Children and Youth Services Review 44 (2014) 356–362

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Children and Youth Services Review

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Associations among the number of mental health problems, stigma, andseeking help from psychological services: A path analysis model amongChinese adolescents

Haide Chen a, Xiaoyi Fang a,b,⁎, Chaoying Liu a, Wei Hu a, Jing Lan a, Linyuan Deng a

a Institute of Developmental Psychology, Beijing Normal University, Beijing, Chinab Academy of Psychology and Behavior, Tianjin Normal University, Tianjin, China

⁎ Corresponding author at: Institute of DevelopmentUniversity, 19 Xinjiekouwai Street, Beijing, China. Tel./fax

E-mail address: fangxy@bnu.edu.cn (X. Fang).

http://dx.doi.org/10.1016/j.childyouth.2014.07.0030190-7409/© 2014 Elsevier Ltd. All rights reserved.

a b s t r a c t

a r t i c l e i n f o

Article history:Received 13 March 2014Received in revised form 2 July 2014Accepted 3 July 2014Available online 10 July 2014

Keywords:Mental health problemsSelf-stigmaPublic stigmaAttitudes toward help-seekingWillingness to seek helpAdolescents

Adolescents with mental health problems are likely to refuse to seek help from psychological services. The aimsof the present study were (1) to examine whether a greater number of mental health problems were associatedwith a lower level ofwillingness to seek help from psychological services among adolescents; and (2) to examinewhether the relationship between the number of problems and the willingness to seek help was mediated byself-stigma, public stigma, and attitudes toward help-seeking. A sample of 251 middle and high school studentswho have had at least one mental health problemwas used for the analyses involved in this study. The bivariatecorrelation analyses showed that adolescents withmoremental health problemswere likely to report more neg-ative attitudes toward help-seeking and to demonstrate less willingness to seek help. Path analyses showed thatthe number of problems did not directly influence the willingness to seek help; however, the relationship be-tween these two variableswasmediated by self-stigma and attitudes towardhelp-seeking. Furthermore,willing-ness to seek help was not directly influenced by the number of internalizing and externalizing problems.However, the relationship between the number of internalizing problems and willingness to seek help was me-diated by public stigma, self-stigma and attitudes toward help-seeking; additionally, the relationship betweenthe number of externalizing problems and willingness to seek help was mediated by self-stigma and attitudestoward help-seeking, except for public stigma. These findings emphasize the importance of stigma, particularlyself-stigma, for adolescents in seeking help from psychological services.

al Psychology, Beijing Normal: +86 010 58808232.

© 2014 Elsevier Ltd. All rights reserved.

1. Introduction

There is a growing public concern for the welfare of children (Lindsey, 1994). Litera-ture on child welfare has focused more on mental health issues over the past decade(Leathers, McMeel, Prabhughate, & Atkins, 2009). Adolescents experience the lateststage of childhood and are particularly vulnerable to mental health problems (Raviv,Raviv, Vago-Gefen, & Fink, 2009). Numerous epidemiological studies have foundthat the percentage of adolescents with mental health disorders ranges from 10 to 20%(e.g., Costello, Egger, & Angold, 2005). Psychological services (e.g., counseling) providedfor children in the child welfare system can aid in addressing mental health problems;however, most adolescents who need care prefer not to seek help from psychological ser-vices (e.g., Raviv et al., 2009). For example, only 20% of adolescents with mental healthproblems has received professional services in Australia (Sawyer, Miller-Lewis, & Clark,2007). Slone, Meir, and Tarrasch (2013) found that adolescents showed a greater ease ofreferral for help from friends or family than from professionals. The phenomenon of refus-ing to accept or access available professional help is commonly referred to as “help nega-tion” (Carlton & Deane, 2000) or the “service gap” (Raviv et al., 2009).

A large number of studies have identifiedmany barriers that are associated with helpnegation and have indicated that the stigma that is associated with psychological servicesmay decrease the likelihood of help-seeking (e.g., Chandra & Minkovitz, 2007; Gerlingeret al., 2013; Livingston & Boyd, 2010). Regarding the relationship between actual help-

seeking behavior and intentions to seek help, several theoretical frameworks (e.g., theTheory of Reasoned Action, the Theory of Planned Behavior, and the Integrated BehavioralModel) have proposed that the best predictor of a behavior is behavioral intention, whichis determinedby attitudes toward the behavior (Montano&Kasprzyk, 2008). Studies haveconsistently found that attitudes toward seeking professional help are significant predic-tors of willingness to seek help (e.g., Carlton & Deane, 2000; Vogel, Wade, & Hackler,2007). To extend our understanding of stigma as amechanism for help negation, the pres-ent study attempted to investigate the associations betweenmental health problems, stig-ma, attitudes toward help-seeking and willingness to seek help from psychologicalservices.

