Examination of the Stigmas Toward Help ... - Wiley Online Library

Received 06/19/14 Revised 05/10/15 Accepted 08/19/15 DOI: 10.1002/jcad.12133

International Examination of the Stigmas Toward Help Seeking Among Turkish College Students Nursel Topkaya, David L. Vogel, and Rachel E. Brenner

This study builds on previous help-seeking research in the United States by examining the role of counseling stigma in Turkey. Undergraduate students in Turkey (N = 520) completed self-report measures of attitudes and intentions to seek counseling and 3 forms of help-seeking stigma. Results indicated that perceptions of public and social network stigma each uniquely contributed to the experience of self-stigma, which, in turn, influenced attitudes toward seeking counseling and then help-seeking intentions. Keywords: stigma, help seeking, diversity in counseling, cross-cultural, Turkey

Mental health concerns in Turkey have been reported to affect between 12% and 20% of the population (Erol, Kılıç, Ulusoy, Keçeci, & Şimşek, 1998; Kılıç, 1998; Küey, Üstün, & Güleç, 1987). Despite these statistics, counseling services are often viewed as intended only for the treatment of severe issues; consequently, Turkish individuals often either avoid counseling services or delay seeking treatment for extended periods of time (Çuhadaroğlu & Yazıcı, 1999; Kılınç & Granello, 2003; Koydemir & Demir, 2005; Koydemir, Erel, Yumurtacı, & Şahin, 2010; Yerin-Güneri, Aydın, & Skovholt, 2003). In fact, Erol et al. (1998) found that less than 14% of those experiencing a mental health concern sought the use of counseling services over a 12-month period. Therefore, it is important to understand the factors that may prevent individuals in Turkey from seeking counseling services. One possible factor is the stigma toward help seeking, or the receipt of counseling and related forms of therapy (Corrigan, 2004; Hess & Tracey, 2013; Vogel, Wade, & Hackler, 2007). This help-seeking stigma has been identified in Western cultures as a key barrier to seeking counseling services. Furthermore, help-seeking stigma has been linked to negative attitudes toward and decreased intentions to seek counseling when experiencing a mental health concern (Hackler, Vogel, & Wade, 2010; Vogel, Wade, & Ascheman, 2009). Although there is clear evidence for the role of a helpseeking stigma in Western countries, the nature of the help-seeking stigma does not necessarily generalize to other cultures (Coker, 2005). Turkey is a diverse country that has

gone through several transitional periods that have led to a blend of traditional Turkish and Western ideas, norms, and behaviors (İmamoğlu, 2003; Kağıtçıbaşı, 2012; MocanAydin, 2000), particularly among the younger generation (Karakitapoğlu-Aygün & İmamoğlu, 2002). Some researchers have suggested that help-seeking stigma may be less salient in countries whose citizens have integrated and diverse backgrounds, such as Turkey, because of a greater tolerance (Sayed, 2002, 2003) or because the norms that one must follow are less clear (Shechtman, Vogel, & Maman, 2010). On the other hand, the potential for stigmatization may be threatening to individuals in Turkey because of the cultural value of social connectedness (Cross, Gore, & Morris, 2003; Markus & Kitayama, 1991; Yeh, 2002) and the related view that the expression of problems to someone outside the family is an admission of failure (Al-Subaie, Marwa, Hawari, & Abdul-Rahim, 1996). In other words, in an effort to preserve interpersonal harmony and connection, an individual may choose not to participate in counseling to avoid stigma and maintain important relationships. For example, Gloria, Hird, and Navarro (2001) found that students from collectivist cultures used counseling services less frequently than did students from individualistic cultures. Furthermore, compared with Western nations, the counseling infrastructure in Turkey is in its nascent stages. The profession of counseling is new in Turkey and, as such, may not be well understood by the general public (see Doğan, 2000). Although the provision of counseling

Nursel Topkaya, Department of Educational Sciences, Division of Counseling and Guidance, Ondokuz Mayıs University, Kurupelit Campus, Atakum/Samsun, Turkey; David L. Vogel and Rachel E. Brenner, Department of Psychology, Iowa State University. Correspondence concerning this article should be addressed to Nursel Topkaya, Department of Educational Sciences, Division of Counseling and Guidance, Ondokuz Mayıs University, OMU Faculty of Education, Kurupelit Campus, Atakum/Samsun, Turkey 55100 (e-mail: [email protected]). © 2017 by the American Counseling Association. All rights reserved.

Journal of Counseling & Development ■ April 2017 ■ Volume 95

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Topkaya, Vogel, & Brenner

services has increased in recent years, the number of colleges and universities with counseling centers is limited (Demir & Aydın, 1995) and these facilities often have inadequate space and restricted service options (Yerin-Güneri, 2006). The recent emergence of counseling services suggests that the perceptions of counseling (i.e., attitudes and intentions) among people in Turkey may be unique from the perceptions of people in Western nations and warrants further exploration to better understand this phenomenon. Unfortunately, examination of counseling and its related stigma is limited in non-U.S. regions and is nearly absent from regions with cultural values more reflective of the Turkish population. Therefore, the purpose of this study was to examine help-seeking attitudes and intentions in Turkey and to test the cross-cultural applicability of a model of stigma that has been applied only to Western cultures.

