Examining the effect of Attitude, Loss of Face, Stigma, and Problem Severity toward the Intent to Seek Face-to-Face or Online Counseling Aylin M. Bello Maxine Joyce T. Pinson Ateneo de Manila University Antover P. Tuliao, University of Nebraska-Lincoln

Introduction: Face-to-Face and Online Counseling Clients expressed a similar level of perceived social presence regardless of whether face-to-face or online counseling was used. -Psychological, emotional, and behavioral components are involved in online counseling despite the lack of face-to-face component Working alliance  can be formed whether or not the same physical space is shared (Holmes & Foster, 2012) 1st bullet – social presence refers to “…the moment-by-moment awareness of the co-presence of another sentient being accompanied by a sense of engagement with the other” (Biocca et al., 2001, p. 2) 2nd bullet on working alliance – online counseling participants reported a significantly strong working alliance

Introduction: Face-to-Face and Online Counseling Online counseling is a computer-mediated communication E-mail, synchronous chat, videoconferencing, Internet phone ATENEO DE MANILA UNIVERSITY PHILIPPINES UNIVERSITY OF NEBRASKA-LIINCOLN USA

Introduction: Stigma Public stigma is the perception held by a group or society that an individual is socially unacceptable and often leads to negative reactions about them. Private stigma or self-stigma is the reduction of an individual’s self-esteem or self-worth caused by the individual self-labeling herself or himself as socially unacceptable. Vogel, D.L., Wade, N.G., & Haake, S. (2006)

Introduction: Attitude Help-seeking attitudes do not appear to be a barrier to seeking professional help among older adults (Mackenzie, Gekoski, & Knox, 2006) Perception of stigma, discomfort with emotions, and lower psychological distress affect attitudes toward seeking psychological help (Komiya, Good, & Sherrod, 2000) ATENEO DE MANILA UNIVERSITY PHILIPPINES UNIVERSITY OF NEBRASKA-LIINCOLN USA

Attitudes towards counseling Stigma and Attitude – Public Stigma Attitudes towards counseling + – Private / Self- Stigma (Vogel, Wade, & Hackler, 2007; Garabiles, & Tuliao, n.d.)

Stigma, Attitude and Help Seeking Attitudes toward Help Seeking Intent to seek Counseling + (Komiti, Judd, & Jackson, 2006) Stigma Intent to seek Counseling + context of session follow-up (Wade, Post, Cornish, Vogel, & Tucker, 2011)

Attitude toward Help seeking Introduction: Hiya Hiya threat or loss of one’s social integrity, and is often pointed as the dominant interpersonal dynamic in social relations among Asians is a painful emotion arising from real or imagined transgressions of social norms or authority figures, and its avoidance is paramount in social interactions (Bulatao, 1964) Cultural factors such as hiya or loss of face impede attitudes towards help-seeking (Leong, Kim, & Gupta, 2011) Bullet 3 – higher loss of face is related to negative help-seeking attitudes among Asian Americans Loss of Face Attitude toward Help seeking -

Problem Severity and Help Seeking Problem severity is associated with willingness to seek professional help (Bunagan et al., 2011; Gong et al., 2004; Tuliao & Velasquez) Interaction between problem severity and willingness to self-disclosure predicts intent to seek help (Hinson, & Swanson, 1993) Problem severity moderated by technology adoption factors affects the intent to seek online counseling (Hechanova, Tuliao, Teh, Alianan, Acosta, 2012)

Loss of face, stigma, attitude and intent to seek help Acculturation (Yakunina & Weigold, 2011) Attitudes + + Values Intent to seek Help + Although this model and the models reported in previous research have shown the relationship of different predictors of help-seeking, it seems that there is a lack of a comprehensive model that integrate the predictors of help-seeking. Stigma + + + Face

Face to Face Counseling Proposed Model Face to Face Counseling Problem Severity Hiya Attitude Online Counseling Private Stigma To bridge this gap in research, this study proposes this model wherein attitudes mediate the effect of factors such as problem severity, hiya, and stigma on intent to seek either face to face or online counseling. Public Stigma

Research Question Do problem severity, hiya (loss of face), and stigma (private and public) lead to attitude which in turn affect the intent to seek online or face-to-face counseling?

