Needing psychological help and applying for it does not always follow each other. Several people who can benefit from psychological help either does not prefer to take it or even if they begin, they can not fully participate. One reason for this discrepancy is “stigma” (1-6). Stigmatization anxiety leads to two dangers that can hamper participation in psychological help process: decreasing self-esteem of the individual or taking away the social opportunities (3).
In recent years, researchers have pointed that, before taking an action, individuals first make an assessment of stigmatization by people close to them (7) and then stigmatization by the society they live in (3) before deciding on whether they will attempt to receive help or not. While it has been known that perceived social stigma is associated with the decision to seek help, the complex role played by stigmatization in this process has not been fully understood since it has been made clear by Corrigan (3). Corrigan mentioned two types of stigmatization that affects an individual’s decision to seek help: social stigmatization and self stigmatization (3). According to the researcher, increased risk of social stigmatization leads to increased possibility of self stigmatization.
Vogel and colleagues (8), suggested that particularly stigmatization by people who are close to the individual increases the risk of self stigmatization and thus leads to individuals’ refraining from seeking psychological help. Authors indicated that when the individual seeks psychological help in spite of self stigmatization which may lead to decreased self-esteem and self-sufficiency and that there is a risk of internalization of the stigmatization by society or close people which may lead to an inferior, insufficient and weak perception of the self (9,10).
While it has been known that an individuals willingness to seek psychological help and perceived social stigmatization is directly associated (3,6,7), the role of self stigmatization has been investigated only in the recent years. Vogel and colleagues (8) showed that when compared with social stigmatization, self stigmatization more closely predicts attitudes towards seeking psychological help and willingness to do it. When seeking professional psychological help is perceived as a threat to self-esteem, in spite of the emotional suffering, the individual may decide not to seek help because taking help is perceived as weakness and acceptance of failure. This may lead the individual to think that accepting the need for help is even worse than the emotional suffering (8).
Vogel and associates indicated that the stigmatization process operates the same way not only when seeking help for psychiatric disorders but also when seeking psychological counseling (6). Stigma due to psychiatric problems may not be the same as stigma due to psychological counseling, however, people who take psychological counseling report that they are stigmatized more than people who are not receiving such help. Sibicky and Dovidio (11) showed in their study, which relies on an experimental design, that people stigmatized for taking psychological counseling and psychotherapy are seen as less attractive and that they face more negative attitudes when compared with people who were not stigmatized. In a study based on a scenario, Ben-Porath (12) reported that people who are said to get help for depression are considered as less emotionally consistent, less interesting and lower self-esteemed when compared with people who are said to get help for back pain and people who are not getting help for depression. As a result, not only having a psychiatric problem but also seeking help for the problem is stigmatized by the society.
Studies conducted on stigmatization in Turkey mostly considers stigmatization of people with psychiatric disorders. September 2004 issue of the journal 3P (psychiatry, psychology, psychopharmacology) was published by the title “Stigma” and it is an important reference source which includes detailed assessment of the issue (13-18). In recent years studies considering attitudes towards help seeking have been increased. In a study which compared the attidues towards seeking psychological help of Turkish and American postgraduate students indicated no significant differences between the two groups regarding attidues towards seeking professional psychological help (19). However, women stated more favorable attitudes towards seeking psychological help then men (19,20). Another study showed a direct negative association between perception of social stigmatization and intention to get psychological help (21).
Studies suggest that when social stigmatization is internalized, possibility of seeking help is decreased further (22,23), therefore, understanding different forms of stigmatization and helping people to overcome burdens against seeking help is an important task for investigators in psychological counseling field. The aim of this study, in this context, is to adapt Self Stigma of Seeking Help Scale (SSOSH) developed by Vogel and associates (8) to Turkish and investigate the psychometric structure of the scale. We think that bringing this scale in to Turkish will make studies on and understanding the stigmatization process easier.
This is a study which adapts Self Stigma of Seeking Help Scale (SSOSH) (8) to Turkish culture and investigates the reliability and validity of the scale.
