Examining between- and within-person effects of the self-stigma of seeking psychological help on the therapeutic working alliance: The moderating role of psychological distress

The self-stigma (i.e., shame) associated with psychotherapy is a prominent barrier to seeking psychological help, but less is known about its effects after treatment begins. Evidence suggests that self-stigma may interfere with the formation of the therapeutic alliance, but no studies have examined this throughout the course of psychotherapy. Self-stigma's erosion of the alliance may be most pronounced when clients experience heightened psychological distress, but this also has not been examined. Therefore, the present study addresses these omissions among 37 clients who completed at least three therapy sessions for research credit. Participants completed measures of self-stigma and past-week symptoms of distress before each session and ratings of the working alliance after. Predictor variables were disaggregated into between-person (time-invariant or average levels) and within-person (time-variant or session-by-session changes) components to enable investigation of for whom (and under what conditions) self-stigma was associated with the therapeutic alliance. Results indicated that higher levels of self-stigma (between and within persons) predicted a worse alliance. When examined as an interaction effect alongside distress in a multilevel moderation model, higher between-person ratings of self-stigma predicted a weaker therapist-client alliance across levels (M ± 1 SD) of within-person distress. Notably, its effects became more pronounced as symptoms of distress increased, indicating a period in which clients are simultaneously most likely to need help yet least likely to feel allied with their therapist. Findings highlight the importance for therapists to simultaneously monitor and consider both average and session-by-session fluctuations in self-stigma and distress to develop and maintain the working alliance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-reliance, Social Norms, and Self-stigma as Barriers to Psychosocial Help-Seeking Among Rural Cancer Survivors With Cancer-Related Distress: Qualitative Interview Study

Background

Even when technology allows rural cancer survivors to connect with supportive care providers from a distance, uptake of psychosocial referrals is low. Fewer than one-third of participants in a telemedicine intervention for identifying rural survivors with high distress and connecting them with care accepted psychosocial referral.

Objective

The purpose of this research was to examine the reasons for which rural cancer survivors did not accept a psychosocial referral.

Methods

We utilized a qualitative design to address the research purpose. We interviewed participants who had been offered psychosocial referral. Semistructured interviews were conducted 6 weeks later (n=14), and structured interviews were conducted 9 months later (n=6). Data were analyzed descriptively using an inductive approach.

Results

Ultimately, none of the rural cancer survivors (0/14, 0%) engaged with a psychosocial care provider, including those who had originally accepted referrals (0/4, 0%) for further psychosocial care. When explaining their decisions, survivors minimized their distress, emphasizing their self-reliance and the need to handle distress on their own. They expressed a preference for dealing with distress via informal support networks, which was often limited to close family members. No survivors endorsed public stigma as a barrier to accepting psychosocial help, but several suggested that self-stigma associated with not being able to handle their own distress was a reason for not seeking care.

Conclusions

Rural cancer survivors’ willingness to accept a psychosocial referral may be mediated by the rural cultural norm of self-reliance and by self-stigma. Interventions to address referral uptake may benefit from further illumination of these relationships as well as a strength-based approach that emphasizes positive aspects of the rural community and individual self-affirmation.

Using Item Response Theory to Develop Revised (SSOSH-7) and Ultra-Brief (SSOSH-3) Self-Stigma of Seeking Help Scales

The current research developed ultra-brief (SSOSH-3) and revised (SSOSH-7) versions of the Self-Stigma of Seeking Help scale. Item response theory was used to examine the amount of information each item provided across the latent variable scale and test whether items functioned differently across women and men. In a sample of 857 community adults, results supported removal of three reverse-scored items to create the SSOSH-7. The three most informative items were retained to create the SSOSH-3. Differential item functioning testing supported the use of both versions across women and men. Results replicated in an undergraduate student sample (n = 661). In both samples, the SSOSH-3 (αs = .82-.87) and SSOSH-7 (αs = .87-.89) demonstrated evidence of internal consistency. The SSOSH-3 (rs ≥ .89) and SSOSH-7 (rs ≥ .97) were highly correlated with the original SSOSH across samples and demonstrated significant correlations with help-seeking constructs and in similar magnitude to the original SSOSH.

An examination of help-seeking preferences via best-worst scaling

OBJECTIVE

This study utilized best-worst scaling and latent class analysis to assess mental health treatment preferences and identify subgroups of college student help seekers.

