Enhancing attitudes and reducing fears about mental health counseling: an analogue study.
Article Type: Report
Subject: College students (Psychological aspects)
Mental illness (Care and treatment)
Mental illness (Research)
Mental health (Research)
Authors: AEgisdottir, Stefania
O'Heron, Michael P.
Hartong, Joel M.
Haynes, Sarah A.
Linville, Miranda K.
Pub Date: 10/01/2011
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2011 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: Oct, 2011 Source Volume: 33 Source Issue: 4
Topic: Event Code: 310 Science & research
Product: Product Code: E197500 Students, College
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 270461806
Full Text: This study examined the effects on 330 college students of addressing and validating negative client attitudes and fears associated with seeking counseling at a university counseling center, and client willingness to engage in counseling past the first session. Results suggest that addressing fears and negative beliefs about counseling during an intake interview influenced male students who had not previously sought counseling. Their image concerns were reduced and their tolerance for stigma associated with seeking counseling increased. Suggestions about how to address negative attitudes and fears about counseling are provided.

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There is a discrepancy between the number of individuals who have a diagnosable psychological disorder and the number who utilize mental health counseling (MHC) services. Regier et al. (1993) found, for instance, that in the United States less than one-third of individuals with a mental disorder seek MHC services. Furthermore, using data from the 2001-2002 U.S. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Blanco et al. (2008) found that in a one-year period only 18% of 18-24-year-old college students with a psychological disorder sought treatment. Because reasons for the discrepancy between those who might benefit from mental health services and those who seek it can be numerous (e.g., effect of time, natural process of healing, and relief provided by a social network), scholars have sought to identify barriers to seeking treatment (e.g., Vogel, Wester, & Larson, 2007). The search for barriers is grounded in the notion that the decision to seek MHC is influenced by two opposing forces (Kushner & Sher, 1991; Vogel et al., 2007): approach factors (e.g., positive counseling attitudes, experience of distress) and avoidance factors (e.g., fear of and negative attitudes to treatment).

BARRIERS TO SEEKING MENTAL HEALTH COUNSELING

Kushner & Sher (1989) described treatment fear as a state of apprehension resulting from negative expectations about seeking and using mental health services. Treatment fear has been linked to attitudes toward seeking psychological help (Cepeda-Benito & Short, 1998; Deane& Chamberlain, 1994); intentions to seek help (Vogel, Wester, Wei, & Boysen 2005); and actual help-seeking (Kushner & Sher, 1989). Kushner and Sher (1989), for instance, found that individuals who had never sought psychological treatment reported being more fearful than actual clients about seeking counseling services. Similarly, Deane and Chamberlain (1994) found that treatment fears were predictive of the likelihood that college students would use psychological services in that greater fear was associated with a decrease in intention to seek help. Moreover, Vogel and Wester (2003) reported that a fear of having to express emotions in therapy decreased help-seeking intentions. Thus, fear appears to affect the help-seeking decision-making process, especially for those who have never previously used mental health services (Hammer & Vogel, 2010). It seemed important, therefore, to target such fears when constructing an intervention designed to increase help-seeking attitudes and intentions.

Another barrier associated with seeking counseling is dread of stigma. Corrigan (2004) divided stigma into two categories: public stigma and self-stigma. Public stigma refers to the negative social labels attached to persons who seek mental health services. Self-stigma is the internalization of the negative stereotyped messages that are given persons who seek such services. Stigmatization can lead to stereotyping, prejudice, and discrimination toward those who seek counseling. Corrigan (2004) suggested that to avoid the stigma of having a psychological disorder, a person might decide not to seek treatment that could be beneficial: not seeking help becomes a way to protect against the fear of being stigmatized.

The relationship between stigma and help-seeking attitudes has been demonstrated. Komiya, Good, and Sherrod (2000) reported that stigma was an important predictor of attitudes toward seeking psychological help. Similarly, in a qualitative study, Boyd et al. (2007) found that college students identified stigma as a serious barrier to seeking MHC. In a more complex study of the relationship among college students between perceived public stigma, perceived self-stigma, attitudes toward counseling, and willingness to seek help, Vogel, Wade, and Hackler (2007) found that the relationship between public stigma and willingness to seek help was mediated by self-stigma and attitudes. That is, public stigma was positively related to self-stigma, self-stigma was negatively related to positive attitudes toward counseling, and positive attitudes toward counseling were related to increased likelihood of seeking counseling.

Finally, negative attitudes toward counseling have consistently been found to suppress intentions to seek counseling (e.g., Cellucci, Krogh, & Vik, 2006; Kleinman, Millery, Scimeca, & Polissar, 2002; Vogel & Wester, 2003; Vogel, Wester, Wei, & Boysen 2005). Furthermore, attitudes toward seeking MHC have been linked to past use of such services; college students who have used counseling services report more positive attitudes than those who have never sought counseling (e.g., AEgisdottir & Gerstein, 2009).

Thus at least three factors have been identified as hindering college student mental health treatment-seeking: negative attitudes toward seeking help, treatment fears, and worries about the associated stigma. Specifically, treatment fears have been linked with attitudes to counseling, intentions to seek counseling services, and actual help-seeking. Stigma has been associated with attitudes to counseling and intentions to seek such services. Finally, negative attitudes to counseling have been linked with lowered help-seeking intentions and past use of counseling services.

INTERVENTIONS TO INCREASE MHC UTILIZATION

Given these barriers, to prevent clients from dropping out prematurely counselors have been encouraged to discuss and normalize common fears and negative attitudes toward counseling (e.g., Lambert, 2007) and to encourage those who need help to seek it (e.g., Hammer & Vogel, 2010). It has also been suggested that educational programs be designed to reduce obstacles to the pursuit of treatment (e.g., Deane & Chamberlain, 1994; Lambert, 2007).