Method: Measurements Intent to Seek Face-to-Face online Counseling Intent to Seek Online Counseling 17-item 4-point Likert scale (1 = very unlikely to 4 = very likely); Mean (SD) = 39.06 (12.82); α = .939 “How likely will you be to seek counseling or professional help for this problem?” 17-item 4-point Likert scale (1 = very unlikely to 4 = very likely); Mean (SD) = 34.15 (15.11); α = .972 “How likely will you be to seek online counseling for this problem?”

Method: Measurements Problem Severity Cepeda-Benito & Short (1998) weight control conflicts with parents, excessive alcohol use speech anxiety relationship difficulties difficulties dating concerns about sexuality difficulty in sleeping depression drug problems 17-item 4-point Likert scale (1 = never to 4 = always); α = .84 “How frequently do you experience these?”

Method: Measurements Loss of Face (Hiya) 21-item 7-point Likert scale (1 = strongly disagree to 7 = strongly agree) Higher scores means a greater tendency to avoid situations that lead to loss of face. Mean (SD) = 70.23 (9.85); α = .803 “I carefully plan what I am going to say or do to minimize mistakes.”

Method: Measurements The Inventory of Attitudes Towards Seeking Mental Health Services (IASMHS) 24-item 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) Mean (SD) = 72.95 (10.29); α = .774 “I would want to get professional help if I were worried or upset for a long period of time.”

Method: Measurements The Self-Stigma of Seeking Help Scale (SSOSHS) 21-item 7-point Likert scale (1 = strongly disagree to 7 = strongly agree) Mean (SD) = 70.23 (9.85); α = .803 “I carefully plan what I am going to say or do to minimize mistakes.” The Self-Stigma of Seeking Help Scale (SSOSHS) is a 10-item instrument that measures private stigma to seeking psychological help, a variable conceptually different from public stigma. Public stigma is the perception held by a group or society that an individual is socially unacceptable and often leads to negative reactions about them. Private stigma or self-stigma, on the other hand, is the reduction of an individual’s self-esteem or self-worth caused by the individual self-labeling herself or himself as socially unacceptable. Participants are asked to rate their agreement on each of the item on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate higher private stigma on seeking professional psychological help.

Method: Measurements Stigma Scale for Receiving Psychological Help (PBS) 5-item 5-point Likert scale (1 = strongly agree to 5 = strongly disagree) higher scores indicating higher levels of stigma attached to seeking help for psychological problems Mean (SD) = 13.09 (3.96); α = .822 “It is a sign of personal weakness or inadequacy to see a psychologist for emotional or interpersonal problems.” 5-item instrument designed to measure an individual’s perception of how stigmatizing it is to receive psychological treatment. Instead of a 4-point Likert scale, the current study increased the range of the scale from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher levels of stigma attached to seeking help for psychological problems.

Method: Participants Out of 359 Filipino College students surveyed, only 79 (22%) went to have counseling, 277 (77%) did not. Mean Age (SD) = 17.67 (.97)

Descriptives and Correlations Mean SD 1 2 3 4 5 6 1. Problem Severity 2.23 .43 ------- 2. Loss of Face 3.34 .47 .22* 3. Private Stigma 2.69 .61 .09 .15* 4. Public Stigma 2.62 .79 .18* .49* ------ 5. Attitude 3.03 .42 -.06 -.32* -.54* -.41* 6. Intent to Seek Face-to-face Counseling 1.95 .64 .38* .17* -.13* .04 7. Intent to Seek Online Counseling 1.70 .76 .28* -.07 .05 .66* LoF: Higher scores means a greater tendency to avoid situations that lead to loss of face. Prob: High  more prob Attitude: high  more positive attitudes Stigma: higher scores indicating higher levels of stigma attached to seeking help for psychological problems Intent: high  very likely to seek help N = 359