METHOD

College students (N = 504; age: M = 20.3, 79.2% female) completed assessments of mental health treatment preferences, self-stigma, and distress.

RESULTS

Students preferred utilizing friends and family, followed by professional mental health providers, self-help, keeping concerns to themselves, physicians, and lastly religious leaders. Latent class analyses identified four classes of respondents.

CONCLUSIONS

Subgroups of student help seekers include Formal Help Seekers who prefer professional mental health providers, Informal Help Seekers who prefer friends and family, Ambivalent Help Seekers who prefer family and friends but also keeping concerns to themselves, and Help Avoiders who prefer keeping concerns to themselves. Assessing treatment preferences among different student subgroups may constitute an initial step in identifying effective ways to address university-wide mental health concerns.

Examining the Dimensionality, Reliability, and Invariance of the Depression, Anxiety, and Stress Scale–21 (DASS-21) Across Eight Countries

This study evaluated the dimensionality, invariance, and reliability of the Depression, Anxiety, and Stress Scale–21 (DASS-21) within and across Brazil, Canada, Hong Kong, Romania, Taiwan, Turkey, United Arab Emirates, and the United States ( N = 2,580) in college student samples. We used confirmatory factor analyses to compare the fit of four different factor structures of the DASS-21: a unidimensional model, a three-correlated-factors model, a higher order model, and a bifactor model. The bifactor model, with three specific factors (depression, anxiety, and stress) and one general factor (general distress), presented the best fit within each country. We also calculated ancillary bifactor indices of model-based dimensionality of the DASS-21 and model-based reliability to further examine the validity of the composite total and subscale scores and the use of unidimensional modeling. Results suggested the DASS-21 can be used as a unidimensional scale. Finally, measurement invariance of the best fitting model was tested across countries indicating configural invariance. The traditional three-correlated-factors model presented scalar invariance across Canada, Hong Kong, Romania, Taiwan, and the United States. Overall, these analyses indicate that the DASS-21 would best be used as a general score of distress rather than three separate factors of depression, anxiety, and stress, in the countries studied.

How Are Personal Values Linked to Help-Seeking Stigma?

The extent to which individuals prioritize different personal values may be conceptually linked to the perceptions of societal stigma associated with seeking psychological help (public stigma), as well as the extent to which they apply that stigma to themselves (self-stigma). We examined how personal values predicted public stigma and self-stigma of seeking psychological help. Undergraduates ( N = 342) from two universities, one historically Black college/university and one predominantly White institution, completed questionnaires assessing personal values and public stigma and self-stigma of seeking psychological help. Self-transcendence values predicted lower self-stigma directly and indirectly via public stigma. Though there were no structural differences between the modeled relationships of values, public stigma, and self-stigma between Black/African American and White/European American undergraduates, the groups differed in their prioritization of self-transcendence, openness to change, and conservation values. Results suggest that understanding how individuals prioritize certain values over others may help explain group-differences in help-seeking stigmas.

Age differences in public stigma, self-stigma, and attitudes toward seeking help: A moderated mediation model

OBJECTIVE

Stigma is commonly identified as a key reason that older adults are especially unlikely to seek mental health services, although few studies have tested this assumption. Our objectives were to: (a) examine age differences in public and self-stigma of seeking help, and attitudes toward seeking help, and (b) see whether age moderates an internalized stigma of seeking help model.

METHODS

A total of 5,712 Canadians ranging in age from 18 to 101 completed self-report measures of public stigma of seeking help, self-stigma of seeking help, and help-seeking attitudes.

RESULTS

Older participants had the lowest levels of stigma and the most positive help-seeking attitudes. Age also moderated the mediation model, such that the indirect effect of public stigma on help-seeking attitudes through self-stigma was strongest for older participants.

CONCLUSION

Our findings have implications for the influence of stigma and attitudes as barriers to treatment across the adult lifespan, and for stigma reduction interventions.