1.1. Mental health problems and seeking help from psychological services

The mental health problems of children are defined in terms of many different syn-dromes or categorization frameworks. Achenbach (1991) proposed nine common syn-dromes among children: anxious/depressed, withdrawn, somatic complaints, socialproblems, thought problems, attention problems, delinquent behavior, and aggressive be-havior. When these syndromes are submitted to a second-order factor analysis, twobroad-band problems emerge: “internalizing” and “externalizing” (Achenbach, 1991;Leung et al., 2006). The internalizing problems are directed toward the individual and rep-resent an inner-directedpattern of behaviors (Achenbach, 1991; Compton, Burns, Egger, &Robertson, 2002); these problems include the following syndromes: anxious/depressed,withdrawn, and somatic complaints. The externalizing problems are directed towardothers and include the following syndromes: delinquent, aggressive, and antisocial

357H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

behaviors. Compared to externalizing problems, internalizing problems are covert andoften go unnoticed (Achenbach, 1991; Kauffman & Landrum, 2001).

Numerous studies have indicated that, among adolescents, willingness to seek help de-creases as the severity of mental health problems increases (e.g., Carlton & Deane, 2000;Wilson, Rickwood, & Deane, 2007). For example, in the case of depressive symptoms, ado-lescents with higher levels of depression are more likely to report minimal intentions toseekhelp (Wilson et al., 2007). Regarding suicidal ideations, about two-thirds of adolescentsthat experience suicidal thoughts fails to seek help (Husky, McGuire, Flynn, Chrostowski, &Olfson, 2009). As suicidal ideations increase, help-seeking intentions decrease (Carlton &Deane, 2000). Additionally, higher levels of substance use (e.g., alcohol and cigarettes) areassociated with less willingness to use prevention services (D'Amico, 2005).

1.2. Mental health problems and stigma

Corrigan (2004) classified stigma into two types: public stigma and self-stigma. Publicstigma refers to the perception of the public that the stigmatized group is socially unac-ceptable while self-stigma refers to the perception of an individual who has internalizedpublic stigma and believes that he or she is socially unacceptable (Corrigan, 2004; Vogelet al., 2007). People are threatened by the stigma of being labeled as havingmental healthproblems in several ways which include stereotypes, prejudice, and discrimination(Corrigan, 2004).

Previous studies have consistently found that the public holds negative attitudes to-ward individuals who have been identified as having a mental illness and often describesthese individuals in negative terms (e.g., Angermeyer &Dietrich, 2006). On one hand, stig-ma is associated with a higher level of psychiatric symptom severity. Livingston and Boyd(2010) conducted ameta-analysis and found that the correlation between self-stigma andsymptom severity wasmoderate (r= .41, p b .001). On the other hand, stigma has a neg-ative influence on the psychosocial variables of people who live with mental illness. Theresults from recent meta-analyses have shown that higher self-stigma was associatedwith lower levels of hope, self-esteem, empowerment, social functioning, and quality oflife (Gerlinger et al., 2013; Livingston & Boyd, 2010).

1.3. Stigma and seeking help from psychological services

Stigma surrounding seeking and obtaining help may one of the greatest barriers thatprevent adolescents from utilizing psychological services (Chandra & Minkovitz, 2007;Cheng, 2009; Vogel et al., 2007). Regarding the effects of public stigma and self-stigmaon help-seeking, a systematic review and meta-analysis found that self-stigma was nega-tively associated with treatment adherence (Livingston & Boyd, 2010). Vogel, Wade, andHaake (2006) estimated the roles of public stigma and self-stigma in predicting attitudestoward seeking psychological help and willingness to seek psychological help and foundthat higher levels of both public stigma and self-stigma were associated with less positiveattitudes and lower intentions to seek help. However, when self-stigmawas entered into aregression model, the role of public stigma in predicting attitudes andwillingness was re-duced and became non-significant (Vogel et al., 2006). Vogel et al. (2007) further exam-ined the association between public stigma, self-stigma, attitudes toward help-seeking,and willingness to seek help and found that public stigma influenced self-stigma, whichconsequently contributed to attitudes toward seeking help and, subsequently, their will-ingness to seek help.

One of the possible reasons for these results may be that self-esteem is threatenedwhen potential help-seekers internalize the stigma of mental illness (Slone et al., 2013).Nadler and Fisher (1986) found that people who seek help from professionals considerthemselves to be inferior and incompetent; that is, they refuse to seek help to maintaina positive image of themselves (i.e.,maintain their self-esteem). According to theModifiedLabeling Theory (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989), the perception ofsocietal devaluation and discrimination toward people with mental health problems re-sults in the internalization of negative information and a fear of being labeled as havinga mental illness, which consequently threatens the self-esteem of potential help-seekers.Adolescents may be reluctant to seek help if they consider help-seeking to be an acknowl-edgment of failure or a sign of weakness (Nadler & Fisher, 1986; Slone et al., 2013).

