The nature of help-seeking in a mental health context has been extensively studied for a variety of disorders and factors affecting responses to them. It is important to assess what the most likely reasons are for people choosing not to pursue potentially beneficial support for their mental health. Here, the factor being explored is that of personality, and whether or not it carries a relation to attitudes on help seeking. A sample from the general population (n=53) answered a survey which contained two scales; the IPIP big-five personality scale (Goldberg, 1992) and the Mental Help Seeking Attitudes Scale (Hammer, Parent, and Spiker, 2018). Results showed no evident correlation between these dimensions of personality and likeliness of seeking mental health support. Possible explanations for this are discussed, along with other factors more likely to influence these attitudes. Implications for future research are explored.
The amount of people seeking treatment for their mental health has increased steadily in recent years, with one in four seeking help back in 2000, and increasing to one in three by 2014 (Mental Health Foundation, 2019). However, it is still currently believed that an estimated 70 percent of people with mental health issues worldwide receive no treatment for their issues (Henderson, Evans-Lacko, and Thornicroft, 2013).
It is important to determine the fundamental differences between those who seek treatment and those who do not. A report by McManus et al. (2016) found that overall rates of common mental disorders (e.g. depression and anxiety) have increased since 2000, with more severe symptoms such as self-harming increasing since 2007. The report did note that these statistics may be attributed to greater awareness of conditions as opposed to an increase in the prevalence of conditions themselves. However, this particular aspect of debate does not detract from the pressing need for mental health services.
By determining what separates service users from those who do not take up the services, findings can be used to adapt the services themselves and accessibility to them. When traits linked to not seeking help are identified, potential at-risk groups can be offered support more directly, and in a way makes the option far more appealing to the individuals. By educating themselves about the general population, mental health services can then in turn more efficiently and adequately educate the general population about themselves.
Research in the area begins from a broader sense; by identifying traits that may be correlated with the likelihood of having mental illness itself, independent of likelihood to seek help. For example, the noted differences between men and women; with women having higher reported rates of PTSD, while men (particularly those aged 20-49) exhibit suicide as being the among the most common cause of death (Office for National Statistics, 2015; McManus et al., 2016). There has been further exploration of the link between age and mental illness, with an ever-increasing number of young people receiving mental health diagnoses, as well as the elderly exhibiting mental illness symptoms in relation to their isolation and physical health (Schnittker, 2005; Patel et al., 2007).
Another relationship that has been explored is that between mental illness and ethnicity, to determine which countries may possess higher or lower instances of a particular mental illness. For example, those from more unstable regions (such as the Middle East) have a far instance of PTSD than those from other areas (Montgomery, 2011; Hawes, Axinn, and Ghimire, 2016). In a similar vein, stigma around mental illness can often be affected by culture, leading those from certain cultures to be less likely to even report symptoms of mental illness (Crisp et al., 2000). A notable instance of this is the pervasive culture in China, which has led to a prominent cultural stigma towards mental illness. There is a social emphasis on ‘saving face’, and a belief (largely inspired by the principles of Confucianism) that an individual is duty-bound to follow moral demands that define themselves in relation to other people (Yang, 2007). Racial differences within a single country have also been explored, with socioeconomic issues pertaining to race often being linked to a higher prevalence of untreated mental illness (Williams et al., 1997; Fernando, 2010; Jackson, Knight, and Rafferty, 2010). Another more contentious association with mental illness is that of religion. For centuries, many have argued that religion is of outstanding benefit to the mentally ill, having played a role in the development of the earliest care for patients. While others have highlighted that religious institutions have often persecuted the mentally ill (Koenig and Larson, 2001).
More specific research has shifted into exploring how these qualities might affect an individual’s attitude towards mental help, and how likely they would be to seek help themselves should the need arise. Generally, women with mental health issues are far more likely than men with similar issues to pursue professional psychological help (Leong and Zachar, 1999). When it comes to age, young adults may not pursue professional help out of fear of negative social repercussions, and instead favour ‘self-concealment’ of their issues (Cepeda-Benito and Short, 1998). For ethnicity, Caucasians often seek help with the encouragement of family or under their own volition, while Asians are typically kept within their families for longer periods before help is considered (Lin et al., 1978). Minority ethnic populations are also less likely to seek help, largely due to issues of accessibility, either perceived or genuine (Shim et al., 2009). Religious attitudes towards seeking mental help vary by the religion itself, with Muslims being less likely than those of other religions, and those of no religious affiliation being most likely (Sheikh and Furnham, 2000).