Do self-compassion and self-coldness distinctly relate to distress and well-being? A theoretical model of self-relating

The current research tested a theoretical model of self-relating that examined the unique relationships of self-compassion and self-coldness with distress and well-being. Self-coldness has recently been identified as theoretically distinct from self-compassion, rather than part of a unitary self-compassion construct. As such, the incremental value of self-compassion and self-coldness on clinically relevant outcomes is unclear. Therefore, the current research tested a theoretical model of the unique relationships of self-compassion and self-coldness and both distress and well-being among university students (N = 457) and community adults (N = 794), as well as interactions between these 2 constructs. Structural equation modeling results in both samples revealed that self-compassion was uniquely related to well-being (βs = .36-.43), whereas self-coldness was uniquely related to distress (βs = -.34) and well-being (βs = .65-.66). Consistent with the Theory of Social Mentalities, across samples self-compassion more strongly related to well-being, whereas self-coldness more strongly related to distress. Self-compassion did not demonstrate a unique direct relationship with distress, but it did buffer the relationship between self-coldness and distress in both samples and the relationship between self-coldness and well-being in the community sample. Overall, results suggest that clinicians would benefit from tailoring the use of self-compassion and self-coldness interventions. Implications for future research and practice are discussed. (PsycINFO Database Record

How Medical Students' Compassionate Values Influence Help-Seeking Barriers

THEORY

Despite high rates of psychiatric illnesses, medical students and medical professionals often avoid psychological help. Stigma may prevent medical students from seeking psychological help when experiencing distress, which may hinder their job performance and mental health. Compassionate values-preferred principles that guide attitudes and behaviors to focus on the wellness of others-may be a relevant predictor of medical students' perceptions of psychological help. The present study examined the association between medical students' compassionate values, help-seeking stigma, and help-seeking attitudes in a convenience sample of medical students.

HYPOTHESES

Rating compassionate values as more important than self-interested values will be associated with less stigma, which in turn will be associated with more positive help-seeking attitudes.

METHOD

There were 220 medical students in their 2nd year of medical training who were recruited in-class and through e-mail between January and March of 2017 at Des Moines University. Students were provided an anonymous online link to a survey composed of validated measures assessing values, psychological distress, and stigma and attitudes related to psychological help.

RESULTS

The survey response rate was 41%, leaving a final sample of 91. For every 1 SD increase in the relative importance of compassionate values over self-interested values, help-seeking stigma decreased 0.40 SDs, and help-seeking attitudes increased 0.23 SDs.

CONCLUSIONS

Prioritizing compassionate values more strongly than self-interested values is associated with medical students' perceiving psychological help-seeking more positively.

Reducing threat responses to help-seeking information: Influences of self-affirmations and reassuring information

This research was an examination of the effects of two types of self-affirmation interventions in reducing threat responses associated with receiving help-seeking information. Help-seeking information can be threatening to one's positive self-perceptions and people may avoid seeking such information to protect themselves. There is evidence that reflecting on personal values (values affirmation) may bolster self-integrity and mitigate this avoidance, and it is possible that reflecting on safe, close social relationships (social affirmation) could exhibit similar effects. To experimentally examine this theoretical idea, we applied a 2 × 2 × 2 factorial design in the present study on 384 participants and experimentally manipulated their values affirmations (values affirmation vs. no values affirmation) and social affirmations (social affirmation vs. no social affirmation). In addition, because there is no consensus as to the most effective presentation of help-seeking information, the type of help-seeking information presented to potential help-seekers was also manipulated (reassuring help-seeking information vs. nonreassuring help-seeking information). Results indicated that values affirmation and reassuring information were linked to lower threat responses, but social affirmation was not. Values affirmation and reassuring information might be effective strategies for reducing threat responses associated with the presentation of psychological help-seeking information. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Do Stereotypical Media Representations Influence White Individuals’ Perceptions of American Indians?

In this study, we examined exposure to stereotypical movie portrayals of American Indians, motivations to respond without prejudice, and awareness of White privilege on racist attitudes. European American participants ( N = 232) were randomly assigned to watch stereotypical representations of American Indians or control videos. Hierarchical regression results revealed that higher internal motivations to respond without prejudice and awareness were associated with lower levels of racist attitudes. Higher external motivations to respond without prejudice were associated with higher levels of modern racist attitudes. For participants high in awareness, there was no significant difference in modern racist attitudes between the control and stereotype conditions. For participants low in awareness, those in the control condition reported lower modern racist attitudes than those in the stereotype condition. Results suggest awareness is an important predictor of lower racist attitudes but needs to be reconceptualized within the counseling literature. Social justice implications and limitations are discussed.