1.4. The present study

To extend our understanding of the underlying mechanisms regarding willingness toseek help from psychological services among adolescents, the present study focused on acomprehensivemodel involving the associations betweenmental health problems, publicstigma, self-stigma, attitudes toward seeking help, and willingness to seek help from psy-chological services.

The present study was conducted within a Chinese patient population. In mainlandChina, counseling and psychotherapy services are not universally known and acceptedby the public, and there are limited numbers ofmental health service institutions and pro-viders (Huang, Zheng, Bi, & Chen, 2007). Additionally, traditional Chinese culture con-siders mental illness to be the product of karma, i.e., mental health problems arethought to result frompre-life activities and are associatedwith immortality,which causesChinesepeoplewithmental illness to refuse psychological help to avoid discrimination (Li,Gao, & Xu, 2008). Given these traditional beliefs, we investigated the suitability of previoustheoretical frameworks for Chinese culture.

As for adolescents with mental health problems, the majority of the previous studieshave examined adolescents with a specific type of problem, such as depression (Wilsonet al., 2007) or emotional difficulties (Slone et al., 2013). However, the co-occurrence of

multiple problems is common in adolescence and is frequently overlooked, i.e., some ad-olescents may have multiple problems (Mun, Windle, & Schainker, 2008). In the presentstudy, the mental health problem variable in our analysis was estimated by the numberof mental health problems and the number of internalizing and externalizing problems.Based on the theoretical frameworks of the Health Belief Model (HBM; Rosenstock,Strecher, & Becker, 1988) and the Youth Help Seeing and Service Utilization Model(YHSSUM; Srebnik, Cauce, & Baydar, 1996), which suppose that the perception of the se-verity of a problem is generally the first stage of help-seeking, we first aimed to examinewhether the number of mental health problems would significantly predict the level ofwillingness to seek help from psychological services. Based on the finding that the rela-tionship between public stigma and willingness to seek help is mediated by self-stigmaand attitudes toward psychological services (Vogel et al., 2007), the present study furtherinvestigated the mediating roles of public stigma, self-stigma, and attitudes toward seek-ing psychological help on the relationship between the number ofmental health problemsand willingness to seek help.

The present study proposed two main hypotheses and one exploratory question.Given the evidence that willingness to seek help decreases (e.g., Carlton & Deane, 2000;Wilson et al., 2007) and self-stigma increases (Livingston & Boyd, 2010) as the severityof mental health problems increases among adolescents, our first hypothesis predictedthat adolescents with more mental health problems would report greater stigma, morenegative attitudes towardhelp-seeking and lesswillingness to seekhelp. Based on the the-oretical frameworks regarding the relationship between attitude and willingness (i.e., theTheory of Reasoned Action, the Theory of Planned Behavior, and the Integrated BehavioralModel) and the relationship between stigma and attitude (i.e., theModified Labeling The-ory), our second hypothesis stated that the relationship between the number of mentalhealth problems and willingness to seek help would bemediated by stigma and attitudestoward help-seeking. Our exploratory question examined the different relationshipsamong variables between internalizing and externalizing problems.

2. Methods

2.1. Participants

Data for the present study were collected using a convenience sam-pling method from two middle schools and two high schools in Beijing,China. A total of 920 students validly completed questionnaires. Accord-ing the criteria of the CBCL (Kroes et al., 2002), the clinical and border-line cutoff values for the problem subscales are the 98th and 95–98thpercentiles, respectively. We chose the 95th percentile; participantswith subscale scores exceeding this percentile were considered tohave mental health problems. Consequently, 251 participants who hadat least one identified mental health problem were selected for furtheranalyses. Among them, 122 participants were middle school students(43 male, 76 female, and three with missing data) and 129 were highschool students (58 male, 69 female, and two with missing data). Theage range of participants was 11 to 17 years with a mean age of14.22 years (SD= 1.46).

2.2. Instruments

2.2.1. Mental health problemsThe mental health problems of our participants were measured

using the Chinese version of the Youth Self-Report (YSR), whichwas re-vised from Achenbach's CBCL by Leung et al. (2006). The YSR contains106 items and evaluates nine syndromes: Anxious/Depressed, With-drawn, Somatic complaints, Social problems, Thought problems, Atten-tion problems, Delinquent behavior, Aggressive behavior, and Otherproblems. Internalizing problems include: Anxious/Depressed, With-drawn, Somatic complaints. Externalizingproblems include:Delinquentbehavior, Aggressive behavior. The students were asked to rate eachitem on a scale from 0 (not true) to 2 (very true or often true) basedon how well that item described them over the preceding six months.Higher scores indicated greatermental health risks. The Chinese versionhas been reported to have an internal consistency of .95 for total prob-lems and a test–retest reliability of .86 for total problems (Leung et al.,2006). The internal consistency of the scalewas .95 in the present study.