While there is some evidence that pretherapy education can reduce fears related to seeking MHC, research has produced mixed results. Gonzales, Tinsley, and Kreuder (2002) compared the effects of two short psychoeducational interventions on college student opinions about mental illness, attitudes, and expectations. In one intervention students read statements that normalized mental illness and psychological help-seeking and emphasized the personal responsibility of individuals seeking help. In the other students read about reasons for seeking counseling, descriptions of different types of counselors, and descriptions of the counseling process and outcomes. Gonzales et al. (2002) found that students who read information on mental illness showed increased positive attitudes toward seeking help and augmented expectations about the need to personally commit to the therapy process. When students were educated only about counseling services, however, they did not change their attitudes toward counseling, though they increased their expectations about personal commitment in therapy. Similarly, Hammer and Vogel (2010) found that depressed men's attitudes toward counseling improved somewhat from reading a brochure about counseling that used male-directed language rather than a gender-neutral brochure. Sturmer and Gerstein (1999) reported a negative attitude change in male and female college students who read advertisements promoting mental health services.

Other types of interventions to increase MHC use have also been tested. Buckley and Malouff (2005) examined whether vicarious reinforcement changed attitudes toward counseling by showing college students and adults a video of a client talking about positive therapy experiences. They found that this resulted in more positive attitudes toward seeking help; it decreased stigma, increased willingness to disclose personal information in treatment, and improved confidence in mental health practitioners. Similarly, focusing on treatment fears Deane, Spicer, and Leathern (1992) found that viewing a video of a counseling session reduced anxiety about treatment. Furthermore, Guajardo and Anderson (2007) compared the effects of a multimedia education program to those of an information-only program on treatment fears and counseling expectations. The multimedia program included clips of re-enacted sessions, text, and narration describing the counseling process and the roles of therapist and client; the information-only program was a black-and-white slide show containing only the text from the video (no narration or video clips). Both interventions were found to reduce fears associated with therapy, but the multimedia presentation was more effective.

PURPOSE OF THE STUDY

Whereas previous studies suggest that preconceived notions about MHC can be altered, there is a continued need to find ways to reduce barriers to seeking counseling services. This is especially important considering that fewer than one-third of those who might benefit actually seek MHC (Blanco et al., 2008; Regier et al., 1993). It may also be necessary to target those who have already entered treatment, because they might bring with them stereotypes, fears, and negative attitudes about engaging in the counseling process--this may in part explain why 35%-48% of clients drop out of counseling prematurely (Wierzbicki & Pekarik, 1993). That is why Walitzer, Dermen, and Connors (1999) suggested beginning therapy by addressing negative client reactions to treatment; Kushner and Sher (1989) recommended interventions to reduce client treatment fears during the intake session or the telephone pre-screening; and Hammer and Vogel (2010) recommended distributing male-sensitive brochures at doctors' offices and medical centers to encourage depressed men to seek counseling.

Despite these suggestions, no studies could be found that examined the effect of addressing client fears and negative beliefs about counseling during an intake session. The aim of this study was to address that gap in the literature. A post-test-only experimental design was employed in which two groups of college students were randomly assigned to read either a neutral vignette describing a "typical" intake session with a counselor or a positive vignette describing an intake session in which client fears and negative attitudes about seeking counseling were discussed and validated by the counselor (see Appendix). Students in both groups were instructed to imagine being the client seeking help for mild depression. After reading the vignette, they rated the likelihood that they would attend additional sessions with the counselor and completed questionnaires assessing their attitudes toward and fears about seeking counseling.

Based on previous findings, it was expected that those who read the positive vignette would express more positive attitudes toward counseling (Expertness, Stigma Tolerance, Intent) than those who read the neutral vignette (hypothesis 1), and would express less fear of counseling (Therapist Responsiveness, Image Concerns, Coercion Concerns; hypothesis 2). It was further hypothesized that those who visualized themselves talking to the counselor in the positive vignette would be more willing to seek further counseling than those asked to visualize themselves attending the intake session described in the neutral vignette (hypothesis 3).

Numerous studies have found that women express more positive attitudes toward counseling than men (e.g., AEgisdottir & Gerstein, 2009; Buckley & Malouff, 2005; Vogel & Wester, 2003) and that women are more likely than men to seek counseling (e.g., McKay, Rutherford, Cacciola, & Kabasakalian-McKay, 1996; Rickwood & Braithwaite, 1994). To date, no studies have examined if men and women respond differently to an intervention geared to enhancing attitudes and reducing fears about counseling. Therefore, this study examined if a student's gender moderated the effect of the intervention. Finally, because research has shown that persons with previous counseling experience report more favorable attitudes toward seeking counseling than those without such experience (e.g., Vogel & Wester, 2003; Vogel, et al., 2005), which might therefore make the former less susceptible to the intervention (Hammer & Vogel, 2010), the hypotheses were tested separately for those with and without previous counseling.

METHOD

Participants

The sample consisted of 334 undergraduate students enrolled in introductory courses at a midsize Midwestern university. Four (1%) were excluded due to missing data. The sample remaining consisted of 63 (19%) men and 266 (81%) women. Six percent were freshmen, 15% sophomores, 33% juniors, 44% seniors, and 3% indicated "other" as their class status. The mean age was 21.69 (SD = 3.42) years. Five percent identified as Black, 89% as White, 2% as Hispanic, 1% as Asian, 1% as biracial, and 2% did not identify with any of the categories provided. Thirty nine percent (30% of the men and 41% of the women) had previously received counseling. The students were randomly assigned to two different vignette conditions, positive and neutral; 49% read the positive vignette (57% of the men and 47% of the women) and 51% the neutral one (43% of the men and 53% of the women).