Stigmas Associated With Seeking Counseling Research has shown that greater helping-seeking stigma is associated with decreased recognition of mental health problems (Alvidrez, Snowden, & Kaiser, 2008; Mishra, Lucksted, Gioia, Barnet, & Baquet, 2008), more negative attitudes toward seeking counseling services (Conner et al., 2010), and decreased intention to seek counseling (Cooper, Corrigan, & Watson, 2003; Hackler et al., 2010; Vogel et al., 2007). Once an individual actually elects to seek counseling, stigma impinges on the efficacy of the counseling itself and is associated with decreased compliance with therapeutic interventions (Fung, Tsang, & Chan, 2009; Sirey, Bruce, Alexopoulos, Perlick, Friedman, & Meyers, 2001), missed appointments (Vega, Rodriguez, & Ang, 2010), early termination of treatment (Sirey, Bruce, Alexopoulos, Perlick, Raue, et al., 2001), and decreased intention to return for subsequent sessions (Wade, Post, Cornish, Vogel, & Tucker, 2011). Furthermore, stigma has been directly linked to decreased well-being, such as lowered self-esteem (Bos, Kanner, Muris, Janssen, & Mayer, 2009; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001), depression (Manos, Rusch, Kanter, & Clifford, 2009), greater feelings of shame (Sirey, Bruce, Alexopoulos, Perlick, Raue, et al., 2001), and fewer social interactions (Kranke, Floersch, Townsend, & Munson, 2010). On the basis of Corrigan’s (2004) assertion that there are two types of stigma (i.e., public stigma [external stigma] and self-stigma [internal stigma]), Vogel and colleagues (Vogel, Wade, & Haake, 2006; Vogel et al., 2007) examined a model of the relationships between stigma and help-seeking decisions. When applied to help seeking, public stigma is an external form of stigma that denotes the perception held by society that an individual

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who seeks counseling services is undesirable or socially unacceptable (Vogel et al., 2006). At the internal level, self-stigma refers to the perception held by the individual that he or she is undesirable or socially unacceptable because of seeking counseling services (Vogel et al., 2007). In other words, whereas public stigma relates to others’ prejudicial attitudes and behaviors toward help seekers, self-stigma occurs when individuals apply the stigmatizing labels to themselves (Corrigan, 2004; Link et al., 2001). Greater public stigma (Komiya, Good, & Sherrod, 2000) and greater self-stigma (Bathje & Pryor, 2011; Blais & Renshaw, 2013; Hackler et al., 2010; Shea & Yeh, 2008) are associated with more negative attitudes and decreased intentions toward seeking counseling services. In line with Corrigan’s (2004) assertion, Vogel, Bitman, Hammer, and Wade (2013) found evidence of this stigma internalization process and its link to attitudes and intentions to seek counseling. Specifically, their crosspanel longitudinal study demonstrated that public stigma is internalized as self-stigma over time. Vogel and colleagues (Ludwikowski, Vogel, & Armstrong, 2009; Vogel, Shechtman, & Wade, 2010) also tested a model in which self-stigma, associated with seeking help, fully mediated the relationship between public stigma and both attitudes and intentions toward seeking counseling in individual, career, and group settings among U.S. samples. In these two studies, higher levels of public stigma were linked to higher levels of self-stigma, and, in turn, higher self-stigma was associated with less favorable attitudes and intentions to seek counseling. Although the distinction between public stigma and self-stigma allows for a more robust understanding of how people feel about seeking counseling, a new type of stigma involving the perceptions of those closest to the individual (e.g., family, friends) may also add to the understanding of help-seeking attitudes and intentions (Ludwikowski et al., 2009). For example, an individual may recognize that seeking counseling is stigmatized by society, but may also feel that his or her particular social network is supportive of seeking help. In this situation, the person would be expected to be more likely to seek services because those he or she personally knows are less likely to react negatively. This recently identified social network stigma denotes the negative stereotypes and prejudices held by those in a person’s direct social group toward seeking counseling (Vogel et al., 2009) and has been linked, as with public stigma and self-stigma, to help-seeking attitudes and intentions (Ludwikowski et al., 2009). However, the inclusion of social network stigma in the help-seeking stigma model has been examined in only one U.S. study (Ludwikowski et al., 2009), which focused on career services as opposed to individual counseling. Thus, no research has fully examined the relationship


Examination of the Stigmas Toward Help Seeking Among Turkish College Students between all three types of stigma in regard to individual counseling or within a non-U.S. sample such as Turkey.