2.2.2. Self-stigma associated with psychological help-seekingSelf-stigma associatedwith seeking psychological helpwasmeasured

using the Self-Stigma of Help Seeking Scale (SSOHSS; Vogel et al., 2006),which is a 10-item self-report scale. Participants rated each question from

Table 1The numbers and percentages of adolescents with mental health problems.

Single mental health problem

A/D W SC S T A D AG O

n 68 68 69 60 66 79 57 64 76% 27.1 27.1 27.5 23.9 26.3 31.5 22.7 25.5 30.3

Multiple mental health problems

1 2 3 4 5 6 7 8 9

n 113 55 36 13 12 5 5 9 3% 45.0 21.9 14.3 5.2 4.9 2.0 2.0 3.6 1.2

Multiple internalizing problems Multiple externalizing problems

0 1 2 3 0 1 2

n 107 99 29 16 161 59 31% 42.6 39.4 11.6 6.4 64.1 23.5 12.4

Note: A/D = anxious/depressed, W = withdrawn, SC = somatic complaints, S = socialproblems, T = thought problems, A = attention problems, D = delinquent behavior,AG = aggressive behavior, O = other problems.

358 H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

1 (strongly disagree) to 5 (strongly agree) on a Likert-type scale. Higherscores represented greater self-stigma. The estimated two weeks oftest–retest reliability of this scale was .72, and the internal consistencyhas been reported to range from .86 to .90 in different samples (Vogelet al., 2006). In the current sample, the internal consistency was .75.

2.2.3. Public stigma toward psychological help-seekingPublic stigma toward psychological help-seeking was measured

using the Perceived Devaluation-Discrimination Scale (PDDS; Linket al., 1989), which contains 12 questions. Participants were asked torate, on a Likert-type scale ranging from 1 (strongly disagree) to 6(strongly agree), how most people view current or former psychiatricpatients. Higher scores reflect greater perceived public stigma. The in-ternal consistency of this scale has been reported to range from .76 to.88 in clinical and community samples (Link et al., 1989). In the presentstudy, the internal consistency of the scale was .87.

2.2.4. Attitudes toward seeking professional psychological helpAttitudes toward seeking help were measured using the Attitudes

Toward Seeking Professional Psychological Help Scale (ATSPPHS;Fischer & Turner, 1970; Hao & Liang, 2007), which contains 29 itemsand has four dimensions: recognition of the need for psychologicalhelp, stigma tolerance, interpersonal openness, and confidence in men-tal health professionals. Participants were asked to rate each questionon a Likert-type scale ranging from 1 (disagree) to 4 (agree). Higherscores indicate positive attitudes toward seeking professional help.Hao and Liang (2007) produced a Chinese version of the ATSPPH thatshows good structure validity. The internal consistency of this scalehas been estimated to be .81 (Hao & Liang, 2007). In the current sample,the internal consistency was .79.

2.2.5. Willingness to seek psychological helpThe Willingness To Psychological Help-Seeking Scale for Middle

School Students (WTPHSS), which was developed by Xu (2008) inChina, was used tomeasure willingness to seek professional psycholog-ical help. The WTPHSS contains 21 items and asks respondents to ratehow likely they are to seek psychological help on a scale ranging from1 (strongly disagree) to 5 (strongly agree). Higher scores indicate great-er willingness to seeking professional help. The WTPHSS includes thefollowing four dimensions: willingness, evaluation, expectation of ef-fects, and mental health knowledge. The internal consistency of thisscale has been estimated to be .87 (Xu, 2008). In our sample, the internalconsistency was .86.

2.3. Procedure

First, the SSOHSS and PDDS were translated into Mandarin Chineseby an expert panel that included psychologists and professional transla-tors. Then, the study was approved by the Beijing Normal UniversityEthics Committee. Subsequently, permission to conduct the surveywas obtained from administrators of the schools in the sample. Theethics committee authorization emphasized that participation wouldbe anonymous for all data collected, risks or immediate benefitswould not be anticipated, and participants' information would be keptstrictly confidential. Finally, students within the schools in the samplewere informed that participation was voluntary. After providing con-sent, participants were asked to complete the survey anonymously intheir class.

3. Results

3.1. Percentages of different numbers of mental health problems

As shown in Table 1, among the present sample, the percentage ofparticipants with a given type of problem ranged from 22.7% to 31.5%.Regarding the number of problems, 45.0% of participants had only one

type of problem and 55.0% hadmore than one type of problem. Regard-ing the two types of problems, 57.4% of participants had at least one in-ternalizing problem and 35.9% had at least one externalizing problem.