Data were collected from 581 individuals from four different groups. Data were collected from 40 college students to determine the problematic and difficult to understand items in the scale, which was translated into Turkish and ready to use. For most of the validity and reliability studies, data were collected from 3rd and 4th grade college students in Ankara University Faculty of Education during 2009-2010. 45.15% of the study group consisted of 3rd grade students while 54.85% were 4th grade students. Age range was 19-30 (X=22). 34.11% of the sample were male and 65.89% were female. Data were collected from a total of 299 individuals from six different departments. 46 (15.38%) students were from “Computer and Teaching Technologies”, 39 (13.73%) were from “Culture of Religion and Moral Values Teaching”, 47 were from (15.73%) “Pre-school Teaching”, 51 were from (17.06%) “Student Advisory Department”, 43 were from (14.38%) “Social Sciences Teaching” and 73 were from (24.41%) “Mental Disability Teaching”.
To calculate test-retest reliability, a separate group of 40 students from 3rd and 4th grades were enrolled. To test criterion validity data were collected from 202 3rd and 4th grade students from 5 different departments of Ankara University Faculty of Education during 2010-2011: 32 (15.84%) from “Computer and Teaching Technologies” department, 68 from 33.66%, “Pre-school Teaching” department, 50 from (24.75%) “Student Advisory” department and 35 (17.33%) from “Primary School Teaching” department and 17 (8.42%) from “Social Sciences Teaching”.
Data Collection Tools
Self Stigma of Seeking Help Scale (SSOSH): Vogel and associates (8) predicted a single dimension and created an item pool and after examining this pool they reduced number of items to 28. Researchers took expert opinion on these 28 items and excluded 3 of them. Reliability and validity of these 25 items were studied and of these 25 adequately working (factor load values >0.30, item total correlations >0.50) items, 10 best items yielding highest factor loadings and item-total correlations were accepted as the final scale. Vogel and associates (8) conducted 5 studies in 5 different groups to investigate the validity and reliability of this 10 item scale.
In Study 1, researchers investigated factor structure and internal reliability. In Study 2, confirmatory factor analysis were conducted to confirm the factor structure as well as construct and criterion validity. In Study 3, test-retest reliability was evaluated along with replication of construcy and criterion validities. In Study 4, cross-validation was assessed in a new sample. Lastly, in Study 5, predictive validity of SSOHS in discriminating individuals who sought psychological services from those who did not across a 2-month period. After the validity and reliability studies, single-factored final scale was stated.
Psychological Help-Seeking Attitudes Scale (PHSAS): Psychological Help-Seeking Attitudes Scale, developed by Türküm (24) was used for construct validity. Scale includes 18 items. 12 items are positive and 6 items are negative statements. A single total score is achieved after the reverse scored items are transformed. Scale is Likert type ranging from 1 to 5. Higher scores reflect positive psychological help seeking attitudes. Cronbach alpha coefficient is 0.90 and test-retest reliability coefficient is 0.77.
In the context of this study, we adapted not the 10-item final scale of Vogel and colleagues (8) but the 25 item long form which was reliable and valid in its original culture, to evaluate how these 25 items work in Turkish culture. Although the original final scale contains 10 items, researchers developed a reliable and valid 25-item test which had high factor loadings. The first 10 items were selected only in terms of briefing the scale. When the recent discussions on scale development process and inter-cultural studies were taken into account, such as that the selected items in fact have interaction with the non-selected items and that these items are selected due to this interaction (25); that adaption studies including trial items had higher internal consistency when compared with studies which do not include trial items (26). We decided to evaluate the 25 items, which were found to be valid and reliable, in the present study in order to find the Turkish counterparts of these items. Adaptation of the scale to Turkish culture is done in accordance with the steps defined by International Test Commision (ITC). Study started after approval. The scale was translated into Turkish by the researchers in addition to three experts with experience on the field and the foreign language. Five translations were merged into one single form by the researchers. Backtranslation was done by two English language experts. Backtranslation was compared with the original scale by the researchers and the statements were revised. Expert opinion was obtained from four experts in guidance and psychological counseling field. Two experts on Turkish language was consulted for understandibility of the expressions, appropriateness to the target group, expression problems, etc. Two experts on measuring and evaluation were also consulted. A pre-administration on 40 students presumably representing the target group was conducted and the students were asked to give feedback on the problematic items. Expressions were revised according to these feedbacks. After these examinations and revisions, 25-item scale became ready for administration. 1-2-4-5-7-8-11-12-14-16-17-19-20-21-22-23-24-25 numbered items were inversely coded before the analysis.