Self-affirming values to increase student veterans' intentions to seek counseling

Student veterans experiencing mental health concerns could benefit from seeking counseling (Rudd, Goulding, & Bryan, 2011), though they often avoid these services. Self-affirmation interventions have been developed to increase openness to health-related behaviors (Sherman & Cohen, 2006), and may also help promote psychological help-seeking intentions. This study explored whether a self-affirmation intervention increased intentions to seek counseling in a sample of 74 student veterans who had not previously sought counseling services. Participants completed pretest (Time 1) measures of distress and help seeking (i.e., self-stigma, attitudes, and intentions to seek counseling). A week later (Time 2), participants completed one of two conditions: (1) a self-affirmation intervention before viewing a psychoeducational video and brochure or (2) only the psychoeducational video and brochure before completing the same help-seeking measures as Time 1. A week after the intervention (Time 3), participants again completed the help-seeking measures. A focused longitudinal mediation model was conducted, examining the effect of the self-affirmation experimental condition on help-seeking intentions. Compared with those in the psychoeducation-only group, student veterans who completed the self-affirmation intervention reported increased intentions to seek counseling both immediately postintervention (Time 2) and a week later (Time 3). (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Stigma of Seeking Psychological Services: Examining College Students Across Ten Countries/Regions

Stigma is an important barrier to seeking psychological services worldwide. Two types of stigma exist: public stigma and self-stigma. Scholars have argued that public stigma leads to self-stigma, and then self-stigma is the primary predictor of attitudes toward seeking psychological services. However, this assertion is largely limited to U.S. samples. The goal of this research was to provide a first step in understanding the relationship between public stigma, self-stigma, and attitudes toward seeking psychological services in international contexts ( N = 3,276; Australia, Brazil, Canada, Hong Kong, Portugal, Romania, Taiwan, Turkey, United Arab Emirates, and United States). Using structural equation modeling, we found that self-stigma mediated the relationship between public stigma and attitudes toward seeking services among college students in each country and region. However, differences in path strengths emphasize the need to pay attention to the role of public and self-stigma on attitudes toward seeking psychological services throughout the world.

Can reflecting on personal values online increase positive beliefs about counseling?

This research developed and tested an online values-affirmation exercise to attenuate threat and enhance positive beliefs about counseling among individuals struggling with mental health concerns. There is evidence that reflecting on personal values (values-affirmation) is an effective approach to eliciting self-affirmation-a psychological process that temporarily bolsters self-worth in order to forestall maladaptive, self-protective responses to counseling information. The present study utilized a randomized 2-group between-subjects design to test the effectiveness of a values-affirmation exercise with an online sample (N = 186) of adults who reported struggling with a mental health concern. It was predicted that values-affirmation would reduce threat related to reading mental health information and increase positive beliefs about counseling. Results indicated that those in the values-affirmation condition reported fewer negative emotions such as feeling upset, irritable, hostile, and scared after reading mental health information, indicating that the information was perceived as less threatening. There was also evidence that engaging in values-affirmation was associated with greater anticipated growth in counseling and greater intent to seek counseling, reflecting greater positive beliefs about counseling. Overall, the results suggest that reflecting on personal values may have the potential to enhance the positive effects of online psychoeducation. (PsycINFO Database Record

Masculinity and barriers to seeking counseling: The buffering role of self-compassion

Less than 1/3 of college men seek psychological help per year when experiencing mental health concerns. Many believe this is because socialized masculine norms are incongruent with help-seeking decisions. In line with this, adherence to masculine norms, like emotional control and self-reliance, is consistently linked to factors associated with lower use of counseling. Identifying constructs that buffer, or reduce, the relationship between masculine norm adherence and common barriers to seeking help, like help-seeking self-stigma and resistance to self-disclosing, could shed light on mechanisms through which effective interventions could be developed. As such, this study examined whether self-compassion, or the ability to show oneself kindness and understanding in the face of challenges, moderated the relationship between masculine norm adherence and both help-seeking self-stigma and the risks associated with self-disclosing to a counselor in a sample of 284 undergraduate men (Mage = 19.68, range = 18-30). Results indicate that self-compassion is associated with lower levels of help-seeking self-stigma and disclosure risks. Additionally, and perhaps more importantly, self-compassion buffered the relationship between overall masculine norm adherence and each of these barriers. Furthermore, when specific masculine norms were examined, self-compassion buffered the relationship between emotional control and disclosure risks. These results support the need for future research focused on the development and assessment of self-compassion based interventions aimed at decreasing the barriers undergraduate men experience toward seeking psychological help. (PsycINFO Database Record