For this research, the factor being explored is personality, and how it might influence attitudes towards seeking mental help. Personality itself has long been one of the many potential indicators of mental illness (Eysenck, White, and Eysenck, 1976). While there is an entire subgroup of personality disorders, research suggesting personality itself can lead to a disorder is minimal at best - as it is generally believed that so many factors can contribute to the development of a disorder before the interrelationship between personality and disorder emerges (Singal, 2017). However, personality is generally a strong indicator of attitudes regardless of topic (Shure and Meeker, 1967; Buckley, Cote, and Comstock, 1990; Williams, 2004; Greenwald, Brock, and Ostrom, 2013). So, using this as a measure, this research will aim to determine whether or not it can be linked to the likelihood of help-seeking, and be better used to help those less likely to step forward. It will explore the possibility that those with more extroverted personality traits may be more confident and prepared to seek help. Or whether those with neurotic personalities might be more willing to seek help out of a sense of necessity.
The measure of personality employed here were the International Personality Item Pool (IPIP) ‘Big-Five’ factor markers (Goldberg, 1992). Under the Big-Five model, the primary facets of personality measured are extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. These areas are typically measured on a scale of 1-5, where 1=disagree, 2=slightly disagree, 3=neutral, 4=slightly agree, and 5=agree. However, a simplified form of the survey was used here whereby there were three possible answers to each question; disagree, neutral, and agree. The more simplified approach lessened the amount of time required by each participant, making the survey more accessible and encouraging a greater number of responses. For the purposes of creating a valid statistical analysis, the same points system was used as in the original survey, so 1=disagree, 3=neutral, and 5=agree.
To assess attitudes towards seeking psychotherapy, the Mental Help Seeking Attitudes Scale (MHSAS) was used (Hammer, Parent, and Spiker, 2018). The MHSAS measures attitudes towards seeking mental health support using 9 descriptive scales for a single question:
“If I had a mental health concern, seeking help from a mental health professional would be…”
The 9 descriptives used were; useless-useful, important-unimportant, unhealthy-healthy, ineffective-effective, good-bad, healing-hurting, disempowering-empowering, satisfying-unsatisfying, and desirable-undesirable. Participants would mark their level of agreement with the descriptors on a scale running from 0-3 on one side, and 0-3 on the other. Quantifying this involved translating responses into a score from 1-7, whereby a higher score indicated a more favourable attitude towards mental health support, after items 2,5,6,8, and 9 were reverse-scored.
Participants were sampled from the general population, and not from service users. This was done to protect potentially vulnerable individuals from the ramifications of discussing their own views on seeking help. There were no requirements for a certain age, sex, occupation etc., as the survey was open to all. The full survey was made available online, so responses could be made with confidentiality. Prior to commencing the survey, participants were asked to confirm their consent, and were made aware of their right to withdraw at any time and reminded of the confidentiality afforded to the information they provide. The full purpose of the study was also made clear at the time of giving consent, as the study did not merit withholding such details prior to taking part. After finishing their responses, a debrief was provided, which reiterated the purpose of the study and gave further information about the scales used. Additionally, while discussing confidentiality once again (and informing them that data would be removed once no longer needed), contact details were provided for them to ask any further questions or to withdraw their consent after the fact.
Once compiled, data was run through SPSS to test for validity and any correlation. Should the scatterplots have indicated a relationship, a multiple regression analysis would explore this further. VIF scores were used between the measures to assess potential multicollinearity. Homoscedasticity was further tested using a residuals scatterplot, while a Durbin-Watson score tested for autocorrelation. Finally, a Cook’s Distance score checked for the presence of any overly influential outliers.
Based upon the results of 52 respondents, analysis of the data has indicated no conclusive correlation between the big-5 personality traits and likelihood to seek mental health support should the need arise. As the survey was confidentially conducted through online channels, specific demographic data was not collected.
MHSAS scores ranged from 3.33, to 5.44, with an average of 4.11. Scores on the five dimensions of personality were also averaged. The average extraversion score among the participants was 2.78. For agreeableness, the average was 3.51. Conscientiousness had a mean of 3.04. Neuroticism averaged at 2.55. Finally, openness to experience presented an average score of 3.46. Across the board, no correlation was found between these dimensions of personality and scores on the MHSAS. Due to this lack of linear correlation, a multiple regression analysis was not performed, as it could not analyse a relationship where none exists.