Exploratory and confirmatory factor analysis were done to detect and confirm the construct of the scale. In order to find the construct of the adapted items, exploratory factor analysis was conducted first. Confirmatory factor analysis was done to verify the factor analysis found in the explorative factor analysis. Confirmatory factor analysis tests whether the implied construct is confirmed by the data set (25), and the validity of the model depends on presentation of the goodness-of-fit statistics and evidence of construct validity together (26,27). Chi-square test was used to test the fitness of the model. Besides indexes such as, Root Mean Square Error of Approximation (RMSEA), Goodness of Fit Index (GFI), Comparative Fitness Index (CFI), Normed Fitness Index (NFI), Adjusted Goodness of Fit Index (AGFI), Incremental Fit Index (IFI) were utilized (26-28).
In the context of reliability studies, test-retest reliability was analyzed by re-administration of the scale in three weeks to a group of 40 participants and computing Pearson product moment correlation coefficient. Besides, Cronbach alpha was computed to measure internal consistency of the scale.
In order to measure criterion validity, 25 item Self Stigma of Seeking Help Scale (SSOSH) (8) and 21 item Psychological Help-Seeking Attitudes Scale (PHSAS) (24) were administered at the same time and correlation between the total scale scores was computed.
Exploratory Factor Analysis
Exploratory factor analysis, followed by confirmatory factor analysis was done to determine construct validity of SSOHS. Keiser-Meyer-Olkin (KMO) test was used to test whether the sample size was adequate for exploratory factor analysis and KMO of the data set was 0.91. Barlett Sphericity Test was significant (=3056.85 p<0.01), indicating the normality of the data set. Two factors were determined in the exploratory factor analysis by investigating the variance explained by the components, the eigenvalues, (eigenvalue1=7.950; eigenvalue2=3.286; eigenvalue3 =1.255; eigenvalue4=1.247; eigenvalue5=1.098) and scree-plot graphics (Figure 1). Varimax rotation was used in the analysis.
Two items which yielded low factor loadings (<0.30) were excluded from the scale and the analysis were repeated. After 4th and 16th items were excluded, factor analysis with the remaining 23 items revealed that factor 1 explained 34.47% and factor 2 explained 12.43% of the variance. Two factors together explained 46.90% of the total variance. Since the original scale has a single dimension, the reason for two factor solution in Turkish culture was investigated by naming the two factors. One of the factors focused mainly on “perception of seeking psychological help as threat to ego” and the other factor focused on “perception of seeking psychological help as a support to ego”. The finding that the scale has two dimensions in Turkish culture was shared with the authors of the original scale and their opinion was taken. Factor loadings are summarized in Table 1 (Table 1).
When Table 1 is examined, it is evident that 16 items form a factor and factor loadings were between 0.533 and 0.771. Seven items were loaded to a second factor with loadings between 0.569 and 0.748. When it was taken into account that the minimum factor loading must be 0.30, it was evident that all items had acceptable and high factor loadings (25).
Cronbach alpha coefficient was 0.90 for the 23 item scale. This showed that internal consistency of the scale was high. Since the scale has two sub dimensions, internal consistency of these subdimensions were also examined. Item-total correalations are summarized in Table 2 (Table 2). Cronbach alpha coefficient of factor one consisting of 16 items was 0.92. When Table 2 is examined, it can be seen that item-total correlations of the first factor changed between 0.461 and 0.754. Cronbach alpha coefficient of factor two consisting of 7 items was 0.79. When Table 2 is examined, it can be seen that item-total correlations of the first factor changed between 0.445 and 0.613. Item-total correlations were also interpreted as a measure of discriminativeness. Since a discriminative item must have at least 040 discriminativeness coefficient, it was evident that all items in the scale were discriminative (29). For test-retest reliability the scale was re-administered in three weeks to a group of 40 participants and consistency coefficient was found to be 0.82.