Experiences of Counseling Stigma in Turkish Contexts As mentioned earlier, counseling services are underutilized in Turkey. Some initial research has suggested that help-seeking stigma is present in Turkey and interferes with help-seeking decisions (Topkaya, 2011b; Towle & Arslanoğlu, 1998). For example, researchers have found that public stigma exists in Turkey (Yerin-Güneri & Skovholt, 1999) and that helpseeking stigma is associated with Turkish adults’ intentions to seek counseling services (Topkaya, 2011b). Furthermore, Vogel, Armstrong, et al. (2013) found support for the presence of self-stigma in Turkey. Although not previously assessed, social network stigma may also be an important concept to assess in Turkish culture relative to the other types of stigma because of the importance of social connectedness and family. In Turkish culture, the family is considered central and relationships with family members are often close (Aytaç, 1998; İmamoğlu, 1987, 2003). Family is also one of the main sources of support in addressing problems (İmamoğlu, 2003). There is great importance on relationships with family members in Turkey, as well as a cultural motivation to maintain these close connections. Thus, the influence of an individual’s social network should play a unique role in the decision to seek counseling over and above other types of stigma. Researchers have started to consider the role of different forms of stigma in Turkey (Topkaya, 2011a, 2011b; Vogel, Armstrong, et al., 2013); however, they have not examined the unique contributions of public, self-, and social network stigma on help-seeking attitudes and intentions in a comprehensive framework. Examining these contributions is important, because the blended cultural climate in Turkey (Sayed, 2002, 2003) can lead to unique relationships between each form of stigma and the decision to use counseling services. For example, increased globalization and contact with Western countries have contributed to changes in values, norms, and expectations in Turkey, especially among younger individuals (Ergüder, Esmer, & Kalaycıoğlu, 1991). Therefore, we sought to expand previous models of help seeking by, for the first time, including all three aspects of stigma in predicting attitudes and intentions to seek counseling among college students in Turkey.

The Current Study Although there is clear evidence for the role of stigma in Western countries and some support for the role of stigma in Far Eastern countries, less is known about how stigma manifests itself in other areas of the world. This is an

important omission, because there is a need to understand the barriers to seeking help in these parts of the world. Researchers have not directly examined a model of how public, self-, and social network stigma are each linked to the use of individual counseling in any sample, let alone a culturally blended nation such as Turkey. As noted previously, these are important omissions to address. In line with previous studies, we hypothesized that public stigma would be positively associated with self-stigma. Moreover, because of the importance of family in Turkish culture, we hypothesized that social network stigma would uniquely and positively predict self-stigma over and above the role of public stigma. Previous research has demonstrated that self-stigma and attitudes fully mediate the effects of external stigmas on intentions (Ludwikowski et al., 2009; Vogel et al., 2007). Therefore, we also hypothesized that the relationships of perceived public stigma and social network stigma to help-seeking attitudes would be indirectly mediated by selfstigma and that self-stigma’s relationship to intentions would be mediated by attitudes. In other words, individuals with higher perceived public stigma and individuals with higher perceived social network stigma would both experience greater self-stigma, which would be related to less positive attitudes toward counseling and a decreased likelihood of seeking professional help (see Figure 1).

Method Participants This study was conducted at a large, urban state university located in the western Anatolia region of Turkey. We recruited 520 students (347 [66.7%] women, 172 [33.1%] men) for the study through announcements in their undergraduate courses. The mean age of the students was 20.11 years (SD = 1.40). Of the participants, 139 (26.7%) were 1st-year students, 215 (41.4%) were 2nd-year students, 130 (25.0%) were 3rd-year students, and 36 (6.9%) were in their 4th year or did not report their year in school. Sixty-five students (12.5%) reported that they had received counseling before, and 454 (87.3%) reported never having received counseling. One student (0.2%) did not indicate his or her gender and help-seeking history. Measures All measures were presented in Turkish. The measure for intentions to seek counseling was developed in Turkey. The other measures, although developed in Western contexts, have all been previously translated and used with Turkish samples. In the following sections, we discuss the psychometric support for the translated versions. Public stigma. Public stigma was measured with the Stigma Scale for Receiving Psychological Help (SSRPH; Komiya et al., 2000). The SSRPH is a five-item scale consisting of items


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Topkaya, Vogel, & Brenner .51

.16

.70

.92 Public Stigma

.15*

.45

.39

.56

.54

.53

.47

.74

.78

.66

.68

.69

.73

.57* Self-Stigma

.56*

–.59*

Attitudes

.17*

.71*

Intentions

.70

.51

.79

.38

.82

.33

Social Network Stigma .94

.96

.94

.11

.07

.12

.07

FIGURE 1 Final Mediated Model Note. Numbers in the boxes indicate the relationships between the measured variables and the latent variables. Numbers outside the boxes refer to the error variances of the measured variables. Numbers next to the arrows indicate the relationships between the latent variables. Solid lines between latent variables indicate a statistically significant relationship. Dashed lines between latent variables indicate a nonsignificant relationship. Attitudes = attitudes toward seeking counseling; Intentions = intentions to seek counseling. *p < .001.

