUC subscales were used. The internal consistency was .90 for each subscale.
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Data Analysis Path analysis, using LISREL 8.8 program, was used to examine the hypothesized model. We used the full information maximum likelihood estimation to address missing data, though there were very few missing data in the sample. Only one participant failed to complete the whole set of questionnaires, leaving items blank for the public stigma and attitudes toward counseling scales. To assess goodness of fit, the root mean square error of approximation (RMSEA; .06 or less), the Comparative Fit Index (CFI; .95 or greater; see Hu & Bentler, 1999; Martens, 2005), and standardized root mean residual (SRMR; .08 or less; Hu & Bentler, 1999) were used. We also compared the hypothesized full mediation model (see Figure 1) against an alternative partial mediation model to determine best fit (Holmbeck, 1997). MacKinnon et al. (2002) reported that the standard errors of the indirect effects reported by the LISREL program are not accurate. As a result, Shrout and Bolger (2002) suggested that a more accurate estimate of the standard error of the indirect effect could be calculated with a bootstrap procedure. The bootstrap procedure is an empirical method of determining the significance of statistical estimates (Efron & Tibshirani, 1993). Therefore, in the current study, we used a bootstrap procedure to test the statistical significance of the hypothesized indirect effects.
Results The means, standard deviations, and correlations for the scales are summarized in Table 1. First we examined the multivariate normality of the data. Results showed that the data were multivariate normal, 2(2, N ⫽ 97) ⫽ 5.75, p ⬎ .05. Results for the hypothesized path model (see Figure 1) indicated an excellent fit to the data, 2(5, N ⫽ 97) ⫽ 1.73, p ⫽ .89, RMSEA ⫽ .00 (95% confidence interval [CI] [.00, .07]), CFI ⫽ 1.0, SRMR ⫽ .02). Table 1 Means, Standard Deviations, and Correlations (N ⫽ 97) M 1. 2. 3. 4. 5.
Public Stigma Self-Stigma Attitudes PIC DUC
10.78 24.21 29.22 29.55 6.44
SD
1
2
3
4
5
2.85 — .44ⴱⴱⴱ ⫺.33ⴱⴱ ⫺.15 ⫺.16 7.07 — ⫺.67ⴱⴱⴱ ⫺.36ⴱⴱⴱ ⫺.24ⴱ 5.23 — ⫺.49ⴱⴱⴱ ⫺.35ⴱⴱ 7.19 — .43ⴱⴱⴱ 1.76 —
Note. Public Stigma ⫽ Stigma Scale for Receiving Psychological Help; Self-Stigma ⫽ Self-Stigma of Seeking Help Scale; Attitudes ⫽ Attitudes Towards Seeking Professional Psychological Help Scale; PIC ⫽ Psychological and Interpersonal Concerns subscale of Intent to Seek Counseling Inventory; DUC ⫽ Drug Use Concern subscale of the Intent to Seek Counseling Inventory. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
Public stigma predicted self-stigma ( ⫽ .44), which predicted attitudes toward BH care ( ⫽ ⫺.67). In turn, attitudes toward BH care then predicted intentions to seek BH care for interpersonal concerns ( ⫽ .50) and for drug concerns ( ⫽ .36). The hypothesized multiple mediation model assumed full mediation. However, there still could be direct effects between public stigma and attitudes, and between public stigma and intentions to seek care for interpersonal concerns and drug concerns. In addition, there could be direct effects between self-stigma and intentions to seek care for interpersonal and drug concerns. Therefore, an alternative partially mediated model was tested which examined the addition of these five direct effects. This model had all paths accounted for and so provided a perfect fit to the data; however, the additional five direct pathways were each nonsignificant (absolute value of all betas at or below .11, ps ⬎ .05). Consistent with this, a 2 difference test between the two nested models showed no significant difference, 2diff ⫽ 1.73, p ⫽ .89, indicating the additional paths did not add significantly to the hypothesized model.
Bootstrapping To conduct the bootstrap procedure we created 1,000 bootstrap samples from the original dataset and saved 1,000 estimates of the path coefficients in the LISREL program. We calculated the indirect effect of public stigma on attitudes (mean indirect effect⫽ ⫺.29; 95% CI [⫺.41, ⫺.17]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes. We calculated the indirect effect of public stigma on intent to seek BH care for interpersonal concerns through self-stigma and attitudes (mean indirect effect ⫽ ⫺.14; 95% CI [⫺.23, ⫺.07]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes and with the 1,000 path coefficients from attitudes to intent to seek BH care for interpersonal concerns. We calculated the indirect effect of public stigma on intent to seek help for drug concerns through self-stigma and attitudes (mean indirect effect ⫽ ⫺.11; 95% CI [⫺.20, ⫺.04]) by multiplying the 1,000 path coefficients from public stigma to self-stigma with the 1,000 path coefficients from self-stigma to attitudes and with the 1,000 path coefficients from attitudes to intent to seek BH care for drug concerns. We also calculated the indirect effect of just self-stigma on intent to seek BH care for interpersonal concerns through attitudes (mean indirect effect ⫽ ⫺.33; 95% CI [⫺.47, ⫺.20]) by multiplying the 1,000 path coefficients from self-stigma to attitudes with the 1,000 path coefficients from attitudes to intent. Finally we calculated the indirect effect of just self-stigma on intent to seek BH care for drug concerns through attitudes (mean indirect effect ⫽ ⫺.24; 95% CI [⫺.40, ⫺.10]) by multiplying the 1,000 path coefficients from self-stigma to attitudes with the 1,000 path coefficients from attitudes to intent to seek BH care for drug concerns. The indirect effect is statistically significant at the .05 level if the 95% CI for these estimates does not include zero (see Shrout & Bolger, 2002). The 95% CI for all indirect effects did not include zero, and therefore were significant at p ⬍ .05.
