Interpreter-Mediated Therapy for Refugees: Graduate Student Journal of Psychology Copyright 2011 by the Department of Counseling and Clinical Psychology 2011, Vol. 13 Teachers College, Columbia University 25 Predictors of Attitudes Toward Psychological Counseling Among Lebanese College Students Hussein Wehbe Teachers College, Columbia University The study investigated the effects of social stigma, self-stigma, and willingness to self-disclose personal distress on attitudes towards psychological counseling among Lebanese college students. One hundred twenty-five participants enrolled in an introductory psychology course were surveyed. Questionnaire packets included questions pertaining to demographic characteristics and four scales assessing attitudes towards counseling, social stigma, self-stigma, and self-disclosure. Contrary to previous findings in the literature, our study found that students expressed favorable attitudes towards counseling. Results also indicated that social stigma and self-stigma were negatively correlated with attitudes towards counseling, whereas comfort with self-disclosure had no relationship with attitudes showing inconsistency with past reviews. Among the three factors hypothesized to impact attitudes towards counseling, only self-stigma had significant predictive power. The results and limitations of the study are discussed, and several implications and future directions for further research are identified. Many people in need of psychological counseling underutilize available mental health services (Shaffer, Vogel, & Wei, 2006). In order to serve more effectively those who need psychological services, practitioners in the Lebanese community would benefit from a comprehensive understanding of factors that influence one’s decision to seek psychological help. Possible factors that may influence one’s decision include: social stigma, self-stigma, and reluctance to self-disclose personally distressing information (Shaffer et al., 2006; Komiya, Good, & Sherrod, 2000).  Social Stigma Public stigma labels counseling as being socially unacceptable (Vogel, Wade, & Haake, 2006; Komiya et al., 2000). Thus, an individual may avoid seeking treatment and express unfavorable attitudes towards psychological services in an attempt to reduce possible social stigma (Vogel, Wade, & Ascheman, 2009). Research suggests that people tend to view individuals who seek mental health treatment less favorably than treatment nonseekers (Sibicky & Dovidio, 1986). Individuals who seek psychological treatment for depression are often described as being emotionally unstable, responsible for their own symptoms, and lacking self- confidence; however, depressed individuals who seek treatment for their condition are viewed more negatively than treatment nonseekers who also suffer from depression. Vogel and colleagues (2009) developed the five item Social Stigma for Receiving Psychological Help Scale in order to investigate the degree to which social stigma is associated with treatment seeking behavior and prevents people from seeking mental Hussein Wehbe, Department of Counseling and Clinical Psychology, Teachers College, Columbia University. Correspondence concerning this article should be addressed to Hussein Wehbe, 145 West 55th Street, New York, NY 10019. Email: hmw2120@columbia.edu. health services. The results of their survey showed that individuals with mental health disorders were not willing to seek psychological help as a result of perceived social stigma (Vogel et al., 2009). Self-Stigma Self-stigma refers to internalized stigma that individuals may have toward themselves due to being labeled as incompetent and socially unacceptable (Vogel et al., 2006). The concept of self-stigma suggests that people may have negative attitudes towards seeking help because if they admit they have mental health problems they internalize the stigma and label themselves as being inadequate, weak, or inferior (Vogel et al., 2006). Studies have shown that individuals with mental health problems internalize negative perceptions of themselves (Link, 1987; Link & Phelan, 2001). Vogel and colleagues (2006) conducted a study among college students to investigate how aspects of one’s self-esteem (i.e., self- regard, self-confidence, satisfaction with oneself and one’s abilities, and overall sense of worth as a person) are subject to change if a person considers seeking psychological help. Using the Self-Stigma of Seeking Help Scale (SSOSH; Vogel et al., 2006), the authors found that study participants believed that seeking help from a psychologist or other mental health professionals would negatively affect one’s self-regard, self-satisfaction, self-confidence, and self-worth. Self-Disclosure Studies have shown that the desire to avoid disclosing personal issues or painful feelings may affect treatment seeking decisions (Vogel et al., 2006). In a study of college students’ attitudes toward self-disclosure, Vogel and Wester (2003) found that comfort with self-disclosing distressing information was highly associated with a willingness to seek psychological help. Vogel and colleagues (2006) measured WEHBE 26 the degree to which a person is comfortable self-disclosing personally distressing information using the Distress Disclosure Index (DDI). Results indicated that the desire to self-disclose personally distressing information significantly predicted attitudes toward seeking professional help (Vogel et al., 2006). Komiya and colleagues (2000) examined the effects of emotional openness on seeking psychological help in a sample of college students. Results indicated that discomfort with expressing emotions accounted for a large percentage of the variance in negative attitudes towards psychological help. Mental Health