Online Counseling

The rejoinder responds to the four reactions by Jeffrey Barnett, Tai Chang, Delida Sanchez-Page, and Franz Caspar and Thomas Berger in the November 2005issue of The Counseling Psychologist. In doing so, the authors emphasize the important need for further clarity regarding the effectiveness of online mental and behavioral health services in delivering a wide range of psychoeducation, self-help, and mutual-help facilities as well as direct counseling. The authors also highlight many of the reactants’ important insights, including the comments on the appropriateness of online mental and behavioral health services for the underserved and whether online counseling should be used as a primary or secondary tool in counseling.

Sex Differences in Emotion

This article examines the findings of several reviews of the empirical literature on biological sex and emotion, focusing on the degree to which perceived sex differences in emotionality are, and in most cases are not, supported while at the same time addressing the implications this body of research has for counseling psychologists. This article also explores potential explanations, such as gender role socialization or situational influences, for the profession’s continued acceptance of large innate sex-based affective differences. Finally, the third section discusses several concerns this continued acceptance raises for the practice of counseling, whereas the last section offers a research agenda building on the review presented herein.

Introduction to the Major Contribution

This article introduces the Major Contribution, which focuses on online counseling. Several acronyms and terms are presented to familiarize the reader with distance-communication technology, including a definition of online counseling. The authors show how counseling psychology provides a framework for specific questions related to the theory, research, and practice of online counseling. In addition, they discuss counseling psychology’s emphasis on the scientist-practitioner model, history of process and outcome research, and unifying themes to provide a context for the succeeding articles on the research and practice of online counseling.

Online Counseling

This article reviews the online-counseling literature with an emphasis on current applications and considerations for future research. It focuses on primary themes of counseling psychology including the history of process-outcome research and multiculturalism. It explores current gaps in the literature from a counseling psychology framework, including the field’s focus on normal and developmental challenges and tasks, client strength and resilience, education and career development, prevention and wellness, and multiculturalism. In general, current evidence indicates that online counseling may be a viable service option for some clients, especially those who are typically isolated; however, questions remain regarding the effectiveness and appropriateness of online counseling.

The Practical Aspects of Online Counseling

This article addresses the practical aspects of online counseling, including ethics, training, supervision, technology, and competency issues. The authors discuss online counseling’s strengths and limitations and present guidelines for what types of clients and counseling psychologists may be appropriate for online counseling. To illustrate the components and skills associated with online counseling, the authors present and discuss an example of a synchronous-chat online session.

Help-Seeking Attitudes of United Arab Emirates Students

The psychological help-seeking patterns of college students in the United Arab Emirates (UAE) have only recently begun to be examined. Initial suggestions indicate that the majority of Emirati students treat help seeking from counselors as a last resort, which may be linked to aspects of Emirati culture including feared loss of societal face, stigma associated with seeking help, and discouragement of self-disclosure to individuals outside of the family. The relationship among fear of losing face, stigma, self-disclosure expectations (i.e., risks and benefits), and help-seeking attitudes was examined using structural equation modeling with 407 Emirati college students. Loss of face and stigma were related to self-disclosure expectations, which in turn were related to help-seeking attitudes. Gender differences were also examined with results indicating significant mean differences across all variables, as well as across two paths of the structural model. These findings are discussed within the cultural context of the UAE.

Does self-stigma reduce the probability of seeking mental health information?

An important first step in seeking counseling may involve obtaining information about mental health concerns and treatment options. Researchers have suggested that some people may avoid such information because it is too threatening due to self-stigma and negative attitudes, but the link to actual help-seeking decisions has not been tested. Therefore, the purpose of the present study was to examine whether self-stigma and attitudes negatively impact decisions to seek information about mental health concerns and counseling. Probit regression models with 370 undergraduates showed that self-stigma negatively predicted decisions to seek both mental health and counseling information, with attitudes toward counseling mediating self-stigma's influence on these decisions. Among individuals experiencing higher levels of distress, the predicted probabilities of seeking mental health information (8.5%) and counseling information (8.4%) for those with high self-stigma were nearly half of those with low self-stigma (17.1% and 15.0%, respectively). This suggests that self-stigma may hinder initial decisions to seek mental health and counseling information, and implies the need for the development of early interventions designed to reduce help-seeking barriers.