3.2. Analyses of the differences in the examined variables

MANOVAswere conducted to test thedifferences betweenpublic stig-ma, self-stigma, attitudes toward help-seeking, and willingness to seekhelp among participants with different numbers of mental health prob-lems. The total number of participants with four, five, six, seven, eight,and nine problems was 13, 12, 5, 5, 9, and 3, respectively. Because thenumber of participants in each cell was less than 30, these values werecombined into the “four to nine” subgroups. As shown in Table 2, partic-ipants with different numbers of mental health problems showed differ-ences in self-stigma (F(3, 287) = 4.09, p = .007, partial η2 = .047,observed power = .84), attitudes toward help-seeking (F(3, 287) =5.93, p= .001, partial η2= .067, observed power= .95), andwillingnessto seek help (F(3, 287) = 5.21, p = .002, partial η2 = .060, observedpower= .92). However, the effect of different numbers of mental healthproblems on public stigma was not significant (F(3, 287) = 1.93, p =.126, partial η2 = .023, observed power = .50). Post-hoc tests (LSD) re-vealed that: (1) the subgroup of participants with four to nine problemsreported greater self-stigma than participants with one, two, or threeproblems; (2) the subgroup of participantswith four to nine problems re-ported more negative attitudes than participants with one or twoproblems; and (3) the subgroups of participants with three or four tonine problems reported less willingness to seek help than participantswith one or two problems.

To test the differences in the examined variables between two typesof problems, the sample was divided into 4 subgroups: (1) 67participants who had neither internalizing nor externalizing problems(i.e., they had other syndromes on the CBCL), (2) 94 participants whohad only internalizing problems, (3) 40 participants who had only ex-ternalizing problems, and (4) 50 participants who had both internaliz-ing and externalizing problems. MANOVAs were conducted and foundthat there were non-significant differences in the examined variablesamong the four subgroups (see Table 2). Pairwise comparisons for theparticipants who had only internalizing problems and the participantswho had only externalizing problems also showed non-significant dif-ferences in the examined variables between the two subgroups (psN .05).

3.3. Bivariate correlations among the study variables

Spearman's correlation analyses were conducted to test bivariatecorrelations among variables. As shown in Table 3, the number of

Table 2Differences in variables according to the number of mental health problems and problem type.

Problem number Problem type

1 2 3 4–9 F LSD Neither IP EP IP&EP F

n 113 55 36 47 67 94 40 50

Public stigma M 3.31 3.43 3.48 3.71 1.93 – 3.29 3.50 3.37 3.57 1.03SD .96 .95 1.02 .92 1.00 .92 .88 1.05

Self-stigma M 2.55 2.64 2.64 2.91 4.09⁎⁎ 1, 2, 3 b 4–9 2.54 2.61 2.74 2.81 2.46SD .52 .67 .55 .66 .56 .55 .61 .68

Attitude M 2.59 2.53 2.46 2.34 5.93⁎⁎⁎ 1, 2 N 4–9 2.57 2.53 2.50 2.40 2.48SD .34 .32 .31 .38 .33 .35 .32 .38

Willingness M 4.07 4.07 3.74 3.74 5.21⁎⁎⁎ 1, 2 N 3, 4–9 4.00 4.02 3.94 3.84 .99SD .65 .53 .60 .65 .64 .63 .67 .60

Note: Problem number = number of mental health problems. Attitude = attitudes toward seeking help from psychological services. Willingness = willingness to seek help from psy-chological services. Neither = participants had neither internalizing nor externalizing problems. IP = participants had only internalizing problems. EP = participants had only external-izing problems. IP&EP = participants had both internalizing and externalizing problems.⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

359H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

mental health problemswas significantly and positively associatedwithpublic stigma and self-stigma andwas significantly and negatively asso-ciated with attitudes toward help-seeking and willingness to seek help.Both public stigma and self-stigmawere significantly and negatively as-sociated with attitudes toward help-seeking and willingness to seekhelp.

3.4. Path analyses

Structural equation modeling, which is one of the most appropriatemethods for examining the relationships among variables, suggests thatthe ratio of sample size to free model parameters should be at least fiveobservations to one free parameter for the minimum threshold level(e.g., Marcoulides & Saunders, 2006). Given that the sample size of thepresent study (n = 251) was insufficient, path analyses using AMOS17.0 software were conducted to examine the pattern of correlationsamong variables. To develop a more parsimonious model, we testedour hypothesized model in two stages. In the first stage, the presentstudyproposed a saturatedmodel of variables based onprevious theoret-ical frameworks and bivariate correlations among variables. The resultsshowed that the direct paths from thenumber ofmental health problemstowillingness to seek help (− .04) and public stigma (.11), and from self-stigma towillingness to seek help (− .10), failed to achieve statistical sig-nificance at p b .05. In the second stage, only the statistically significantdirect paths were included. The final path model with standardizedpath coefficients is presented in Fig. 1 (defined as “Path Model A”). Sev-eral indices were considered to determine the fit of the model testedand showed: χ2 = 6.74, df = 3, RMSEA = .071, NFI = .97, CFI = .98,and IFI = .98. The final model explained 36.8% of the variance in willing-ness to seek help and 21.4% of the variance in attitudes toward help-

Table 3Bivariate correlations among study variables.