One of the key focuses of the study, extraversion scores compared to MHSAS scores demonstrated a random pattern of distribution across all participants. When analysed against other dimensions, no statistically significant multicollinearity was found as VIF scores were calculated as being relatively low, where a score of >5 would typically suggest multicollinearity (James, 2017).
The random allocation of results persisted when looking at agreeableness and MHSAS. And while multicollinearity scored slightly higher when compared against neuroticism and extraversion, the VIF and tolerance scores were still considerably below the threshold for statistical significance.
A further absence of correlation occurred with conscientiousness and MHSAS. When exploring multicollinearity, the highest VIF score of all comparisons was found against extraversion at 4.045, however this was still short of the value required to suggest significance.
Neuroticism MHSAS scores were further lacking in correlation, with noticeable low VIF scores across the board.
Finally, openness and MHSAS continued the similar trend. For multicollinearity, the highest score was 4.042 against extraversion, which once again was statistically insignificant.
Further analysis of the data was conducted to test for the possible presence of autocorrelation. A Durbin-Watson score of 2.188 was determined, indicating no major issues with autocorrelation, where a scores of <1 or >3 are needed in order to present issues (Durbin and Watson, 1950).
Homoscedasticity of the data was assessed using a further scatter graph which measured standardised residuals against predicted values, where a random distribution is preferential (Casson and Farmer, 2014). Here, the distribution produced satisfied the random requirement, indicating that residuals had a normal distribution.
When these residuals were placed in a probability plot (P-Plot), the distribution was much tighter to the central line of best fit, further supporting the previous finding that homoscedasticity was consistent in this study.
Finally, the data was tested to determine whether or not there were any overly-influential outliers potentially skewing the results. Cook’s Distance was used as the primary measure of this, and any item of data would be required to score >1 in order to suggest an excessive influence (Cook, 1977). Throughout the data set, Cook’s Distance scores ranged from .00002 to .21487, indicating no prevalent issues with outliers.
One such explanation for this lack of correlation could be an issue with the group themselves. The highest-scored personality trait was that of agreeableness. This raises the question of whether or not demand characteristics might have come into play (Orne, 1962). Individuals who score a higher mark for agreeableness tend to lean towards more socially favourable points of view in an acting of ‘saving face’ (Kristjánsson, 2006; Miles, 2010). As such, when given a survey asking for attitudes on mental health support, many may have been less inclined to respond with unfavourable, less socially acceptable views. As the sample was voluntary, and drawn from the general public, it would certainly follow that agreeable individuals are considerably more likely to put themselves forward for the study.
Another issue could have been with the measures of personality and help seeking attitudes. The big five personality trait model has been a prominent feature in personality research since its inception, with some regarding it as somewhat of a paradigm shift in its own right (John, Robins, and Pervin, 2008). However, common criticism of the approach is that it is an oversimplification; and that true personality is a construct that is far more complex than the model suggests (Mount, Barrick, and Strauss, 1994). The effect of individual differences has a strong influence in determining attitudes and behaviour, in a way which may not suit the generalised approach of the big five (Eysenck and Eysenck, 1987). Personality-based research might benefit more from a combined quantitative and qualitative (mixed methods) approach, allowing for the determination of correlation as well as the great level of detail in personality exhibited by individuals.
The MHSAS suffers from similar detriments. Being a quantitative approach, it allows for empirical statistical analysis. But as a far more recently developed scale of attitudes, there has been little time for further studies to thoroughly assess its validity. There have been some alternative approaches to assessing help seeking behaviours, though there remains no prominent method for this. Other studies have tended to favour combining an original survey with a more established alternative scale, such as the 12-item General Health Questionnaire, or the General Help Seeking Questionnaire (Goldberg and Hillier, 1979; Oliver et al., 2005; Wilson et al., 2005; Mitchell, McMillan, and Hagan, 2017). For future studies, it would be worth considering combining scores from the participants’ big-five scores with qualitative interviews. Using this favourable and unfavourable comments could be weighed against certain personality measures. For example, a high frequency of favourable attitudes expressed towards mental health support might correlate with a greater agreeableness score. More critical views might be linked to high neuroticism rankings.
The target demographic for sampling was the general population. While this has meant that the research obtains an idea of how the layman might view mental help, it has left the question open as to how those with existing mental health issues and service users view the support, and how likely they are to seek it. Due to the strict ethical limitations and logistical requirements for carrying out such a study using vulnerable individuals, it was not possible to utilise a population of service users at this time. However, as a consideration for a potential next stage of this research, such a focus would certainly prove pertinent to the issue. While challenging, research of this nature is absolutely possible, thanks to the plethora of guidelines that exist surrounding use of vulnerable individuals in psychological studies (Clements, Rapley, and Cummins, 1999; de Chesnay and Anderson, 2019).