Instruments

Counseling Attitudes. A modified version of the Beliefs About Psychological Services scale (BAPS; AEgisdottir & Gerstein, 2009) was used to measure attitudes toward seeking counseling services, with the BAPS items changed to refer to mental health counselors rather than psychologists. The 18-item BAPS consists of three subscales: Intention (6 items), Stigma Tolerance (8 items), and Expertness (4 items). Intention refers to intentions to seek counseling if in need; Stigma Tolerance to indifference to societal stigma and labeling related to seeking mental health services; and Expertness to beliefs in the merits of seeking counseling. Scoring consists of summing items on each subscale and dividing by the number of items. Higher scores reflect greater intent to pursue MHC, more tolerance for stigma, and greater beliefs in the merits of counseling.

In a series of three studies, AEgisdottir & Gerstein (2009) demonstrated that the BAPS had good internal consistency reliability, with Cronbach's alpha ranging from .81 to .90 for Intent; .59 to .81 for Stigma Tolerance; and .72 to .78 for Expertness. Test-retest reliability over a two-week period was reported as .88 for Intent, .79 for Stigma Tolerance, and .75 for Expertness. For the current study Cronbach's alpha reliability was .80 for Intent, .76 for Stigma Tolerance, and .69 for Expertness--comparable to what was reported for the original BAPS.

In terms of validity (concurrent, discriminant, factorial, and known groups), AEgisdottir & Gerstein (2009) suggested that the BAPS was comparable to other measures of attitudes toward seeking psychological help (e.g., ATSPPH short forms, Fischer & Farina, 1995, and long forms, Fischer & Turner, 1970). It discriminated between persons with and without counseling experience and detected gender differences in attitudes in accordance with patterns reported in the literature. Also, the BAPS was found to be highly related to other measures of attitude construct and minimally related to measures of social desirability (AEgisdottir & Gerstein, 2009).

Treatment Fears. The Thoughts About Psychotherapy Survey (TAPS; Kushner and Sher, 1989) was used to assess fear of psychological services. The TAPS was adapted from the Thoughts About Counseling Survey (TACS; Pipes, Schwarz, & Crouch, 1985). In addition to the 15 TACS items, the TAPS includes four items representing fear of change (Kushner & Sher, 1989). Items are rated on a 5-point Likert-type scale ranging from 1 (no concern) to 5 (very concerned). Scores are calculated as a summation of all ratings, with higher scores indicating more concern or fear about seeking MHC.

Kushner & Sher's (1989) analysis of the TAPS revealed three factors: Therapist Responsiveness (7 items), referring to fears about counselor competence and professionalism; Image Concerns (8 items), referring to concerns about being judged negatively by self or others for seeking counseling; and Coercion Concerns (4 items), relating to whether clients would be pushed to think or behave in a way that is against their will. Cronbach's alpha internal consistency reliability was reported as .92 for Therapist Responsiveness, .87 for Image Concerns, and .88 for Coercion Concerns (Kushner & Sher, 1989). In the current study, Cronbach's alpha was .88 for Therapist Responsiveness, .75 for Image Concerns, and .69 for Coercion Concerns.

Evidence of TAPS convergent validity has been demonstrated by high correlations with Spielberger's (1983) State-Trait Anxiety Inventory-Form Y (STAIY): r = .94 with TAPS total score, and correlations of .89 with Therapist Responsiveness, .82 with Image Concerns, and .80 with Coercion Concerns (Deane& Chamberlain, 1994). Further, Kushner and Sher (1989) found the TAPS discriminated between those who seek and those who avoid MHC, with those who avoid treatment expressing more fears.

Willingness to Seek Help. Willingness to seek help was assessed using one item created specifically for this study: "Based on the experience you just had with the mental health counselor, if you were experiencing this problem, how likely is it that you will seek further counseling?" This item was rated on a 6-point scale ranging from 1 (highly unlikely) to 6 (very likely). There were two reasons for creating and using a single item to measure the willingness construct: (l) No multiple item scale available fit the counseling scenarios used in the current study. (2) It was determined that the willingness construct was unambiguous to the raters in terms of the object of the measurement (counseling sessions described in vignettes) and the attribute of the measurement (willingness to seek further counseling) and therefore would qualify as a "doubly concrete construct" (Rossiter, 2002). The validity of using tailor-made single items to measure such unambiguous constructs has been demonstrated in market research (see Bergkvist & Rossiter, 2009). The correlation between this item and the BAPS Intent scale, which measures general intentions to seek counseling services, was .42 for those with prior counseling experience and .44 for those without. The correlations suggest that this item has convergent validity.

Procedure

Undergraduate students enrolled in introductory counseling courses were recruited to participate by posting a sign-up sheet on a bulletin board that listed psychology and counseling research open for enrollment. In exchange for their participation students were offered one research credit in fulfillment of a course requirement. On the sign-up sheet students had the option of selecting a time and location for the study that best fit their schedule. They were tested in groups in a classroom setting. The format was paper-and-pencil.

Students were randomly assigned to receive either a neutral vignette describing a typical intake session with a counselor or a positive vignette describing an intake session in which client fears and negative attitudes about seeking counseling services were discussed and validated with the client. The students were instructed to imagine seeking MHC for mild depression at a college counseling center. In the intake session described, a female counselor assessed the presenting problem, was caring toward the client, and discussed goals for continued counseling. In the positive vignette condition the counselor was also described as discussing and normalizing common fears about seeking counseling and everyday negative beliefs and attitudes about the counseling process (see Appendix).

After reading the assigned vignette, students rated the likelihood that they would attend additional sessions with the counselor (Willingness to Seek Help). They then completed the demographic information sheet, and the questionnaires assessing their attitudes toward counseling (BAPS; AEgisdottir & Gerstein, 2009) and fears about seeking counseling services (TAPS; Kushner & Sher, 1989). The BAPS, the TAPS, and the demographic sheet were presented in a counterbalanced order.