in the Arab Society Arab college students are prone to developing psychological distress, including symptoms of anxiety, distress, and depression, as a result of the abrupt transition to college life (Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2009). Problems such as moving away from home, dealing with academic demands, attaining appropriate study habits and making vocational decisions are a few examples that accompany such a transition (Al-Krenawi et al., 2009). Arab college students, however, tend to avoid making contact with professional services (Al-Krenawi et al., 2009). Al- Krenawi and Graham (2005) found that mental health patients in the Arab population tend to express their psychological problems in terms of physical symptoms, thereby avoiding the stigma attached to mental illness. The present study seeks to explore Lebanese college students’ attitudes towards psychological distress. The primary aim of the study is to investigate the factors involved in predicting attitudes towards counseling among Lebanese college students. This study will extend the work of previous research by examining the comparative effects of three predictor variables (social stigma, self-stigma, and comfort with self-disclosure) on attitudes towards psychological counseling. No prior research has been conducted in Lebanon with respect to the social stigma, self-stigma or self- disclosure. As a result, this study will investigate which variable possesses the strongest predictive power in predicting attitudes towards counseling among Lebanese college students. Based on the findings reported in the literature, it was hypothesized that: (1) Lebanese college students would endorse high levels of negative attitudes towards psychological counseling; (2) negative attitudes towards psychological counseling would be predicted by high levels of social stigma and self-stigma; (3) positive attitudes towards counseling would be predicted by high levels of self- disclosure; and (4) the reluctance to self-disclose personally distressing emotions would account for significant and unique variance in predicting psychological help seeking behavior. Method Participants Participation was entirely voluntary. The criterion for participation was that the subject be Lebanese and at least 17 years of age. One hundred and twenty-five students were initially surveyed, of which 17 (13.6 %) were non-Lebanese (i.e., Jordanian, Palestinian, Columbian, Cypriot, Canadian, American, Brazilian, and French). The final sample consisted of 108 participants (59 males and 49 females) of Lebanese origin aged 17-22 years (see Table 1). Instruments Attitudes Toward Seeking Professional Psychological Help Scale–Short Form. The measure consists of ten items rated from 1 (strongly disagree) to 5 (strongly agree) that were summed; lower scores reflected negative attitudes towards counseling (five items are reverse-scored). A sample item is “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.” The internal consistency for this scale was α = .84 in a college sample (Vogel et al., 2009). Stigma of Seeking Professional Psychological Help Scale (SSPPH). The SSPPH consists of five items rated from 1 (strongly disagree) to 5 (strongly agree) that assess perceptions of the societal stigma associated with seeking professional help, with higher scores reflecting greater perceptions of social stigma. A sample item is “People will see a person in a less favorable way if they come to know that he/she has seen a psychologist.” The SSPPH correlated with attitudes toward seeking counseling and had a reported internal consistency of α = .73 in college samples (Vogel et al., 2009). Self-Stigma of Seeking Help Scale (SSOSH). The 10- item SSOSH assesses threats to one’s self-evaluation for seeking psychological help (e.g., “I would feel inadequate if I went to a therapist for psychological help”). Items are rated from 1 (strongly disagree) to 5 (strongly agree) and higher scores reflect perceptions of self-stigma associated with treatment seeking. The SSOSH has shown good internal Table 1 Frequencies of Demographic Variables Demographic Variables N % Gender Male 59 54.6 Female 49 45.4 Age 17 2 1.9 18 39 36.1 19 37 34.3 20 19 17.6 21 9 8.3 22 2 1.9 Year in University Freshman 4 3.7 Sophomore 50 46.3 Junior 38 35.2 Senior 12 11.1 Graduate 4 3.7 LEBANESE COUNSELING ATTITUDES 27 consistency, with Cronbach α ranging from α =.86 to α = .90 in college samples (Vogel et al., 2006). Distress Disclosure Index (DDI). The DDI is a 12-item questionnaire measuring comfort with the self-disclosure of distressing emotions (e.g., “When I feel upset, I usually confide in my friends”). Items are rated on a 5-point Likert- type scale ranging from 1 (strongly disagree) to 5 (strongly agree), with six items being reverse-scored. Items are summed up so that higher scores reflect a greater willingness to disclose personally distressing emotions. The DDI has been found to have good internal consistency (Cronbach α = .93) in college samples (Vogel et al., 2006). Procedure Sixty-three students enrolled in an introductory psychology course were given two questionnaire packets, one for themselves and one to give to a friend of the same age range (17-22 years) also enrolled in the same college. Each packet had (1) a consent form informing participants of the purpose of the study, that their participation was voluntary, and ensuring confidentiality and anonymity of their responses; (2) a demographic questionnaire, assessing socio- demographic information on the participants’ gender, age, nationality, and year and major in university; (3) the Attitudes Toward Seeking Professional Psychological Help Scale–Short Form (Vogel et al., 2009); (4) the Stigma of Seeking Professional Psychological