such as “People will see a person in a less favorable way if they come to know that he/she has seen a psychologist.” Items are rated on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree), with higher scores reflecting greater perceptions of public stigma. In Turkey, SSRPH scores have been negatively correlated with attitudes toward seeking counseling (Topkaya, 2011b). Estimates of the internal consistency of the SSRPH total score have been reported to be .73 in a U.S. sample (Komiya et al., 2000) and .80 in a sample in Turkey (Topkaya, 2011b). In the current study, the internal consistency of the total score was .80. Social network stigma. Social network stigma was measured with the Perceptions of Stigmatization by Others for Seeking Help scale (PSOSH; Vogel et al., 2009). The PSOSH is a five-item scale that asks participants to “imagine you had an emotional or personal issue that you could not solve on your own. If you sought counseling services for this issue, to what degree do you believe that the people you interact with would ______.” Items are rated on a 5-point, partly anchored scale ranging from 1 (strongly disagree) to 5 (strongly agree) and consist of statements such as “React negatively to you.” Scale Point 3 is anchored by agree and disagree equally. Higher scores reflect greater perceived stigmatization by one’s social network. In U.S. samples, estimates of the internal consistency of the PSOSH total score ranged from .78 to .89, with a 2-week test–retest reliability of .77 (Vogel et al., 2009). The internal consistency of the total score has been reported to be .93 in a Turkish sample (Sezer & Kezer, 2013). In the current study, the internal consistency of the total score was .96.

216

Self-stigma. Self-stigma was measured with the SelfStigma of Seeking Help scale (SSOSH; Vogel et al., 2006). The SSOSH is a 10-item scale consisting of items such as “It would make me feel inferior to ask a therapist for help.” Items are rated on a 5-point, partly anchored scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scale Point 3 is anchored by agree and disagree equally. Five items are reverse scored so that higher scores reflect greater selfstigma. In U.S. samples, estimates of the internal consistency of the SSOSH total score ranged from .86 to .90, with a 2-week test–retest reliability of .72 (Vogel et al., 2006). The internal consistency of the total score has been reported to be .81 in a Turkish sample (Topkaya, 2011a). In the current study, the internal consistency of the total score was .80. Attitudes toward seeking counseling. Attitudes toward seeking counseling were measured with the Attitudes Toward Seeking Professional Psychological Help Scale–Short Form (ATSPPHS-SF; Fischer & Farina, 1995). This scale is a 10-item revision of the original 29-item measure (Fischer & Turner, 1970) and consists of items such as “A person should work out his or her own problems; getting psychological counseling would be a last resort.” Items are rated on a 4-point scale ranging from 1 (disagree) to 4 (agree). Five items are reverse scored so that higher scores reflect more positive attitudes toward seeking counseling. Higher scores on the ATSPPHS-SF have been correlated with previous use of professional help for a problem (Fischer & Farina, 1995). In Turkish samples, the translated ATSPPHSSF has also been negatively correlated with public stigma (Topkaya, 2011b). In U.S. samples, the internal consistency


Examination of the Stigmas Toward Help Seeking Among Turkish College Students of the ATSPPHS-SF total score was found to be .84, with a 1-month test–retest reliability of .80 (Fischer & Farina, 1995). The internal consistency of the total score has been reported to be .76 in a Turkish sample (Topkaya, 2011b). In the current study, the internal consistency of the total score was .72. Intentions to seek counseling. Intentions to seek counseling were measured with the Help-Seeking Intentions Scale (HSIS; Topkaya, 2011b), which was originally developed in Turkey. The HSIS is a 12-item measure in which respondents rate how likely (1 = very unlikely, 4 = very likely) they would be to seek counseling if they were experiencing the issues listed. Examples of issues include self-regard, anxiety, and sexual problems. All items are coded straightforwardly and summed. Higher scores indicate a greater likelihood of seeking counseling. The HSIS has been negatively correlated with public stigma (r = –.17) and positively correlated with attitudes toward seeking help (r = .34; Topkaya, 2011b). These associations are similar to those found in previous research measuring these concepts in English (Vogel et al., 2007). The internal consistency of the HSIS total score has been reported to be .84 in a Turkish sample (Topkaya, 2011b). In the current study, the internal consistency of the total score was .87. Procedure Before data collection, we obtained approval from the sponsoring university’s institutional review board. The study took place in student classes. Students were informed that participation in this study was voluntary and that they could discontinue at any point. After completing an informed consent form, participants received a packet containing the aforementioned measures and demographic questions. Upon completion of the questionnaire, participants were debriefed on the purpose of the study. We used structural equation modeling (SEM) to examine the relationships between public stigma, one’s social network stigma, self-stigma, attitudes toward seeking counseling, and intentions to seek counseling services.

Results Table 1 presents the means, standard deviations, and zero-order correlations for the study variables. In line