Manipulation Check

To ensure that the actual manipulation (discussing negative attitudes, stigma, and fears about counseling) was salient in the positive vignette and not the neutral one and that the two vignettes did not differ in other respects, the two vignette types were administered to 19 other undergraduate students before the main study. After reading the vignette assigned, students rated it on 17 questions that focused on the counseling process and the counselor's behavior using a scale ranging from 1 (not at all) to 6 (completely). Ten statements such as "The counselor introduced me to the counseling process" and "The counselor was caring in her responses to me" were expected to be rated similarly regardless of vignette. A series of t-tests indicated that the mean score for each statement did not differ significantly by vignette type (p > .05), suggesting that both the neutral and positive vignettes demonstrated a "typical" nurturing counseling environment.

Seven statements inquired if the vignettes addressed negative attitudes and fears; we expected a higher score (more agreement) on these for those reading the positive vignette. This prediction was supported. Statements such as "The counselor attended to my fears about counseling" and "The counselor discussed stigma attached to counseling" yielded mean scores that differed significantly by vignette type (p < .05). Based on these analyses, it was concluded that the only difference between the two vignettes was the counselor's discussion about negative attitudes and fears about receiving counseling services.

RESULTS

Mean scores for the BAPS, the TAPS, and the willingness question by gender and vignette condition are reported in Table 1 for students with prior counseling and in Table 2 for students without. As the tables reveal, the students expressed relatively positive attitudes toward seeking counseling, with the mean score ranging from 3.49 to 4.96. Student fears about counseling were low to moderate and were comparable to what has previously been reported for nonclinical college student samples (e.g., Kushner & Sher, 1989). Further, the students rated their likelihood of seeking continued counseling relatively high, with scores ranging from 3.75 to 5.33.

To test hypothesis 1 about the effects of vignette type and gender on counseling attitudes, a two (vignette type: positive & neutral) by two (gender: men & women) MANOVA was performed on the two samples (prior counseling experience: yes, no), with the mean scores of the three BAPS subscales (Intent, Stigma Tolerance, Expertness) as the dependent variables. For students with counseling experience, neither vignette type (F [3, 138] = .75, p > .05, [[eta].sup.2] = .02) nor gender (F [3, 138] = .80, p >.05, [[eta].sup.2] = .02) affected scores on the subscales (see Table 1). For students without counseling experience, however, there was a significant vignette type-by-gender interaction (F [3, 179] = 3.34, p < .05, [[eta].sup.2] = .05). Univariate analyses revealed a significant interaction on the Stigma Tolerance subscale score (F [1, 181] = 4.82, p < .05, [[eta].sup.2] = .03) such that male students reading a vignette in which the counselor validated negative client attitudes and fears about seeking counseling expressed more tolerance against the stigma attached with seeking counseling (M = 4.77, SD = .52) than male students reading the neutral vignette (M = 4.32, SD = 1.01). This was not found for female students (see Table 2). Thus, hypothesis 1 was partially supported.

A two by two MANOVA was also conducted to test hypothesis 2 about the effects of vignette type and gender on the three TAPS subscales (Therapist Responsiveness, Image Concerns, Coercion Concerns). For students with counseling experience, neither vignette type (F [3, 138] = .64, p > .05, [[eta].sup.2] = .01) nor gender (F [3, 138] = 1.60, p > .05, [[eta].sup.2] = .03) affected scores on the subscales (see Table 1). For those without, however, there was a significant gender-by-vignette type interaction (F [3,179] = 3.73,p < .05, [[eta].sup.2] = .06). Univariate analyses indicated a significant interaction on the Image Concern subscale (F [1, 181] = 4.44, p < .05, [[eta].sup.2] = .02). That is, male students reading the positive vignette reported lower Image Concerns (M = 20.04, SD = 7.04) than male students reading the neutral vignette (M = 23.79, SD = 8.73). This effect was not found for female students (see Table 2). These findings offer partial support for hypothesis 2.

To examine whether student willingness to seek further counseling from the counselor varied as a function of vignette type and gender (hypothesis 3), ANOVAs were conducted with willingness to continue counseling as the dependent variable. With regard to students with counseling experience, a main effect was found for gender (F [1, 140] = 18.07, p < .001, [[eta].sup.2] = .11) but not vignette type (F [1, 40] = 2.73, p > .05, [[eta].sup.2] = .02). Women, regardless of vignette type (M = 5.16, SD = 1.02), were more willing to seek further counseling than men (M = 3.95, SD = 1.54). For students without counseling experience, neither gender (F [1, 180] = 2.54, p > .05, [[eta].sup.2] = .01) nor vignette type (F [1, 180] = 2.07, p > .05, [[eta].sup.2] = .01) had an effect on willingness to pursue counseling. Thus, hypothesis 3 was not supported. Yet the gender differences discovered are in line with previous research that found women more willing to seek help than men (e.g., McKay, et al., 1996; Rickwood & Braithwaite, 1994).

Supplementary Analyses

To provide additional information about how college students perceive counseling services, partial correlations were computed to explore the relationships between the dependent variables by men and women with and without counseling experience, while controlling for vignette type (see Table 3). Because these findings are exploratory and the low number of male students thwarts significance, they should be interpreted with caution.

As Table 3 reveals, there was a positive relationship between general intentions to seek counseling services and tolerance for stigma and expertness beliefs. Counseling experience did not seem to moderate this relationship. Furthermore, for both male and female students, with and without counseling experience, the higher the tolerance for stigma, the lower the concerns that seeking counseling services would result in negative self-image and in being coerced into making changes against their will.

DISCUSSION

The effect of discussing client fears and negative attitudes about counseling in an initial session on attitudes, fears, and willingness to seek counseling was examined by randomly assigning students to read either a positive vignette describing a counselor discussing and validating negative client attitudes and fears or a neutral vignette describing a typical intake interview. A post-test-only experimental design was employed instead of a pre-test post-test design to reduce the threat of demand characteristics (Campbell & Stanley, 1963). It was expected that discussing negative client beliefs about counseling in an intake session would improve attitudes, decrease fears, and result in greater willingness to continue counseling.