It could be argued that attributing an attitude of a topic to a single factor such as personality runs the risk of being reductionist and does not take into account a variety of complex additional factors linked to a subject’s individual differences (Eysenck and Eysenck, 1987). There is no doubt a variety of other factors in effect, occurring in varying degrees dependent upon the participant.
One such factor to consider is the impact of age on help-seeking attitudes. Younger people are generally less likely to seek help, as they report having a preference for self-reliance, and a wish to avoid potential stigma associated with being a service user (Rickwood et al., 2005; Gulliver, Griffiths, and Christensen, 2010).
Once people reach university age, fear of both personal and public stigma restrains the likelihood of seeking mental help (Eisenberg et al., 2009; Hunt and Eisenberg, 2010). Dependent on the specific disorder, the proportion of students opting not to receive help ranges from thirty-seven percent to as much as eighty-four percent (Eisenberg, Golberstein, and Gollust 2007). Other reasons given by students as to why they chose not to receive help include; being of a low socioeconomic background, doubts as to whether or not treatment will work (and how well), lack of perceived need, lack of awareness as to which options for support are available (Eisenberg, Golberstein, and Gollust 2007).
As people get older, their views towards help-seeking tend to become more favourable. Approximately eighty percent of older adults exhibit positive help-seeking attitudes, with more than seventy percent possessing positive beliefs about the treatments (Mackenzie, Gekoski, and Knox, 2006; Mackenzie et al., 2008). Help-seeking tends to decline in later years, with elderly individuals favouring other coping mechanisms over seeking professional help, such as pastoral care, friends and family, and use of hobbies (Husaini, Moore, and Cain, 1994). Additionally, there was a greater level of scepticism towards mental health professionals by the elderly, which could largely be attributed to rapid developments in mental health care leaving the current support looking radically different to what they were once used to (Waxman, Carrier, and Klein, 1984). This phenomenon can also be linked to another finding; that the elderly report a higher level of stigma surrounding mental illness, likely due to the fact that they were raised in an era where many of today’s mental health issues were not recognised (Conner et al., 2010).
The difference between men and women in mental help seeking behaviour has been widely publicised, with men being significantly less likely to seek help (Galdas, Cheater, and Marshall, 2005). One such explanation for this is the social construct of masculinity; in that seeking help would make the individual appear ‘weak’ or a ‘burden’ (Addis and Mahalik, 2003; Smith, Braunack-Mayer, and Wittert, 2006). It is important to recognise that the low treatment rates for men do not indicate greater health, rather they indicate a greater tendency towards inhibiting emotional expressiveness, suggesting that symptoms might even be underreported (Möller-Leimkühler, 2002). Women on the other hand, have been found to be significantly more likely to seek help. This could be due to greater willingness to disclose issues and greater social emotional support (Rickwood and Braithwaite, 1994). Another explanation could be that of ‘stressor appraisal’, that women are more likely to regard their stressors as more severe, and as such more worthy of needing help (Tamres, Janicki, and Helgeson, 2002). This fundamental difference in problem recognition has been evidenced in many different studies over several decades as having a key influence on the likelihood to seek help (Kessler, Brown, and Broman 1981). Linking back to the big-five scores, men typically score lower on openness to experience, which has led to a greater reported degree of stoicism and personal stigma (Judd, Komiti, and Jackson, 2008). For transgender and gender non-binary individuals, research on mental help-seeking currently remains scarce (Mizock and Fleming, 2011). This could be largely due to barriers to help-seeking being less personal and far more social; such as fear of stigma, previous bad experiences, and the ability of the help to adequately and compassionately support those who are transgender and gender non-binary (Shipherd, Green, and Abramovitz, 2010). A suggestion for future research would be to explore the potential relationship between alternative gender identities and mental help seeking, as this could be utilised in the improvement of services for such individuals (Benson, 2013).