with previous research, all three forms of stigma (i.e., public stigma, social network stigma, and self-stigma) were positively associated with one another and inversely associated with attitudes toward seeking counseling. Self-stigma was also significantly related to intentions to seek counseling. Finally, there was a positive relationship between attitudes toward seeking counseling and intentions to seek counseling. Researchers have suggested that SEM is the preferred method for testing mediation (Frazier, Tix, & Barron, 2004; MacKinnon, Krull, & Lockwood, 2000). With regard to testing mediation using SEM, Anderson and Gerbing (1988) suggested following a two-step procedure: (a) conducting a confirmatory factor analysis to develop a measurement model with an acceptable fit to the data and then (b) conducting a structural model to test the hypothesized relationships. We also followed the recommendation of Holmbeck (1997) and compared the hypothesized, partially mediated structural model with a fully mediated model to select the best fitting model. To examine the measurement and structural models, we used the maximum likelihood method in LISREL (Version 8.54). The following four indices were used to assess the goodness of fit of the models: the comparative fit index (CFI; .95 or greater), the incremental fit index (IFI; .95 or greater), the standardized root-mean-square residual (SRMR; .08 or less), and the rootmean-square error of approximation (RMSEA; .06 or less; see Hu & Bentler, 1999; Martens, 2005). Item Parcels Observed indicators (or parcels) were created for each of the latent variables except for intentions to seek counseling, which was estimated from the three HSIS subscales. We used parcels based on individual items to reduce the number of parameters, improve the distribution of the observed indicators, and improve estimates of model fit (Russell, Kahn, Spoth, & Altmaier, 1998). Furthermore, we used parcels, rather than additional measures of each construct, because many of the constructs (e.g., self-stigma) had only one validated scale for use in Turkey and using fewer measures reduced participant burden. We chose the method of Russell et al. (1998) over other methods of parceling because Russell and colleagues asserted that “when this procedure is used, the

TABLE 1 Means, Standard Deviations, and Zero-Order Correlations for the Study Variables Variable 1. Intentions to seek counseling 2. Attitudes toward seeking counseling 3. Public stigma 4. Social network stigma 5. Self-stigma

M 32.44 24.33 10.33 41.37 23.86

SD 6.63 4.22 3.25 17.60 6.74

1

2

3

—

.49 —

–.08 –.32 —

4 –.02 –.20 .48 —

5 –.25 –.47 .51 .41 —

Note. N = 520. Correlations greater than or equal to |.20| are significant at p < .05.


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resulting item parcels should reflect the underlying construct . . . to an equal degree” (p. 22). Having equal loadings across the parcels should maximize the benefits of parceling for the measurement model. Two indicators were created for public stigma, and three indicators were created for each of the other latent help-seeking variables (i.e., social network stigma, self-stigma, and attitudes toward seeking counseling). The parcels were created by separately fitting a one-factor model using exploratory factor analyses with the maximum likelihood method on the items from each scale. The items on each scale were then rank ordered according to the magnitude of their factor loadings. To equalize the average loadings of each parcel on its respective factor, we assigned the highest and lowest ranking items in pairs to a parcel (see Table 2 for parcel correlations). Normality Next, we examined the multivariate normality of the observed variables because the maximum likelihood procedure used to test the hypothesized model assumes normality (see Bollen, 1989). Results indicated that the multivariate data were not normal, χ2(2, N = 520) = 212.97, p < .001. Therefore, we report the Satorra–Bentler scaled chi-square (see Satorra & Bentler, 1994) in the subsequent analyses. Measurement Model A test of the measurement model provided a good fit for the data, χ2(67, N = 520) = 111.18, p < .001, CFI = .99, IFI = .99, RMSEA = .04, 90% confidence interval (CI) [0.02, 0.05],

SRMR = .04. The zero-order correlations for the 14 observed variables (i.e., parcels) are shown in Table 2. The measured variables’ loadings on the latent variables were all statistically significant (p < .001). Structural Model First, we tested the hypothesized, partially mediated structural model (see Figure 1) using the maximum likelihood method in LISREL (Version 8.54) with the same fit indices used earlier. The structural model provided a good fit to the data, χ2(70, N = 520) = 114.34, p = .000, CFI = .99, IFI = .99, RMSEA = .04, 90% CI [0.02, 0.05], SRMR = .04. All paths were significant except for the direct path from social network stigma to intentions to seek counseling. Next, following the recommendation to examine other comparative models against the hypothesized model (see Martens, 2005), we compared the hypothesized partially mediated model against a fully mediated model using the Satorra–Bentler scaled chi-square difference test. In the fully mediated model, the direct paths from public stigma and social network stigma to intentions to seek counseling were constrained to zero. Results of the fully mediated model indicated a good fit to the data, χ2(72, N = 520) = 130.99, p < .001, CFI = .99, IFI = .99, RMSEA = .04, 90% CI [0.03, 0.05], SRMR = .06. However, a Satorra–Bentler scaled chi-square difference test comparing the models showed a statistically significant difference between the partially and fully mediated models, χ2(2, N = 520) = 16.65, p < .001. Therefore, the hypothesized partially mediated model—with the inclusion of the direct

TABLE 2 Zero-Order Correlations Among the 14 Observed Variables Variable

1

2

3

4

5

6

7

8

9

10

11

12

13

14

1. Public stigma 1 2. Public stigma 2 3. Social network stigma 1 4. Social network stigma 2 5. Social network stigma 3 6. Self-stigma 1 7. Self-stigma 2 8. Self-stigma 3 9. Attitudes toward seeking counseling 1 10. Attitudes toward seeking counseling 2 11. Attitudes toward seeking counseling 3 12. Intentions to seek counseling 1 13. Intentions to seek counseling 2 14. Intentions to seek counseling 3