Help Scale (SSPPH; Vogel et al., 2009); (5) Self-Stigma of Seeking Help Scale (SSOSH; Vogel et al., 2006), and (6) the Distress Disclosure Index (DDI; Vogel et al., 2006). The students were asked to return the packets the next day to the researcher in exchange for course credit. All measures were administered in English. Statistical Analysis We first conducted preliminary statistical analyses to test for accuracy of entry and outliers, normal distribution of the study variables, and multicollinearity problems. We then calculated the means and standard deviation for each scale’s total scores. To assess the relationship between the study variables we conducted a correlation matrix. A stepwise multiple regression was then conducted to evaluate which variables (i.e., social stigma, self-stigma, self-disclosure, and general attitudes) would significantly predict attitudes towards psychological counseling. Statistical analyses were performed using the SPSS statistical software package for Microsoft Windows (version 14.0, SPSS Inc, Chicago, IL, USA). Results Prior to analysis, the data was examined for accuracy of entry and outliers. No univariate outliers were detected from the analysis (Z scores >│3.26│) (Tabachnick & Fidell, 2001). Reliability analyses of all the scales and items yielded high alpha coefficients for the self-disclosure and self-stigma scales and a good alpha coefficient for the general attitudes scale (see Table 2). The reliability analysis for the social stigma scale reported unreliable results; therefore, any results associated with the social stigma scale should be interpreted with caution. Given that several predictors were fitted into a model to predict an outcome variable, the statistical design that was implemented was a multiple regression analysis. The data was plotted and the assumption of normality was met. Also, according to Tabachnick and Fidell (2001), since we were interested in the overall correlation and the individual predictors, our sample N should be larger than both (50 + 8m) and (104 + m), where m is the number of predictors. In this case our sample was larger than both (50 + 8(3)) = 74 and (104+3) = 107. Hence, the assumption of ratio of cases to independent variable (IV) was met. The total means and standard deviations of the scales are presented in Table 3. The total means of attitudes towards counseling, social stigma and self-disclosure were above average (given the range from 1, strongly disagree, to 5, strongly agree). The mean score for items above a midpoint score of 3 suggests high levels of favorable attitudes towards psychological counseling, high levels of perceived social stigma associated with counseling, and greater willingness to self-disclose personally distressing emotions to a counselor among the students in the investigated sample. The mean for self-stigma was around midpoint suggesting that on average, participants expressed no opinion on the items pertaining to self-stigma. The fact that participants expressed high levels of favorable attitudes towards counseling contradicted our first hypothesis and demonstrated inconsistency with the study conducted by Al-Krenawi and colleagues (2009). The Pearson correlations between the variables are displayed in Table 4. Significant negative correlations were found between self-stigma and attitudes, social stigma and attitudes, and self-disclosure and self-stigma; the correlation between self-stigma and attitudes was the highest. Table 2 Reliabilities of Scales Scale Number of Items Cronbach’s α Self-Stigma 10 .83 Self-Disclosure 12 .92 General Attitudes 10 .74 Social Stigma 5 .67 Table 3 Means and Standard Deviations of All Variables M SD N General Attitudes 31.04 5.92 108 Social Stigma 14.10 3.81 108 Self Stigma 24.63 6.85 108 Self-Disclosure 40.88 10.09 108 WEHBE 28 Nonsignificant negative correlations were found between self-disclosure and social stigma, (p > .05), and self- disclosure and general attitudes, (p > .05). A significant positive correlation was found between self-stigma and social stigma. Higher perceptions of self-stigma related to seeking psychological services were associated with lower levels of willingness to disclose personally distressing emotions (p < .01). Furthermore, higher perceptions of social stigma were associated with higher perceptions of self-stigma associated with seeking counseling (p < .01). To test for multicollinearity problems we followed recommendations by Field (2005), and scanned a correlation matrix of all of the predictor variables to see if there were variables that correlated with each other very highly (r > .80). We also looked at the variable inflation factor (VIF), which according to Myers (1990) if above 10 is considered a potential sign for multicollinearity. Finally, we looked at the tolerance values, given that values below 0.1 are a potential sign for multicollinearity (Field, 2005). The values of the correlation matrix were all below r = .75 and both the tolerance and VIF coefficients indicated that the assumptions of singularity and absence of multicollinearity were met. The Durbin-Watson statistics indicated that the assumption of independence of errors was met. The stepwise regression revealed a good fit of the variance explained. The results indicated that the overall model was significant R 2 = .405, F(106) = 72.23, p < .05, indicating that these predictors (social stigma, self-stigma, and self-disclosure) accounted for 40.5 % of the variance in attitudes towards psychological counseling. Examining the Standardized Beta coefficients (β), self-stigma was the best predictor of attitudes towards psychological counseling in the investigated sample (see Table 5). Both social stigma and self-disclosure were excluded from the