Discussion The results support our hypothesis that self-stigma fully mediates the relationship between public stigma and help seeking
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HELP-SEEKING STIGMA IN THE MILITARY
attitudes and intent to seek BH care. These results suggest that the relationships between public stigma, self-stigma, and help-seeking attitudes and intentions observed in civilian samples (e.g., Vogel et al., 2007) may operate in a very similar way for those in the military, particularly those presenting at a concussion clinic. The present analyses were conducted with the same measures used in civilians samples and the strength of the relationship among the variables in the present study match very closely with a previous study of university students, where the direct effects between public stigma and self-stigma and self-stigma and attitudes were .26 and ⫺.76, respectively (Vogel et al., 2007). Although previous models of military mental health stigma indicated that both public and self-stigma may act independently of one another to influence a service members’ decision to seek BH care (Greene-Shortridge et al., 2007), the results from this study indicate that self-stigma appears to be a more proximal predictor of attitudes about and intentions to seek professional BH services. In contrast to some findings in the past, however, public stigma was not directly related to intentions to seek counseling in the present sample. Despite this nonsignificant direct effect, self-stigma and attitudes toward counseling appeared to link public stigma with intentions. This indirect multiple mediation despite a direct effect might be the effect of public stigma being positively related to variables that have opposite relationships with intentions. For example, from our study, we know that public stigma is positively related to self-stigma, which is negatively related to intentions. However, past research has indicated that public stigma is also positively related to psychological distress, which in contrast to self-stigma is positively related to intentions. As a result, important mediating variables may have opposing relationships with the two variables to be mediated, resulting in a nonsignificant direct effect. As such a result of these findings, this study reveals important new details about the relationship between stigma and BH help seeking in the military. Considering the sample consisted largely of individuals who had experienced mild traumatic brain injuries and are at potentially increased risk for developing psychological disorders (Schwarzbold et al., 2008), these results have implications for future interventions. Estimates indicate the prevalence of BH problems like depression and PTSD in postdeployment military personnel ranges from 19% to 26% of returning service members (Hoge et al., 2004). Research also indicates that rates of mental illness like PTSD and depression persist, or even increase, even after returning from deployment (Thomas et al., 2010). Since military personnel utilize BH care at very low rates (Hoge et al., 2004), interventions aimed at decreasing the self-stigma associated with seeking help could lead to more individuals seeking out BH support. Recent work on interventions aimed at reducing self-stigma has advocated increasing self-esteem (Corrigan, Larson, & Rüsch, 2009; Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012), increasing self-affirmation (Lannin, Guyll, Vogel, & Madon, 2013), or utilizing cognitive restructuring (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008; Masuda et al., 2007) to decrease the effect of self-stigma on help-seeking attitudes. Online interventions have also recently been developed and have been found to be effective (Wade, Cornish, & Vogel, 2013).
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Limitations and Conclusions The relatively small sample size and preponderance of male participants limited our ability to examine potential moderating variables such as biological sex. Previous studies have indicated that stigma is internalized by men more than women (Vogel et al., 2007) and, therefore, could be a more salient barrier to seeking help for men than for women. In addition to gender, other factors that are specific to military personnel might influence the relationship between stigma and help-seeking attitudes and intentions. Factors such as rank in the military or number of deployments are unique to military personnel that could play a role in decisions to seek help. For example, personnel ranked more highly might not experience stigma as strongly due to their leadership role. Conversely, this group might experience stigma more strongly, as they might be expected to be stronger both physically and mentally. Further research is needed to address the potential moderating effects of these variables. The study was also limited by the nature of the sample, which was taken from a concussion clinic rather than a BH setting. While many of the service members in this sample had concurrent BH diagnoses, the precise role of concussion in their responses could not be determined. To this end, the external validity of the current study could be limited by the history of concussion in a number of these participants. Validation of the current results in a BH specific sample, especially in those without a history of BH treatment, would be a valuable extension to this line of research. Another limitation of the present study is the reliance solely on the Intentions to Seek Counseling scale without a measure of actual behaviors. This is one of the most important steps for researchers to take in the future. Although intentions are predictive of behaviors (Ajzen, 1991) and are often used as a proxy for behaviors in the literature, understanding the impact of public and self-stigma and attitudes on actual help-seeking behavior is paramount. Without information about the degree to which stigma relates to actually seeking psychological help, the information in this area is incomplete. In addition, sampling of military personnel who had followed through on an assessment referral is a third limitation. Therefore, the present results might not fully generalize to all military personnel, especially those who have psychological concerns but did not follow through after being referred or who were never referred. Our hypothesis would be that the relationship between public and self-stigma on the one hand and attitudes toward counseling and intentions to seek counseling on the other would actually be stronger in such a sample because these individuals are likely to see treatment more negatively. However, this might not be the case. In addition, the mediation effect of self-stigma might not be present either. These are research questions that will need to be addressed more fully in future research. Additionally, while this study helps clarify the relationship between public stigma, self-stigma, and help seeking in military personnel, it is cross sectional in design and is therefore limited in its ability to draw causal conclusions. Longitudinal analyses examining the relationship between stigma and help seeking attitudes over time would allow for causal conclusions to be made. Additional research on interventions targeting self-stigma would also be useful, as this study only addresses the relationship between stigma
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and help seeking attitudes. Assessing the impact of various selfstigma interventions (i.e., in person, online, etc.) within the context of the military is an important next step that must be taken.
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Received March 28, 2014 Revision received December 15, 2014 Accepted January 26, 2015 䡲