—

.64 —

.37 .46 —

.38 .45 .90 —

.38 .47 .88 .90 —

.37 .49 .42 .42 .41 —

.32 .45 .27 .29 .29 .57 —

.26 .38 .31 .31 .31 .46 .55 —

–.17 –.31 –.19 –.21 –.20 –.33 –.39 –.31

–.23 –.30 –.17 –.22 –.17 –.29 –.32 –.24

–.11 –.24 –.06 –.10 –.07 –.25 –.32 –.27

–.04 –.07 .00 –.05 –.01 –.11 –.17 –.22

.04 –.05 .00 –.02 .03 –.04 –.16 –.19

–.04 –.12 –.03 –.04 –.03 –.13 –.18 –.25

—

.48

.49 .29

.28

.28

—

.50 .32

.30

.36

.37

.40

.45

—

.55

.56

—

.65

—

—

Note. N = 520. Two indicators (or parcels) were created for public stigma, and three indicators were created for social network stigma, selfstigma, and attitudes toward seeking counseling (see Item Parcels section for a discussion of this procedure). Indicators for intentions to seek counseling were estimated from the three subscales of the Help-Seeking Intentions Scale. All correlations are statistically significant at p < .001.

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Examination of the Stigmas Toward Help Seeking Among Turkish College Students paths from public stigma and social network stigma—was selected as the best fit to the data and was subsequently used in the bootstrap procedure. The parameter estimates for the hypothesized partially mediated model are presented in Figure 1. As shown in Figure 1, the link from public stigma to intentions to seek counseling was positive. However, on the basis of the present zero-order correlations and previous research, which both indicated a negative link between public stigma and intentions to seek counseling, this positive link is likely the result of a suppression effect in the model (MacKinnon et al., 2000). Significance Levels of Indirect Effects We used the bootstrap procedure recommended by Shrout and Bolger (2002) to evaluate the significance levels of the indirect effects. Given that indirect effects are not normally distributed, using a standard error to perform a z test may produce inaccurate results. Bootstrap procedures provide asymmetric confidence limits, which offer an empirical means for determining statistical significance (Efron & Tibshirani, 1993) that circumvent the need to assume normality. If the 95% CI for the estimate of an asymmetric indirect effect does not include zero, it can be concluded that the indirect effect is statistically significant at the .05 level (Shrout & Bolger, 2002). Therefore, the first step was to create 10,000 bootstrap samples (N = 520) from the original data set using random sampling with replacement. The partially mediated structural model was then run once with each bootstrap sample to yield 10,000 estimations of each path coefficient. We used LISREL’s (Version 8.54) output of the 10,000 estimations of each path coefficient to calculate an estimate for each indirect effect. The indirect effects of public stigma and of social network stigma on intentions to seek counseling were calculated through the self-stigma and attitudes toward seeking counseling mediators by multiplying 10,000 pairs of the following path coefficients: (a) from public stigma or from social network stigma to self-stigma, (b) from self-stigma to attitudes toward seeking counseling, and (c) from attitudes toward seeking counseling to intentions to seek counseling. The final step was to see whether the 95% CI for the estimate of a given indirect effect included zero. All of the indirect mediated paths were significant. Specifically, the 95% CI [–1.87, –1.84] confirmed that the indirect pathway from public stigma through self-stigma to attitudes toward seeking counseling (mean indirect effect: β = –1.86, SE = .01) was significant. The 95% CI [0.99, 1.01] also confirmed that the indirect pathway from social network stigma through self-stigma to attitudes toward seeking counseling (mean indirect effect: β = 1.00, SE = .01) was significant. Furthermore, the 95% CI [–0.02, –0.01] confirmed that the indirect pathway from public stigma through the self-stigma and attitudes toward seeking counseling mediators to intentions to seek counseling (mean indirect effect: β = –0.02, SE = .00) was significant.

Finally, the 95% CI [0.01, 0.01] confirmed that the indirect path from social network stigma through the self-stigma and attitudes toward seeking counseling mediators to intentions to seek counseling (mean indirect effect: β = 0.01, SE = .00) was significant. It is also important to note that 46% of the variance in self-stigma was explained by public stigma and social network stigma; 35% of the variance in attitudes toward seeking counseling was explained by public stigma and social network stigma; and 44% of the variance in intentions to seek counseling was explained by public stigma, social network stigma, and attitudes toward seeking counseling.