Partial support was found for the first hypothesis regarding attitude change in that male students who had never received counseling and who read the positive vignette reported greater tolerance for stigma than male students who read the neutral vignette. This finding corresponds with those of Gonzales et al. (2002), who reported that reading information educating persons about mental illness increased positive attitudes toward seeking psychological help. Yet in the present study, only men who had never received counseling were affected.

The prediction that treatment fears would decrease as a function of reading the positive vignette (hypothesis 2) was also only partially supported. Again, the intervention only affected men who had not previously received counseling. For them, concerns about being judged negatively by themselves and others for seeking MHC were reduced.

It therefore appears that discussing fears and common negative attitudes about counseling in the first session may benefit men seeking counseling for the first time. However, reasons why the intervention affected only men without a counseling history but not women and those with counseling experience are not readily obvious. Two possible overlapping explanations come to mind. First, the intervention employed may have been too weak to produce noticeable changes in attitudes and fears among those already receptive to the idea of counseling. Past research has shown that women report more positive attitudes toward counseling than men (e.g., AEgisdottir & Gerstein, 2009; Vogel & Wester, 2003) and that previous counseling experience is linked with positive attitudes toward counseling (e.g., AEgisdottir & Gerstein, 2009; Vogel & Wester, 2003); it is therefore highly likely that we may have been trying to convince women and those with prior counseling experience to believe something with which they already agreed. A significant shift in attitudes and fears of these students might have required a much more powerful intervention.

Second, according to social judgment-involvement theory (Sherif & Sherif, 1967), individuals who are not personally involved with an issue (i.e., men without previous counseling experience) have more latitude for accepting persuasive information that is discordant with their beliefs than those for whom the issue is personally relevant. Therefore, the significant shift in stigma tolerance and image concerns for men with no counseling experience may be because they are more open to changing to a more positive point of view about therapy than women and those with counseling experience, for whom counseling is more personally relevant. Supporting this interpretation is our finding that the intervention did not significantly change these men's willingness to continue with counseling. Thus, even though their previous beliefs regarding self and other stigma were reduced, their willingness to seek continued counseling did not change, perhaps not because they disliked therapy or were afraid of it but because engaging in the counseling process might not be relevant to how they handle problems. Thus, these men's cognitive processing about counseling may have changed as a result of the intervention without causing behavioral changes.

Again, if the intervention was to affect all participants' attitudes, fears, and willingness to seek counseling regardless of the relevance they place on counseling as a viable source of help, it needed to be stronger to significantly affect both cognitive and behavioral aspects of help-seeking. Therefore, future research should employ stronger messages geared at enhancing pre-counseling attitudes, fears, and willingness, in which the moderating effects of gender and counseling history are taken into account. An examination of resulting attitudinal and behavioral changes is also needed.

The finding that the intervention did not affect any participant scores on the BAPS Intention and Expertness scales further supports the notion that the intervention lacked persuasive power. In fact, ideas about the expert characteristics of mental health practitioners and the benefits of counseling were not conveyed much more strongly in the positive vignette than in the neutral one, though the contrast between vignettes was greater with regard to ideas about stigma. Studies are needed to more emphatically target these areas (e.g., benefits of seeking counseling, professional counseling expertise) in order to better test how to impact these attitudinal domains using a similar intervention. The size of the samples further limited the power of our findings, especially with regard to discerning the effect of the intervention on men regardless of counseling experience; future studies on changing counseling attitudes and fears should seek a larger and more gender-balanced sample. Also, as ethnic minorities are prone to underuse college mental health services and attend significantly fewer sessions than do Caucasian students (Kearney, Draper, & Baron, 2005), studies are needed on interventions to enhance positive attitudes and reduce fears about counseling among ethnic minority students.

It was hypothesized that those who read the positive vignette would be more willing to continue with counseling than those who read the neutral one. Unexpectedly, willingness to continue counseling was not influenced by vignette type, and a gender effect was found only for students with counseling experience: Women with counseling experience were more willing to continue with counseling than men with such experience. Previous studies suggest that women generally express more intentions to seek counseling than men (e.g., AEgisdottir & Gerstein, 2009) and are more willing to seek counseling for depression (e.g., Addis & Mahalik, 2003), but in the current study this gender effect was moderated by counseling experience. As this type of interaction has not been previously reported, studies are needed to discern whether this finding is isolated to the specific context. It should also be noted that because the willingness variable was measured with only one item, using a valid and reliable scale might have yielded different results. However, a scale fitting the scenario used here does not exist.

The generally small to medium effects (Cohen, 1988) reported in the current study correspond with what has been previously discovered: While analogue studies might be somewhat effective in changing perceptions about counseling, any effects found tend to be weak and require large samples to be statistically significant. In fact, the effects of the intervention in the current study are similar in size to the statistically significant effects reported by Hammer & Vogel (2010) in their study on the effects of using gender-sensitive versus genderneutral brochures to change men's fears of stigma and attitudes toward seeking counseling for depression.

Furthermore, in their review of the literature on manipulation of counseling expectations, Tinsley, Bowman, and Ray (1988) noted that studies using printed material were not as successful in facilitating change as studies using video or audio interventions. Finally, Sturmer and Gerstein (1999) reported that among participants who read printed advertisements designed to improve counseling attitudes, their attitudes actually became more negative. Therefore, given the weak and inconsistent results of interventions relying on printed material, more studies are needed that use strong and powerful messages for current and future clients. These could be delivered via video or audio (see Walitzer, Dermen, & Connors, 1999) presenting testimonials about counseling outcomes. Also needed are in vivo studies where counselors educate their clients about the counseling process, discuss the benefits of seeking counseling, and discuss, validate, and refute common negative attitudes and fears about the process. In the meantime, the question of whether attitudes and fears related to counseling can be modified so as to increase help-seeking and prevent premature termination needs further examination.