Modeling stigma, help-seeking attitudes, and intentions to seek behavioral healthcare in a clinical military sample

OBJECTIVE

This study examined the relationship between public and self-stigma of seeking behavioral health services, and help-seeking attitudes and intent in a sample of active duty military personnel currently being assessed for traumatic brain injuries in a military health center. Although it has been suggested that many military personnel in need of care do not seek services due to concerns with stigma it is not fully clear what role different types of stigma play in the process.

METHOD

Using previously collected data from a clinical sample of 97 military personnel, we conducted path analyses to test the mediation effects of self-stigma on the relationship between public stigma and attitudes toward and intentions to seek behavioral health care.

RESULTS

In contrast to a model of military stigma but in line with research with civilian samples, results from this study indicate that self-stigma fully mediates the relationship between public stigma and help-seeking attitudes and intentions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These results indicate that programming aimed at increasing mental health care use in the military might best focus on reducing self-stigma associated with seeking mental health services.

Factor Structure of the Gender Role Conflict Scale-Short Form in Chinese Heterosexual and Gay Samples

The current study examined the validity of Gender Role Conflict Scale-Short Form (GRCS-SF) among a sample of 256 Chinese heterosexual men and 250 Chinese gay men. Confirmatory factor analysis (CFA) supported the conclusion that a Chinese translated version of the GRCS-SF had acceptable structural validity. Specifically, the four-factor solution (i.e., Success, Power, Competition; Restricted Emotionality; Restricted Affectionate Behavior Between Men; Conflict Between Work and Family Relations) was confirmed with all items loading on their respective factors. Furthermore, the four-factor solution provided a better fit than either a single factor or a four-factor solution with a higher-order single factor. Cronbach's α reliabilities reached the acceptable criterion in both samples for the overall score as well as for the subscale scores. Measurement invariance also suggested that the GRCS-SF has a similar structure between heterosexual and gay Chinese men.

Measuring thought content valence after a breakup: Development of the Positive and Negative Ex-Relationship Thoughts (PANERT) scale

The end of a romantic relationship is a common and serious presenting concern among clients at university counseling centers. Researchers have highlighted the need to understand the nature of thoughts about an ex-relationship, because they may lead to unique clinical interventions. One aspect of thought that may be clinically relevant is content valence, or the positive or negative emotions associated with the content of the thought. Unfortunately, content valence has not been addressed in the romantic relationship dissolution literature. To address this omission, we developed the 12-item Positive and Negative Ex-Relationship Thoughts (PANERT) scale across 4 samples. In Sample 1 (n = 475), exploratory factor analyses demonstrated a multidimensional scale with 2 factors: positive content valence and negative content valence. Sample 2 (n = 509) and Sample 3 (n = 291) confirmed the factor structure in college and community samples. Internal consistencies ranged from .88-.94 for positive content valence and from .87-.94 for negative content valence. In Sample 4 (n = 133), construct validity was supported, with the PANERT factors uniquely predicting breakup distress, relationship preoccupation, depression, loss of self-concept, rediscovery of self-concept, negative emotional adjustment, and positive emotional adjustment. Further, the direction of these relationships suggest that positive thought content valence may be consistently maladaptive to recovery from an ex-relationship, and negative thought content valence may have maladaptive and adaptive features. Implications for future research and practice are discussed.

Predicting Self-Esteem and Intentions to Seek Counseling

This investigation introduced the Internalized Stigma Model to test the mechanisms by which the stigma of mental illness and of seeking psychological help affect self-esteem and intentions to seek counseling. We hypothesized that both stigmas would predict decreased self-esteem, but only stigma of seeking psychological help would predict decreased intentions to seek counseling. Furthermore, we predicted that these links follow a process wherein people’s perceptions of societal stigma are fully mediated by internalization of that stigma. Public stigmas predict their respective self-stigmas, which subsequently predict self-esteem and intentions. Using structural equation modeling, we tested the hypothesized relationships in a sample of undergraduates ( N = 448). Results supported the hypotheses. Self-stigma mediated the relationship between public stigma and both outcomes; both self-stigma of mental illness and self-stigma of seeking psychological help predicted decreased self-esteem, but only self-stigma of seeking psychological help predicted decreased intentions to seek counseling.