Discussion This study applied a model of help-seeking stigma that has been examined in Western cultures to predict counseling attitudes and intentions in Turkey. Our findings support the cross-cultural applicability of this model of stigma in Turkey. Specifically, SEM results support the existence of three distinct forms of stigma and their unique relationships to attitudes and intentions toward seeking counseling. In line with previous research, public stigma and social network stigma were each indirectly linked to intentions to seek counseling through both self-stigma and attitudes toward seeking counseling (Ludwikowski et al., 2009). Specifically, public stigma and social network stigma were positively linked to self-stigma. Self-stigma was then negatively linked to attitudes toward seeking counseling, and attitudes toward seeking counseling were positively linked to intentions to seek counseling. That is, individuals with higher perceived public stigma and social network stigma experienced greater self-stigma, which was related to less positive attitudes toward counseling and decreased intentions to seek counseling. By supporting the cross-cultural applicability of this model to Turkey, the current findings add a meaningful contribution to the literature by expanding the understanding of how help-seeking stigma may operate worldwide. Specifically, our results support the existence of some universal factors underlying help-seeking stigma by further supporting Corrigan’s (2004) assertion that external stigmas are internalized. This internalization of both public and social network stigma as self-stigma (i.e., the almost full mediation by self-stigma on subsequent attitudes and intentions toward seeking counseling) in a Turkish sample is a particularly important and interesting finding. Researchers have suggested that cultures that include collectivist values might be less influenced by self-stigma because there is a greater focus on others rather than the self (Kirmayer, 2007; Vogel et al., 2010). However, our findings suggest that the importance placed on others may still elicit feelings of shame, possibly as a result of increased concerns about having let others down. Individuals who seek counseling run the risk of bringing shame on the family, as well as an increased risk of personal embarrassment and shame due to feeling responsible for failing, or shaming,


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the family (Shea & Yeh, 2008). In other words, individuals may experience self-stigma because of a desire to protect not only their own reputation, but also that of their family. Another important finding of this study was that Turkish college students perceived the concept of social network stigma as a unique predictor of their help-seeking attitudes and behaviors. That is, in addition to perceived public stigma, the perceived stigmatization by one’s social network seems to play an additive role in Turkish individuals’ internalization of the stigmatizing aspects of seeking counseling (Vogel et al., 2009). Thus, in addition to the clear importance of public stigma, it may be important in Turkey to address social network stigma as well. However, it is interesting that although both public and social network stigma were unique predictors of self-stigma, public stigma appeared to have a stronger relationship to self-stigma than did social network stigma. At first glance, this result may seem counterintuitive given the Turkish cultural focus on the importance of the family. Nevertheless, the significant role of family in help seeking may rely less on whether individuals anticipate feeling shame from their family for seeking counseling (i.e., social network stigma) and more on whether they anticipate bringing shame to their family for seeking counseling. Thus, in cultures where individuals experience pressure to honor one’s family (Cross et al., 2014), not seeking help may be a way to protect one’s family from the experience of public stigmatization. In Turkey, then, social network stigma may be part of the individual’s experience of stigma, whereas public stigma may be applied to both the individual and his or her family. In line with this idea, Walter, Yon, and Skovholt (2012) suggested that one’s social network “cannot persuade them [individuals] to change their beliefs . . . if their general community believes that needing assistance for their mental health is a shameful idea” (p. 196). Implications for Counseling In addition to broader campaigns aimed at reducing stigma more globally, it may be beneficial for practitioners to address each of these types of stigma in counseling because stigma may hinder participation in the therapeutic process (Wade et al., 2011). One general implication for counseling is that it may be important to assess each of the three types of stigma separately, as well as how a client’s cultural background manifests in the presentation of, and relationships between, the different forms of stigma (Walter et al., 2012). Self-stigma, in particular, is an important topic for counselors to address in Turkey, given that clients with high levels of self-stigma may experience this shame in session. Knowing whether the act of engaging in counseling itself elicits feelings of shame is important for the client’s wellbeing and for the efficacy of the therapeutic process (Gilbert & Leahy, 2007). This experience of stigma and shame could be directly addressed in counseling with Turkish clients

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through emotion-focused and other present moment–focused interventions. Similarly, Wade et al. (2011) suggested that counselors should continue to focus on reducing self-stigma throughout the course of counseling, starting with the first session. Assessment for self-stigma could be done in a screening or during first session. For example, counselors could explicitly ask clients how they feel about their decision to enter counseling and affirm the strength required to seek help. An open dialogue about the stigma a client may feel toward seeking counseling prevents it from becoming a taboo topic. Awareness of the stigma a client perceives from society for seeking counseling helps shape targeted interventions in Turkish and other populations. Specifically, the nature of public stigma requires counselors to help clients recognize public stigma as an active influence in their help-seeking process that is driven by the societal norms and expectations of the clients’ respective culture. Counselors trained in acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) can implement interventions to increase clients’ awareness of the negative thoughts and feelings they may have toward themselves for seeking counseling (Masuda et al., 2007). The use of ACT interventions aimed toward increasing psychological flexibility—such as defusion of thoughts, acceptance, connection with values, and committed action—may also increase treatment adherence in the face of these negative thoughts and feelings. Social network stigma may be important to address in session with Turkish clients. In addition to early termination of counseling, fears about how family members would react to an individual’s decision to seek help could lead to decreased support in addressing his or her issues. In other words, social network stigma can directly interfere with progress. Ideally, clients would be able to practice or share what they are learning in session with those important to them. Therefore, helping clients identify close individuals who may respond positively to their involvement in counseling could have a therapeutic influence that is actually beneficial to the client. Being met with a positive response to their disclosure would be one avenue to receiving social support, which, in itself, is a reparative part of counseling. In addition, the therapeutic relationship itself could provide a corrective emotional experience for the client. In turn, clients struggling with negative perceptions from those close to them may benefit from learning new coping strategies to deal with the potentially negative messages. Finally, to increase the support clients might receive from close others, and thereby decrease the stigma, counselors can develop handouts aimed toward close friends and family members of those seeking counseling (Walter et al., 2012). These handouts might focus on normalizing the act of seeking counseling and the benefits of providing encouragement to those who could benefit from counseling.