M ± SD 4 5 6 7

1 Problem number 2.42 ± 1.94 .16⁎ .22⁎⁎⁎ − .25⁎⁎⁎ − .17⁎⁎

2 Internalizing problemnumber

.82 ± .88 .14⁎ .11 − .12 − .01

3 Externalizing problemnumber

.48 ± .71 .05 .19⁎⁎ − .17⁎⁎ − .12

4 Public stigma 3.44 ± .97 – – – –

5 Self-stigma 2.65 ± .60 .26⁎⁎⁎ – – –

6 Attitude 2.51 ± .35 − .28⁎⁎⁎ − .42⁎⁎⁎ – –

7 Willingness 3.96 ± .63 − .28⁎⁎⁎ − .36⁎⁎⁎ .58⁎⁎⁎ –

⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

seeking. Thus, we concluded that the overall model tested offered agood model-to-data fit.

Path Model A indicated that the direct influence of the number ofproblems on willingness to seek help was not significant; however,the relationship between them was mediated by self-stigma and atti-tudes toward help-seeking. The direct influence of public stigma onwillingness to seek help was significant; furthermore, the relationshipbetween them was mediated by self-stigma and attitudes towardhelp-seeking.

Additionally, a path analysis was conducted to examine the ef-fects of the number of internalizing and externalizing problems onstigma and help-seeking. The final path model is shown in Fig. 2 (de-fined as “Path Model B”) and the fit indices showed: χ2 = 7.94, df=7, RMSEA= .023, NFI = .97, CFI = .99, and IFI = .99. The final modelexplained 37.2% of the variance in willingness to seek help and 20.6%of the variance in attitudes toward help-seeking. Thus, the finalmodel was accepted as having a good fit to the data.

PathModel B indicated that the direct influence of the number of in-ternalizing problems on willingness to seek help was not significant;however, the relationship between them was mediated by public stig-ma, self-stigma and attitudes toward help-seeking. The direct influenceof the number of externalizing problems on willingness to seek helpwas also not significant; however, relationship between them was me-diated by self-stigma and attitudes toward help-seeking.

To test the statistical significance of the hypothesized indirect effect,the present study used a bootstrapping procedure, which created 5000bootstrap samples from the original data set (N=251) by random sam-plingwith replacement. The indirect effect is considered statistically sig-nificant at the .05 level if the 95% confidence interval (CI) for theseestimates does not include zero (Shrout & Bolger, 2002). The resultsfrom the 5000 bootstrap samples showed that the 95% CI for these indi-rect effects in our study did not include zero, indicating that they werestatistically significant (see Table 4).

4. Discussion

The present study found that 55% of participants had more than oneproblem. In addition, the percentage of participants with internalizingand externalizing problemswas 57.4% and 35.9%, respectively. Previousstudies have suggested that individuals with mental health problemmay have multiple problems. Mun et al. (2008) explored the types ofmental health problems in adolescents and indicated that the co-occurrence of multiple problem behaviors is common. There are severalpossible explanations for this observation. First, there are strong corre-lations between syndromes. For example, the withdrawn syndrome isstrongly related to the anxious/depressed syndrome (Liu, Cheng, &

Problem number

Self-stigma

Attitude

Publicstigma

.31***

-.35***

.55***-.13*

-.15*

-.15*

.20***

Willingness

Fig. 1. Path Model A.

360 H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

Leung, 2011). Thus, the presentation of one problemmight be followedby the presentation of other problems. Second, people with problemsmight be predisposed to mental health problems because of low levelsof self-resilience, negative coping strategies, high levels of trait-depression and trait-anxiety, or maladaptive patterns of behavioraland emotional self-regulation. Third, the occurrence of multiple prob-lems can be predicted by a comprehensive set of risk factors that en-compasses issues related to community (e.g., low neighborhoodattachment), school (e.g., low commitment to school), family (e.g., fam-ily conflict), and peers (e.g., interaction with antisocial peers; Bond,Toumbourou, Thomas, Catalano, & Patton, 2005).