Confirmatory Factor Analysis
Confirmatory factor analysis was utilized to confirm the two factor structure of 23 item SSOHS. Diagram of the model is provided in Figure 2 when the independent and latent variables were taken into account (Figure 2).
Chi-square was 645 (p<0.01), and the ratio of chi-square value to degree of freedom was 2.87 in the confirmatory factor analysis. Literature in the field suggest that chi-square value is not adequate to display a good model by itself. Therefore, goodness of fit indexes were also examined.
Root Mean Square Error of Approximation (RMSEA) was 0.08. Non-normed Fitness Index (NNFI), Comparative Fitness Index (CFI), and Incremental Fit Index (IFI) were 0.96. Normed Fitness Index (NFI) was 0.94 and Goodness of Fit Index (GFI) was 0.84. Adjusted Goodness of Fit Index (AGFI) was 0.81. When these values of model fit were investigated, it was evident that they are in the acceptable range (30,31).
In order to measure criterion validity, 25 item Self Stigma of Seeking Help Scale (SSOSH) and 21 item Psychological Help-Seeking Attitudes Scale (PHSAS) were administered at the same time to a sample of 202 students and correlation between the total scale scores was found to be 0.71.
It becomes harder everyday to adjust to modern life which becomes more complex ever. This shows the importance of fulfilling the need for psychological support services. However, as discussed, social and individual concerns holdback people to use these services even when they need them. Studies support the notion that stigmatization may prevent individuals’ seeking psychological help and their full participation in these services. Particularly social rejection and decreased self-esteem threats, which come with stigma, lead to less than necessary use of the services. Measurement tools were necessary in Turkey in order to conduct more substantial studies on the subject.
With this study, SSOHS, which was developed by Vogel and colleagues (8) and which measures self stigmatization of seeking psychological help is translated into Turkish. By translating SSOHS into Turkish, obtaining quantitative data on the association of stigmatization with different variables and supporting the theoretical background of the subject and in this way conducting studies on prevention of self stigmatization will be easier.
Having a better understanding of the process of making a decision to seek psychological help or not will help to make better interpretation of burdens on psychological help services and to find better solutions. This study contributes to the field on issues such as drawing attention to self stigmatization in psychological help seeking process, helping researchers in the psychological counseling field to study the topic in more detail and taking steps on preventive measures.
Limitations of the study included the sample consisting of college students, including a group with high empathy and certain qualities which have a more limited range of reactions when compared with Turkish population, to protect the original structure of the scale in Turkish culture. Replicating the results and elaborating the present study with broader and different samples in Turkey will contribute and support the current findings. We hope that this study will enlighten future standardization studies on stigmatization, an important issue in psychological counseling and psychotherapeutic services for both service providers and service users, which has been started to be evaluated recently in Turkey.
In this study, exploratory and confirmatory factor analysis were done in order to evaluate construct validity of SSOHS and it was seen that there were two factors of the scale in Turkish culture. The decision of the authors of the original scale to include only 10 items with the highest factor loads out of 25 possible items only for the sake of shortening the scale can be discussed from a psychometric point of view. We tried to present validity and reliability results for the 25 items, however, since 2 items did not work at all, these items were excluded for keeping these items would endanger the reliability and validity of the wholse scale. In light of the current study, reliabilitiy and validity of both 25 item long form and 10 item short form of the scales can be investigated again in larger samples. Cronbach alpha coefficient for the complete 23 item scale was 0.90, indicating a high internal consistency. Since there were two subdimensions of the scale, internal consistency for each subscale was also computed. Cronbach alpha coefficient of the first factor including 16 items were 0.92, and Cronbach alpha coefficient of the second factor including 7 items were 0.79. For test-retest reliability the scale was re-administered in three weeks to a group of 40 participants and consistency coefficient was found to be 0.82. In order to measure criterion validity, PHSAS developed by Türküm (24) was used. Criterion validity coefficient was found to be 0.71. In conclusion, results of the present study indicated that Turkish form of SSOHS is a valid and reliable tool to measure self-stigmatizaion of individuals.
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