Examination of the Stigmas Toward Help Seeking Among Turkish College Students Implications for Outreach Evidence of the presence of three distinct forms of help-seeking stigmas in Turkey can help counselors in Turkey address the issues this barrier presents. Support for public stigma and social network stigma as influential constructs on intentions to seek help, as well as the mediating roles of self-stigma and attitudes toward seeking counseling, allows for discussion of several practical implications in Turkey. One implication is that public stigma, social network stigma, and self-stigma can be targeted for reduction distinctly. One study of college students from Turkey indicated that the media shapes the basis of their knowledge about mental illness (Kılınç & Granello, 2003), and this finding likely applies to counseling as well. Therefore, the use of media in outreach efforts may be an important avenue to individually target each of these stigmas. Indeed, public stigma has often been targeted through larger scale educational campaigns focused on mental illness and the benefits of counseling. An experimental study by Masuda et al. (2007) suggested that the integration of targeted ACT exercises into educational workshops might increase their effectiveness in reducing stigma. In turn, social network stigma could be mitigated through educational messages by conveying to individuals how they can support those close to them to seek help. Self-stigma might be addressed through messages that normalize the process of seeking help (Schreiber & Hartrick, 2002). Furthermore, stigmas can be addressed, even before counseling, through public workshops based in local communities, brochures, or web-based information. Limitations and Future Directions Although the results of our study provide new and important implications for those attempting to understand the relationship between stigma dimensions and help-seeking intentions, several limitations may be identified for the study. First, even though students at this university come from diverse regions of Turkey, the restricted age group might limit how well the results generalize to Turkish populations from different generations. Furthermore, because of the self-report nature of the instruments used in the study, it is possible that the participants did not fully disclose their true attitudes or intentions toward seeking help. However, one could expect that if university students, who have greater access to counseling services, are experiencing stigma and choosing not to seek help, then the results would only be stronger for the general population. This study provides an empirical link among perceptions of public stigma, social network stigma, self-stigma, attitudes toward seeking counseling, and intentions to seek counseling in a blended cultural region; however, additional research is needed to confirm the external validity of these results and to explore other mediators that may distinguish between the different stigma dimensions. Because this study was the first to incorporate social network stigma into this model in an individual counseling framework, future

researchers could assess how social network stigma may generalize to Turkish individuals in other phases of life where the developmental expectations may be different. Future researchers could also examine this construct as a unique component in other countries and incorporate other psychological variables in the extant literature (e.g., anticipated benefits and risks, psychological distress) in exploring these potential mediation effects in the relationship between help-seeking stigma dimensions and intentions to seek counseling. From a culturally focused perspective, it may also be beneficial for researchers to investigate cultural characteristics, such as the importance of honoring the family, as a moderator in future studies. This line of research could allow counselors to predict the effect of these stigmas in undocumented regions and adapt stigmareduction efforts more effectively. Furthermore, future researchers could consider incorporating different research methodologies (e.g., individual interviews, focus groups) to better illuminate the interrelationships between various dimensions of stigma and intentions to seek counseling among Turkish college students. Understanding how important aspects of identity may relate to different forms of help-seeking stigma in Turkey may be another important avenue to examine in future studies. Women, for example, are generally found to have more positive attitudes toward help seeking compared with men (Topkaya, 2014). However, no study has examined the relationship between gender and social network stigma, which may manifest differently in men and women. For example, men in Turkey may internalize social network stigma to a greater extent if they feel greater pressure to honor their families. In addition, individual differences in the degree to which Turkish individuals identify with their religion may be important. Several studies with Middle Eastern populations have indicated that treatment from religious leaders is less stigmatizing than counseling (Al-Krenawi & Graham, 1999; Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2008; Savaya, 1998). As a result, many people seek these traditional forms of treatment before considering counseling (Al-Krenawi, Graham, Ophir, & Kandah, 2001; Gearing et al., 2013). This trend, however, has been examined only in Arab populations in the Middle East, which differ from the population in Turkey. Prior to this study, researchers could not yet examine these and other potential subgroup differences because a clear understanding of stigma in Turkey had not been established. This study provides that foundation. Therefore, future studies could use this model to examine how each form of stigma may differ among these and other subgroups.

Conclusion The world is filled with a variety of unique cultures, but no region is entirely immune to the need for counseling.


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Unfortunately, stigma research has been predominantly conducted in the United States and other Western nations without examining the cross-cultural applicability of models of stigma (Vogel et al., 2006, 2007). The current study addresses this omission by replicating previous findings that public stigma negatively affects help-seeking intentions indirectly through self-stigma. Furthermore, our findings expand the understanding of the unique role of social network stigma. In all, these results suggest that practitioners and researchers need to be aware of the roles of the different stigma dimensions to reach out to individuals who are in need of counseling services.

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