As expected, our results indicated that increasing numbers ofmentalhealth problems were associated with less positive attitudes towardhelp-seeking and less willingness to seek help. The following reasonsmay explain why adolescents with more problems do not like to seekhelp. First, the intent to seek helpmay depend on the disparity betweenthe cost and the benefit of seeking help. According to the HBM(Rosenstock et al., 1988),when people perceive that the benefit of seek-ing help is much more than its cost, they will decide to seek it; other-wise, they will not seek help. For adolescents with a large number ofproblems or a high severity of mental health problems, the cost of re-covery may be high; these adolescents may have to spend more timeand money for professional services (Wilson, Deane, Biro, & Ciarrochi,2003). Meanwhile, the benefit of seeking helpmight be limited becauseof a lower possibility of recovery from more severe problems. Previousstudies have found that a lower expectation of therapy outcomes wasassociated with negative attitudes toward help-seeking (Vogel,Wester, Wei, & Boysen, 2005). Second, according to the frameworks ofthe Behavioral Model of Health Care (BMHC; Andersen, 1995) and theYHSSUM (Srebnik et al., 1996), a number of factors might inhibit help-seeking. For adolescents with multiple problems, inhibiting factorsmight include negative attitudes of school personnel (e.g., indifference,negativity, and judgmental attitudes) and feelings of alienation (i.e., be-liefs that adults cannot understand adolescents' problems; Stanhope,Menna, &Newby-Clark, 2003). Third, the risk factors that causemultiplemental health problems may inhibit help-seeking; examples of suchrisk factors include low socioeconomic status, child abuse and neglect,and weak school connectedness.

.33***

-

.18*

.12*

.19*

Publicstigma

Self-stigma

Externalizingproblemsnumber

Internalizingproblemsnumber

Fig. 2. Path M

In addition to the explanations above, stigma is one of the most sig-nificant barriers to help-seeking. The path analyses in the present studyshowed that the relationship between the number of mental healthproblems and willingness to seek help was mediated by self-stigmaand attitudes toward help-seeking. Specifically, the number of mentalhealth problems contributed to self-stigma, which consequently influ-enced attitudes toward help-seeking and eventually influencedwilling-ness to seek help. There are three possible reasons for this result. First,multiple problems in adolescents were positively associated with self-stigma. According to Societal Reaction Theory and Labeling Theory(Link et al., 1989), society's discrimination and negative attitudes to-ward mental health problems might lead adolescents to internalizepublic stigma, accept negative social reactions, and label themselves ashaving an illness. Second, self-stigmawas negatively associatedwith at-titudes toward psychological services. Modified Labeling Theory (Linket al., 1989) proposes that self-discrimination may result in shame andloss of self-esteem, self-efficacy, and social interaction. If a person inter-nalizes stigma from the public, he/shemight believe that otherswill ste-reotype and reject him/her (Link, Struening, Neese-Todd, Asmussen, &Phelan, 2001); this person might even consider help-seeking to be asign of weakness or incompetence. As a result, this person may refuseto seek help from others to maintain his/her self-esteem. Third, atti-tudes toward psychological services were positively associated withwillingness to seek help. According to the Theory of Reasoned Action,the Theory of Planned Behavior, and the Integrated Behavioral Model,one of the best predictors of individuals' behavioral intentions is theirattitudes toward those behaviors (Montano & Kasprzyk, 2008). Regard-ing willingness to seek help, previous studies have found that attitudestoward help-seeking have a significant effect on intentions to seek help(Carlton & Deane, 2000; Vogel et al., 2007).

Interestingly, the present study found that help-seeking was greatlyinfluenced by self-stigma. It has been suggested that one of themost po-tent causes of the negative relationship between the number of mentalhealth problems and willingness to seek help is self-stigma. One possi-ble reason for this effect may be that the self-consciousness of helpseekers is directly influenced by self-stigma. First, self-concepts areperturbed by increased self-stigma. People who perceive public stigmainternalize that prejudice as being focused on them andmay eventually

-.38***

.55***

.16*-.15*

Attitude Willingness

odel B.

Table 4Bootstrap analyses of indirect effects.

Variable Path Model A Path Model B

Standardized indirect effect 95% CI mean indirect effect Standardized indirect effect 95% CI mean indirect effect

Effect on willingnessProblem number − .110⁎⁎ − .043, − .187 – –

Internalizing problem number – – − .037⁎ − .010, − .078Externalizing problem number – – − .037⁎⁎ − .014, − .071Public stigma − .144⁎⁎ − .064, − .222 − .154⁎⁎ − .088, − .220Self-stigma − .193⁎⁎⁎ − .110, − .286 − .209⁎⁎⁎ − .141, − .284

Effect on attitudeProblem number − .070⁎⁎ − .030, − .127 – –

Internalizing problem number – – − .035⁎ − .009, − .075Externalizing problem number – – − .068⁎⁎ − .025, − .122Public stigma − .109⁎⁎⁎ − .057, − .188 − .124⁎⁎⁎ − .076, − .191

⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

361H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

approve of the stereotypes of others, which ultimately results in an un-reasonable self-concept (e.g., “Yes, I am weak and I cannot take care ofmyself.”) Second, self-worth, self-efficacy, and self-esteem decreasewith increasing self-stigma. Schonert-Reichl and Muller (1996) foundthat help-seekers report lower levels of self-worth than non-help-seekers. Garland and Zigler (1994) found that more negative help-seeking attitudes are associated with lower self-efficacies. Nadler andFisher (1986) proposed that seeking help from professional services isa threat to self-esteem. Third, the large effect of self-stigma might con-tribute to the characteristics of self-identity development for adoles-cents. Self-identity is the main developmental task for adolescents andsuggests that ego development significantly influences behavior, will-ingness and attitudes.