IMPLICATIONS FOR COUNSELING

Despite this study's limitations (a college student sample with limited numbers of male and minority students, an analogue design, and reliance on printed material), its results have implications for mental health and college student counseling. At the beginning of therapy counselors might consider discussing with clients, especially men seeking counseling for the first time, their attitudes and fears about counseling. Our results suggest that it is important to discuss and normalize novice men's concerns about how seeking counseling may affect their image and how the stigma attached to seeking counseling may affect them. This type of intervention in the first session may be particularly helpful for men who are not self-referred and do not appear very invested in the process. Attending to these issues might increase their counseling satisfaction and commitment to the counseling process and decrease the likelihood of them not returning after the intake interview.

These results may also have implications for advertising counseling services. Although they somewhat support the use of written material to enhance attitudes and reduce fears, especially for men who are counseling novices, given the effect sizes found there is reason to believe that video presentations might be more beneficial. For instance, an online video tour of a counseling center showing mock sessions might help reduce unrealistic fears about the process and enhance attitudes toward counseling by showing "normal" men and women in therapy.

Finally, our results suggest a close relationship between general intentions to seek help and tolerance for the stigma attached to counseling and belief in the merits of counseling because counselors provide professional services. They also indicate that the higher their tolerance for stigma, the lower the image and coercion concerns of students. Thus, educational material geared at reducing stigma and concerns about counseling, such as fear of labeling and being forced to change against one's will, and emphasizing the education and professional skills of counselors may help increase willingness to seek mental health services. This type of education might be delivered through printed material left at public locations or as part of outreach on college campuses.

APPENDIX

Neutral Vignette

Please read the following vignette and place yourself in the position of a client seeking counseling services.

Imagine that in the last two weeks your mood has changed. During that time you have begun to feel sad. You have trouble focusing on tasks that you need to complete. You are falling behind in getting your work completed. Also, you feel tired all the time, but when you try to sleep, you cannot. You become concerned and consider seeking professional help from a mental health counselor.

You have certain attitudes and beliefs about mental health counseling. These include your general beliefs about the counseling process as well as some specific fears. You, for instance, may worry about the stigma against mental illness, you may fear that a counselor may not understand your problem, and you may wonder if counseling will be helpful. You may also be afraid to talk about personal issues with a stranger. Despite your concerns, you make an initial appointment with a mental health counselor to help you decide if seeking counseling is something that may benefit you. In the initial session, the counselor introduces herself; she explains confidentiality and asks if you have any questions. She asks you about your reasons for seeking counseling, explaining that the questions she asks you will help her understand you so she can help you as much as possible. The counselor is warm and caring in response to you. She expresses the understanding that you may have some questions regarding the counseling process. She reassures you that in counseling you will be encouraged to discuss your concerns and that she will treat you with respect. She also informs you about her training in counseling, how she conducts counseling, and the nature of your working relationship with her.

As the hour proceeds, the counselor encourages you to be honest and open about your problems and concerns so that she will be in a better position to help you. She informs you that counseling will be dedicated to working on your problems and asks you to give a detailed account of what you have been going through as well as your current life situation and recent history. You inform the counselor that you have been feeling "down" recently and that you have been unable to concentrate and your work has been piling up. You also discuss your inability to sleep well and that you always feel tired. You tell the counselor that you have not felt this way before and that you feel like you cannot cope with things any more. While you describe your concerns to the counselor she attentively listens to you, looks directly at you, and does not interrupt you or make unrelated comments while you tell her your story. As you describe your problems and life situation to the counselor, she asks you questions and clarifications regarding what you have said to help her understand what you are going through. At times, the counselor summarizes the things you have said and asks you if she has understood you correctly. Moreover, she provides you with an opportunity to clarify things that she may not have understood correctly. After having discussed your concerns, the counselor asks about your goals of counseling. As the hour ends, the counselor expresses that she looks forward to working with you.

Positive Vignette

Please read the following vignette and place yourself in the position of a client seeking counseling services.

The first two paragraphs repeat the first two paragraphs of the Neutral Vignette.

As the session proceeds, the counselor encourages you to discuss your problems openly and honestly, as well as your fears and negative beliefs about counseling. She informs you that you may fear that she will not be able to understand your problems and may not have the ability to help you. She encourages you to discuss these fears as they relate to the problems you are going through. She talks with you about apprehension regarding how your friends and family will perceive you for coming into counseling, such as believing you are "crazy." Also, the counselor addresses your fears that in the future, you might be stigmatized for having sought counseling. The counselor also discusses your concern about being open in counseling, as you may believe that you will be judged and that she may not like you. Likewise, she discusses with you your worries about her ability to understand the seriousness of your problems and how they have affected your life. Furthermore, the counselor informs you that you may become uncomfortable as you learn more about yourself and reveal your thoughts and feelings to her. Moreover, as she asks you about your problems, she discusses your concerns about feeling pressured to discuss things. She further discusses with you your potential apprehension about being pressured to make changes in your life that may alleviate your problems but that you feel unable to make at this time. After having discussed your concerns, the counselor asks about your goals of counseling. As the hour ends, the counselor expresses that she looks forward to working with you.

REFERENCES

Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist. 58, 5-14.

AEgisdottir, S., & Gerstein, L. H. (2009). Beliefs About Psychological Services (BAPS): Development and psychometric properties. Counselling Psychology Quarterly, 22, 197-219.

Bergkvist, L., & Rossiter, J. R. (2009). Tailor-made single-item measures of double concrete constructs. International Journal of Advertising, 28, 607-621.

Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S. M., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers: Results from the National Epidemiological Study on Alcohol and Related Conditions. Archives of General Psychiatry, 65, 1429-1437.