Standardized Path Estimates of Structural Model Face to Face Counseling Problem Severity Hiya Private Stigma Less adequate fit Online Counseling Attitude Public Stigma Chi-Square Test of Model Fit = 86.88, p =.000 CFI = .84 TLI = .73 RMSEA = .15

Face to Face Counseling POST HOC ANALYSIS Face to Face Counseling Problem Severity Hiya Private Stigma Post-Hoc Analysis  product of consulting the Modification Index (e.g., LM Test) and deleting nonsignificant paths. Model comparisons is not possible because the 2 models are non-nested. Online Counseling Attitude Public Stigma Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Standardized Path Estimates of Structural Model stigma was not responsible for students' negative attitudes toward seeking online help Standardized Path Estimates of Structural Model (Vogel, Wade, & Hackler, 2007; Garabiles, & Tuliao, n.d.) Private Stigma r2 = .21 -.41 Attitude .46 -.17 Public Stigma r2 = .34 Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Standardized Path Estimates of Structural Model Face to Face Counseling Hiya .26 Private Stigma -.23 Thoughts affect attitude which in turn affects the intent to seek either face to face or online counseling. Indeed, public stigma seems to have an indirect effect on the intent to seek counseling. Strongest predictor of attitude is private stigma. Our findings also indicated that stigma and loss-of-face concerns were positively associated with participants’ intentions to seek counseling. A possible explanation may be that loss of face and stigma might increase Asian international students’ anxiety about sharing psychological problems with significant people in their lives (Mau & Jepsen, 1990; Olivas & Li, 2006). Online Counseling r2 = .21 -.41 Attitude .46 -.17 .18 Public Stigma r2 = .34 Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Standardized Path Estimates of Structural Model .37 Face to Face Counseling Problem Severity .16 r2 = .21 Hiya .26 Problem does not have to get through Attitude to predict help-seeking. Strongest predictor of face-to-face is problem severity. Attitude Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Standardized Path Estimates of Structural Model Problem Severity Hiya .27 .16 Similarly, the strongest predictor of online counseling is problem severity Online Counseling Attitude .18 r2 = .12 Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Standardized Path Estimates of Structural Model .37 Face to Face Counseling Problem Severity .16 r2 = .21 Hiya .27 .16 .26 Private Stigma -.23 Post-Hoc Analysis  product of consulting the Modification Index (e.g., LM Test) and deleting nonsignificant paths. Model comparisons is not possible because the 2 models are non-nested. Provided empirical evidence for this model that accounts for the interaction of different drives and barriers to help seeking. Online Counseling r2 = .21 -.41 Attitude .46 -.17 .18 Public Stigma r2 = .34 r2 = .12 Chi-Square Test of Model Fit = 6.41, p =.49 CFI = 1.00 TLI = 1.00 RMSEA = .000

Discussion Problem Severity and Loss of Face (Hiya) have direct effect on Intent seek either face-to-face or online counseling. Attitude mediates the effect of Loss of face, Private and Public Stigma on the intent to seek either face-to-face or online counseling. Factors that contribute to the intent to seek help on both face-to-face or online counseling are similar.

In conclusion… (-) Barriers (to Attitude) (+) Drives (to Face-to-face and Online Help Seeking) Private Stigma Problem Severity Hiya Public Stigma Attitude

Implications & Recommendations Integrated and built upon prior research to a model that suggests the importance of ensuring confidentiality and consideration of the help-seeking factors. Thoughts affects behavior Theory of reasoned action (Ajzen & Fishbein, 1991) Sample is limited to college students Limitations:Get another set of participants “The way culture shapes attitudes and behaviors towards the mentally ill (public stigma) gets internalized, which subsequently results in low self-efficacy, shame, and reluctance to seek treatment.” (Tuliao)

aylin.bello@gmail.com Thank you!