In addition, Chinese culture might affect stigma to influence help-seeking among adolescents. Inmainland China, themental health prob-lems and counseling services have largely gone unnoticed by the publicuntil recently in the past decade (Huang et al., 2007). The Chinese publicstill holds irrational and discriminatory beliefs for mental health prob-lems. Some consider mental health problems to be the result of poormoral character or poor ideals, while others judge mental health prob-lems as a mental disease that is aggressive and dangerous, warrantingavoidance from persons with mental health problems. Others mayhold superstitious beliefs from traditional Chinese culture, where men-tal health problems are the product of karma or misfortune. To avoidpublic discrimination, people with mental health problems mightchoose to conceal his/her problem and refuse to seek help from others.Furthermore, Chinese culture has a highly developed sensibility to pre-serving, not humiliating, the face of self or others. Face, which is relevantto stigma, is the need to be respected by others and not be embarrassedin social interactions (Hwang, Ang, & Francesco, 2002). The notion offace is a concern for not only the individual but also the individual's fam-ily in Chinese culture (Hwang et al., 2002). Thus, an individual mustavoid poor performance and personal embarrassment because this cre-ates not only a loss of individual face but also a loss of family face(Stevenson & Lee, 1996). For a person with mental health problems,he/shewould feel a loss of face when seeking help from counseling ser-vices because help-seeking suggests incapacity or weakness. Therefore,he/shewould choose to conceal the problem and refuse help-seeking toprevent loss of face for the individual and family.

Regarding the differences between internalizing and externalizingproblems, the present study found that there were non-significant dif-ferences in public stigma, self-stigma, and help-seeking between thesetwo types of problems. However, the path analysis showed differentpathways between internalizing and externalizing problems. The effectof the number of internalizing problems on willingness to seek helpwas mediated by public stigma, while the effect of the number of exter-nalizing problems on willingness to seek help was mediated by self-

stigma. One possible reason may be that the public holds different atti-tudes toward these two types of problems. Internalizing problems aredirected toward the individual self and represents an over-controlledand inner-directed pattern of behaviors (Compton et al., 2002); some-times these behaviors are covert and go unnoticed (Kauffman &Landrum, 2001). Therefore, other persons may find these behaviors dif-ficult to understand and consider them to be mysterious. Thus, internal-izing problems would significantly predict public stigma. In contrast tointernalizing problems, externalizing problems are directed towardothers. The public may find it easy to consider externalizing problemsas being poor moral character or conduct deviation rather than as men-tal health problems. Thus externalizing problems did not predict publicstigma for mental health problems. These findings may have other ex-planations; therefore, further investigation is warranted.

The theoretical frameworks of the HBM and the YHSSUM empha-size the effects of enabling or inhibiting factors in understandinghelp-negation. The present study explored the effects of self-stigma, public stigma, and attitudes toward help-seeking and foundthat the relationship between the number of mental health problemsand help-seeking was mediated by self-stigma and attitudes towardhelp-seeking. These results support and extended the hypothesis ofthe Modified Labeling Theory and provide a new explanation forwhy adolescents with mental health problems fail to use psycholog-ical services. The most significant implication for clinical practice isthat interventions should be designed to address adolescents' nega-tive perceptions of themselves and reduce self-stigma. Regardingmental health education at school, administrators and teachersshould increase students' awareness of mental health problems andcounseling services, especially for students with mental health prob-lems who are in need of psychological services.

The present study has several limitations that should be investigatedfurther. The number of adolescents with four or more types of mentalhealth problems was below 15, and the current study combined sub-groups of participants. Future studies should include more participantsand analyze differences between sub-groups with different numbersof mental health problems. Additionally, future studies should investi-gate actual help-seeking behavior or service utilization, as anintention–behavior gapmay exist (Webb & Sheeran, 2006). In addition,causal relationships between help-seeking and related variables shouldbe further explored.

5. Conclusions

The findings from this study suggest that adolescents with moremental health problems will report less willingness to seek help. Addi-tionally, the relationship between the number of mental health

362 H. Chen et al. / Children and Youth Services Review 44 (2014) 356–362

problems andwillingness to seek helpwasmediated by self-stigma andattitudes toward help-seeking.

Acknowledgments

This work was supported by the Research Foundation of EssentialTasks in Philosophy and Social Science of the Ministry of Education ofthe People's Republic of China (Grant 11JZD037).

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