Boyd, C., Francis, K., Aisbett, D., Newnham, K., Sewell, J., Dawes, G., & Nurse, S. (2007). Australian rural adolescents' experiences of accessing psychological help for a mental health problem. The Australian Journal of Rural Health, 15, 196-200.

Buckley, G. I., & Malouff, J. M. (2005). Using modeling and vicarious reinforcement to produce more positive attitudes toward mental health treatment. The Journal of Psychology, 139, 197-209.

Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental designs for research. Chicago, IL: Rand McNally.

Celluci, T., Krogh, J., & Vik, P. (2006). Help seeking for alcohol problems in a college population. The Journal of General Psychology, 133, 421-433

Cepeda-Benito, A., & Short, P. (1998). Self-concealment, avoidance of psychological services, and perceived likelihood of seeking professional help. Journal of Counseling Psychology, 45, 58-64.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 29, 614-625.

Deane, F. P., & Chamberlain, K. (1994). Treatment fearfulness and distress as predictors of professional psychological help-seeking. British Journal of Guidance and Counseling, 22, 207-217.

Deane, F. P., Spicer, J., & Leathern, J. (1992). Effects of videotaped preparation information on expectations, anxiety, and psychotherapy outcome. Journal of Consulting and Clinical Psychology, 60, 980-984.

Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking psychological help: A shortened form and considerations for research. Journal of College Student Development, 36, 368-373.

Fischer, E. H., & Turner, J. L. (1970). Orientations to seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35, 79-90.

Gonzalez, J.M., Tinsley, H.E., & Kreuder, K.R. (2002). Effects of psychoeducational interventions on opinions of mental illness, attitudes toward help seeking, and expectations about psychotherapy in college students. Journal of College Student Development, 43, 51-63.

Guajardo, J. M., & Anderson, T. (2007). An investigation of psychoeducational interventions about therapy. Psychotherapy Research, 17, 120-127.

Hammer, J. H., & Vogel, D. L. (2010). Men's help seeking for depression: The efficacy of a male-sensitive brochure about counseling. The Counseling Psychologist, 38, 296-313.

Kearney, L. K., Draper, M., & Baron, A. (2005). Counseling utilization by ethnic minority college students. Cultural Diversity and Ethnic Minority Psychology, 11, 272-285.

Kleinman, B. P., Millery, M., Scimeca, M., & Polissar, N. L. (2002). Predicting long-term treatment utilization among addicts entering detoxification: The contribution of help seeking models. The Journal of Drug Issues, 32, 209-230.

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.

Kushner, M. G., & Sher, K. J. (1989). Fear of psychological treatment and its relation to mental health service avoidance. Professional Psychology: Research and Practice, 20, 251-257.

Kushner, M. G., & Sher, K. J. (1991). The relation of treatment fearfulness and psychological service utilization: An overview. Professional Psychology: Research and Practice, 22, 196-203.

Lambert, P. (2007). Client perspectives on counselling: Before, during and after. Counselling and Psychotherapy Research, 7, 106-113.

McKay, J., Rutherford, M., Cacciola, J., & Kabasakalian-McKay, R. (1996). Gender differences in the relapse experiences of cocaine patients. Journal of Nervous and Mental Disease, 184, 616-622.

Pipes, R. B., Schwarz, R., & Crouch, P. (1985). Measuring client fears. Journal of Consulting and Clinical Psychology, 53, 933-934.

Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto US mental and addictive disorders service system. Epidemiologic

Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85-94.

Rickwood, D., & Braithwaite, V. (1994). Social-psychological factors affecting help-seeking for emotional problems. Social Science & Medicine, 39, 563-572.

Rossiter, J. R. (2002). The C-OAR-SF procedure for scale development in marketing. International Journal of Research in Marketing, 19, 305-335.

Sherif, M., & Sherif, C. W. (1967). Attitude as the individual's own categories: The social judgment-involvement approach to attitude and attitude change. In M. Sherif & C. W. Sherif (Eds.), Attitude, ego-involvement, and change (pp. 294-316). New York, NY: John Wiley and Sons.

Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press.

Sturmer, P., & Gerstein, L. (1999). Message source characteristics and Employee Assistance Program advertising: Beliefs in program effectiveness and intentions to self-refer. Employee Assistance Quarterly, 15, 77-105.

Tinsley, H., Bowman, S., & Ray, S. (1988). Manipulation of expectancies about counseling and psychotherapy: Review and analysis of expectancy manipulation strategies and results. Journal of Counseling Psychology, 35, 99-108.

Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54, 40-50.

Vogel, D. L., & Wester, S. R. (2003). To seek help or not to seek help: The risks of self-disclosure. Journal of Counseling Psychology, 50, 351-361.

Vogel, D. L., Wester, S. R., & Larson, L. M. (2007). Avoidance of counseling: Psychological factors that inhibit seeking help. Journal of Counseling and Development, 85, 410-422.

Vogel, D. L., Wester, S. R., Wei, M., & Boysen, G. A. (2005). The role of outcome expectations and attitudes on decisions to seek professional help. Journal of Counseling Psychology, 52, 459-470.

Walitzer, K. S., Dermen, K. H., & Connors, G. J. (1999). Strategies for preparing clients for treatment. Behavior Modification, 23, 129-151.

Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190-95.