Ethnicity could also be a significant factor in likelihood to seek mental help. Samples of people of the same nationality but different racial ethnicities show little difference in the frequency of favourable attitudes towards mental health services, however those who were black generally expressed greater doubt over the efficacy of treatments (Hall and Tucker, 1985). Despite this, further findings have demonstrated that black and minority ethnic groups report a much lower level of personal stigma surrounding mental illness, suggesting that other factors must have a significant influence over their lower frequency of taking up mental health services (Gonzalez, Alegria, and Prihoda; 2005; Shim et al., 2009). One such argument has been that socioeconomic limitations have impeded availability of services and deterred many from seeking them as a result (Padgett et al., 1994). Another issue could be that of trust in those providing the treatment, as some have reported lack of racial representation in mental health professionals has led to people being undereducated about fostering trust with black and ethnic minority patients (Nickerson, Helms, and Terrell, 1994; Neighbors, Caldwell, and Williams, 2007). Additionally, families of certain ethnicities demonstrate certain shared attitudes towards mental help seeking; with black and hispanic families less likely to resort to it as their first preference for addressing the issue, instead trying to support it themselves before that (Lin et al., 1978; McMiller and Weisz, 1996).
The issue of ethnicity on mental help seeking also overlaps with the issue of culture and society (Cauce et al., 2002). Take for example, those from Asian cultures. For the Chinese, the societal emphasis on ‘saving face’ has often led to more reserved personalities among Chinese individuals, and as such a significantly reduced likelihood to express emotional distress and seek help for it (Kung, 2004; Shea and Yeh, 2008). Other Asian cultures exhibit this inhibition against mental help seeking as well. For samples from the Vietnamese population, there was far less of an inclination to associate mental health symptoms with stressful life events, and as such less of a desire to pursue help, especially where this help might have interfered with pre-existing cultural values (Guo et al., 2015). Filipino individuals have further issues with mental help seeking, expressing a cultural mistrust towards such interventions (David, 2010). There is one example of a paradigm shift with those of Asian cultures; and it is that of refugees from Southeast Asian countries. Following resettlement in a western country, Southeast Asian refugees exhibit a dramatically increased uptake of mental health support, even though it might be counterintuitive to some previous cultural values (Chung and Lin, 1994). The previous findings have led to somewhat of a false cultural stereotype that Asians are somehow immune to mental distress and do not ever require such help (Sue, 1994). It is important to recognise that this is not the case, as it would allow for the adaptation of mental health services to better suit a group that previously so readily declined its use.
There is also the issue of how individuals of certain cultures might seek help. Some may do so more overtly, laying out symptoms in great detail for their GP. Others may be more subtle, allowing just some indication of symptoms to show to encourage others to intervene for them, while some may use euphemism to describe their symptoms without recognising them fully. Comparisons between Punjabi and English individuals has found no difference between the prevalence of the mental disorders themselves, however it has found key differences in the rate of successful detection due to the help seeking styles. English individuals were more likely to receive accurate diagnoses and treatments from their GP, while Punjabi individuals were often assessed as having ‘physical and somatic symptoms’, as opposed to the same common mental disorders as their English counterparts (Bhui et al., 2001).
Those of Middle-Eastern and Muslim countries have been found to not pursue mental help due to fear of stigmatisation by their communities, which results in them favouring more traditional approaches, such as support from their local mosque (Al-Krenawi et al., 2009; Amri and Bemak, 2013). When it comes to the Middle-Eastern refugee population, they do not show the same level of adaptation to western mental health support as Southeast Asian refugees do. Instead, Middle-Eastern refugees have been found to be very unlikely to not venture beyond their close social circles for support, largely due to the trust formed over their shared experiences that they might not have with a mental health professional (de Anstiss and Ziaian, 2009).
In Western cultures, mental help seeking is generally looked on far more favourably than in other cultures around the world. However, there still remains hesitancy among those who seek it. A very common reasoning for delaying help was a personal lack of knowledge about available options (Thompson, Hunt, and Issakidis, 2004). Stigma, while less prevalent, was still an issue for many in deciding whether or not to seek help - particularly in those from more rural communities (Wrigley, Jackson, Judd, and Komiti, 2005; Komiti, Judd, and Jackson, 2006).
While personality alone may not be a major predictor of likelihood to seek mental health support, it is vital to remember that the inherently complex nature of personality necessitates a complex approach to study. Personality is the ‘uniqueness of the individual’ and as such may not be adequately representable under a limited quantitative scale (Allport, 1937). When considering that definition - the uniqueness of the individual - personality becomes just one of many factors influencing that individual’s attitudes on any given topic, especially mental help-seeking. Attitudes change constantly for many reasons, and mental health services often need to adapt to keep up with that, or else risk wholly alienating those who might already be apprehensive about seeking support.
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