model. Discussion The purpose of this study was to investigate the roles of social stigma, self-stigma, and self-disclosure in predicting attitudes towards psychological counseling among Lebanese college students. All of the aforementioned variables were assessed through four different scales as previously mentioned. The study showed that among the three predictor variables, only social stigma and self-stigma showed a significant predictive power, with self-stigma being the variable with the greatest effect. The findings from our correlation analysis illustrated that higher perceptions of self-stigma and social stigma were associated with higher levels of negative attitudes towards counseling, while self-disclosure showed no significant relationship with such attitudes. Regression analysis found only one strong predictor among the variables measured. Contrary to our hypothesis, self-stigma appeared to be the only strong predictor of negative attitudes towards counseling. Research has shown that social stigma and self-stigma are important factors of negative attitudes towards counseling. Previous studies have found that individuals may decide not to seek help, even when they are experiencing emotional pain, because of the belief that labels such as “unreliable” or “emotionally unstable” would be applied to them and that such a decision would be a sign of weakness or an acknowledgment of failure (Vogel et al., 2006). Our findings are largely consistent with previous research. First, previous studies have found that participants’ attitudes towards psychological treatment were significantly associated with the social stigma and that participants’ self- stigma impacted psychological help seeking behavior (Vogel et al., 2009; 2006). However, findings pertaining to self- disclosure were inconsistent with Vogel et al.’s (2006) study in which the desire to self-disclose personally distressing information significantly predicted attitudes toward seeking professional help. Results were also inconsistent with the study by Komiya and colleagues (2000) in which discomfort with expressing emotions accounted for a large percentage of the variance in negative attitudes towards psychological help. Limitations Despite the importance of these findings, some limitations should be noted. First, a major limitation in the study lies in the procedure. As previously mentioned, participants were given two questionnaire packets and were asked to complete one packet, and give the other to a friend. There is a possibility that participants failed to abide by the instructions of the study, and instead filled out both questionnaires. There is also the possibility that participants shared answers with their friends in an attempt to express similar views on the presented scales. Second, we cannot generalize the results to the whole Lebanese college population. In the study at hand, the sample size was not sufficiently large. A small sample size (N = 108) is probably not large enough to draw meaningful conclusions Table 4 Correlations between Scales Scales Social Stigma Self- Stigma Self- Disclosure General Attitudes Social Stigma 1 Self Stigma .42** 1 Self- Disclosure -.06 -.28** 1 Attitudes -.36*** -.64*** .156 1 *p < .05. **p < .01. *** p < .001 Table 5 Standardized β Coefficients for the Predictor Variables Model Standardized β Coefficient Sig. Self-Stigma -.64 .000 Social Stigma -.12 .15 Self-disclosure -.02 .76 LEBANESE COUNSELING ATTITUDES 29 and implications. Moreover, low reliability for the social stigma scale was revealed. A disadvantage of relying on survey methods is that they are dependent on self-report and do not measure behavior directly. As a result, social desirability and demand characteristics may shape participants’ responses regardless of assurances of confidentially and anonymity. For instance, on items measuring attitudes, respondents may wish to deny unfavorable attitudes towards mental health services to present themselves in a positive light, as open minded individuals, especially considering that they were enrolled in a psychology course. As students with background knowledge in psychology, it is far more likely for them to be biased. Implications and Recommendations for Future Research In order to reach individuals who typically avoid psychological treatment, mental health education in school settings, work environments, and within institutions could be the optimal solution. Educating the public about mental health services will help combat the adverse effects of stigma. Psychologists and other health care providers may also reach individuals who typically avoid psychological treatment by using alternative means to implement psychoeducational goals such as broad-based advertisements (print, radio, and TV). Such efforts would be directed towards those who might not seek help for psychological distress because of the social stigma or self-stigma related to psychological treatment (Vogel et al., 2006). Based on the aforementioned findings, several suggestions could be made for future research. Evidence was presented in this study on how social stigma and self-stigma are associated with seeking psychological help. However, further research may examine potential mediating effects of personality. Future investigations may also choose to examine the results of educational programs targeted toward reducing stigma (e.g., media efforts). Another consideration for future research is to consider implementing longitudinal studies that integrate psychoeducation with ongoing investigations of attitudes towards counseling and mental health services in general. Such an approach will help in reducing stigma and increasing willingness to seek counseling services. 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