Stefania JEgisd6ttir, Michael P O'Heron, and Joel M. Hartong are affiliated with Ball State University, Sarah A. Haynes with Damar Services, Inc., and Miranda K. Linville with Hillcrofl Services, Inc. Correspondence regarding this article should be sent to Dr. Stefania /Egisdottir, Associate Professor of Psychology--Counseling, Department of Counseling Psychology and Guidance Services, TC 609, Ball State University, 2000 W. University Ave., Muncie, IN 47306. E-mail: stefaegis@bsu.edu. Acknowledgement: The authors thank Terry D. Brown and Scott Olenick for their assistance with data collection and management.
Table 1. Means and Standard Deviations of Attitudes and Fears About
Counseling Services and Willingness to Seek Continued Services by
Vignette Type and Gender for Students with Counseling Experience

                                Neutral         Vignette
                                 Men             Women
                                (n=8)           (n=70)

                            Mean      SD    Mean     SD
BAPS
Intention                    4.02    0.61    4.28   0.87
Stigma Tolerance             4.84    0.90    4.95   0.68
Expertness                   4.72    0.74    4.64   0.80
TAPS
Therapist Responsiveness    19.38   10.25   19.77   8.97
Image Concerns              19.38    5.97   21.49   8.18
Coercion Concerns            9.75    2.92   10.35   4.36
Willingness                  4.25    1.58    5.33   0.88

                               Positive       Vignette
                                  Men          Women
                                (n=12)         (n=54)

                            Mean     SD    Mean     SD
BAPS
Intention                    3.93   0.79    4.25   0.98
Stigma Tolerance             4.63   0.72    4.96   0.61
Expertness                   4.23   0.85    4.62   0.83
TAPS
Therapist Responsiveness    25.42   7.34   18.05   7.38
Image Concerns              22.67   7.76   22.78   7.19
Coercion Concerns           12.17   3.93   10.39   3.88
Willingness                  3.75   1.54    4.94   1.14

Note. A higher score indicates a more positive attitude toward
counseling (BAPS), greater fears about counseling (TAPS), and
greater willingness to continue counseling; scores range from 1-6
for Intention, Stigma Tolerance, Expertness, and Willingness, 7-35
for Therapist Responsiveness, 8-40 for Image Concerns, and 4-20 for
Coercion Concerns.

Table 2. Means and Standard Deviations of Attitudes and Fears About
Counseling Services and Willingness to Seek Continued Services by
Vignette Type and Gender for Students Without Counseling Experience

                                Neutral        Vignette
                                Men            Women
                                (n=19)         (n=72)

                           Mean     SD    Mean     SD
BAPS
Intention                   3.73   1.16    3.81   0.74
Stigma Tolerance            4.32   1.01    4.75   0.66
Expertness                  4.51   0.90    4.44   0.74
TAPS
Therapist Responsiveness   18.05   7.05   18.69   7.81
Image Concerns             23.79   8.73   20.81   7.08
Coercion Concerns          11.21   4.48   10.07   5.30
Willingness                 5.00   1.82    5.15   1.07

                                Positive       Vignette
                                Men            Women
                                (n=24)         (n=70)

                           Mean     SD    Mean     SD
BAPS
Intention                   3.49   0.84    3.88   0.86
Stigma Tolerance            4.77   0.52    4.67   0.71
Expertness                  4.41   1.00    4.57   0.89
TAPS
Therapist Responsiveness   20.38   9.73   17.50   8.16
Image Concerns             20.04   7.04   22.76   8.29
Coercion Concerns           9.58   4.00   10.81   4.71
Willingness                 4.58   1.14    5.03   1.11

Note. A higher score indicates a more positive attitude toward
counseling (BAPS), greater fears toward counseling (TAPS), and
greater willingness to continue counseling; scores range from 1-6
for Intention, Stigma Tolerance, Expertness, and Willingness, 7-35
for Therapist Responsiveness, 8-40 for Image Concerns, and 4-20 for
Coercion Concerns.

Table 3. Partial Correlations Between Dependent Variables by Gender
and Previous Counseling Experience Controlling for Vignette Type

                                Intentions            Stigma
                                                    Tolerance

                               M         W         M         W
Previous Counseling
Intentions
Stigma Tolerance             .42       .46 **
Expertness                   .70 **    .62 **    .31       .44 **
Therapist Responsiveness     .21       .03      -.03      -.12
Image Concerns               .09      -.24 *    -.63 **   -.60 **
Coercion Concerns           -.01      -.06      -.48 *    -.27 **
Willingness                  .09       .47 **    .12       .26 **
No Previous Counseling
Intentions
Stigma Tolerance             .58 **    .41 **
Expertness                   .64 **    .57 **    .38 *     .31 **
Therapist Responsiveness    -.26      -.12      -.22      -.30 **
Image Concerns              -.28      -.20 *    -.65 **   -.66 **
Coercion Concerns           -.37 *    -.12      -.56 **   -.42 **
Willingness                  .40 **    .46 **    .20       .28 **

                                Expertness           Therapist
                                                  Responsiveness

                               M         W        M         W
Previous Counseling
Intentions
Stigma Tolerance
Expertness
Therapist Responsiveness     .31      -.08
Image Concerns               .15      -.20 *     .37      .36 **
Coercion Concerns            .16      -.02       .56 *    .60 **
Willingness                  .28       .25 *    -.13      .00
No Previous Counseling
Intentions
Stigma Tolerance
Expertness
Therapist Responsiveness    -.21      -.10
Image Concerns               .04      -.11       .29      .56 **
Coercion Concerns           -.03      -.15       .22      .54 **
Willingness                  .39 **    .32 **   -.30 *   -.06

                                Image            Coercion
                               Concerns          Concerns

                               M         W       M       W
Previous Counseling
Intentions
Stigma Tolerance
Expertness
Therapist Responsiveness
Image Concerns
Coercion Concerns            .59 *     .59 **
Willingness                  .10      -.11      .12     -.15
No Previous Counseling
Intentions
Stigma Tolerance
Expertness
Therapist Responsiveness
Image Concerns
Coercion Concerns            .87 **    .67 **
Willingness                 -.O6      -.10      -.09    -.15

Note. M: Men; W: Women. Higher scores on each measure refer to more
positive attitudes, intentions, and greater fears and willingness to
continue counseling.

* p<.05; ** p<.001.
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