...psychological distress seek help from mental health professional (Andrews, Issakidis, & Carter, 2001). In fact, people tend to see counseling as a last resort (Hinson & Swanson, 1993), something to be considered only after their attempts to handle things on their own or in concert with individuals close to them have failed (Wills, 1992). These perceptions of counseling persist, despite studies showing that seeking counseling services is often helpful (see Bergin & Garfield, 1994) and that the consequences for not seeking help are often severe (Dubow, Lovko, & Kausch, 1990). Thus, there is a need to clearly identify the factors that lead individuals to avoid seeking professional help. Our goal in this article was to examine the broad array of research on help seeking from counseling, clinical and social psychology, social work, and psychiatry perspectives to assist counselors in providing professional service to individuals who are reluctant to seek help despite the need for such help.

* To Seek Help or Not to Seek Help

One way to conceptualize help seeking is to view the decision to seek help as a classic approach/avoidance conflict. Kushner and Sher (1989) first conceptualized the act of seeking professional help as being an approach/avoidance conflict wherein approach factors, such as one's level of distress and the desire to reduce that distress, increase the likelihood that one will seek out counseling services; on the other hand, avoidance factors, such as the risks of being perceived as crazy, decrease the chances that an individual will seek out services. As with other approach/avoidance conflicts, avoidance factors are thought to become increasingly stronger as one moves toward the decision to seek professional help. Kushner and Sher found that individuals who needed counseling or psychotherapy but had not sought it had the highest level of treatment fears, suggesting that avoidance factors can inhibit help-seeking behavior even for individuals who could benefit from treatment. It seems, therefore, that many individuals perceive the act of seeking counseling or psychotherapy as a dilemma; although they are experiencing negative emotional, interpersonal, or psychological consequences, the thought of seeking help carries with it a negative perception, which may, in fact, be perceived as worse than the problem.

Both approach and avoidance factors offer counselors ways in which to understand individuals' reluctance to seek counseling services. However, studies examining only approach factors, have generally accounted for a small amount of the variance associated with professional help-seeking attitudes or intent. One potential reason for this large amount of unexplained variance is that the relative importance of avoidance factors remains unknown (Kushner & Sher, 1989). A discussion of the relative impact of the various avoidance factors should allow counselors to understand more about the help-seeking attitudes, intent, and behavior of individuals who are considering seeking help. A better understanding of the role of the factors in professional help-seeking decisions is critical for counselors and other mental health professionals to design interventions and education programs that reduce the barriers to seeking help. Therefore, in the following sections of the article, we examine the specific psychological avoidance factors that have recently been identified in the mental health literature. Then, factors that have been studied recently, but not necessarily identified as an avoidance factor, are discussed. For each factor, the conceptual support for the importance of the factor is presented first, and then the previous studies that have directly examined the relationship of that factor and professional help seeking are summarized. Important variations in the setting, problem type, as well as demographic and cultural characteristics that can influence the degree to which avoidance factors affect help-seeking decisions are then examined. Finally, we discuss the implications of these factors for counselors who are attempting to reach out to those least likely to seek help.

* Avoidance Factors

Five factors have been described recently as avoidance factors in the help-seeking process: social stigma (Komiya, Good, & Sherrod, 2000), treatment fears (Deane& Todd, 1996; Kushner & Sher, 1989), fear of emotion (Komiya et al., 2000), anticipated utility and risks (Vogel & Wester, 2003; Vogel, Wester, Wei, & Boysen, 2005), and self-disclosure (Hinson & Swanson, 1993; Vogel & Wester, 2003). There are also at least two other factors that have been found to be potential barriers to seeking help, although they have not necessarily been discussed as such in the professional help-seeking literature; these are social norms and self-esteem. In this section of the article, these factors and the degree to which the extant literature supports the usefulness of them in understanding why individuals do not seek professional services are presented.

Social Stigma

Social stigma is defined as the fear that others will judge a person negatively if she or he sought help for a problem (Deane & Chamberlain, 1994). The social stigma attached to seeking professional help has been conceptualized as one of the most significant barriers to treatment (Sibicky & Dovidio, 1986; Stefl & Prosperi, 1985). This may be because the public in general tends to provide negative descriptions of individuals who experience mental illness (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). A history of having sought outpatient mental health services can lead others to have more negative perceptions of the individual (Dovidio, Fishbane, & Sibicky, 1985), including being labeled more awkward, cold, defensive, dependent, insecure, sad, and unsociable (Sibicky & Dovidio, 1986); to view that individual as less in control of her or his emotions (Oppenheimer & Miller, 1988); and to describe the individual as weak or disturbed (King, Newton, Osterlund, & Baber, 1973). Some researchers have also found that being labeled a "former mental hospital patient" led to greater social rejection than was true for someone with no such label (Link, Cullen, Frank, & Wozniak, 1987). Furthermore, although people who experience depression are seen as emotionally unstable, those who seek help for depression are viewed as particularly unstable (Ben-Porath, 2002), suggesting that it is not simply having a disorder but the seeking of help from a professional that is stigmatized.

Perhaps, then, it is not surprising that people have been found to seek help less for problems that are associated with greater negative judgments by others (Overbeck, 1977), and most of those who have been to therapy perceive that there is social stigma associated with their having sought help (Sirey et al., 2001). Studies directly measuring the relationship between perceived social stigma and professional help seeking have also demonstrated that social stigma predicted a person's attitudes toward seeking help (Deane & Todd, 1996; Komiya et al., 2000; Vogel et al., 2005), as well as predicted the intention to seek help at a future date (Deane& Chamberlain, 1994). For example, Stefl and Prosperi (1985) found that individuals who needed treatment but did not go to therapy were twice as likely as those who needed treatment and went to therapy to report stigma as an important treatment barrier. In addition, more than 90% of the sample in another study (Nelson & Barbaro, 1985) agreed that the fear that they would be thought of as crazy was a potential barrier to seeking help. Finally, Rochlen, Mohr, and Hargrove (1999) found that the stigma associated with seeking help for career issues was associated with more negative attitudes toward counseling and less intent to seek help for career issues. Thus there is general support for the importance of social stigma in understanding why people might not seek help, even when they have a serious problem.

Treatment Fears

Researchers have also become interested in another possible avoidance factor labeled treatment fears. Treatment fears have been defined as a "subjective state of apprehension arising from aversive expectations surrounding the seeking ... of mental health services" (Kushner & Sher, 1989, p. 251). These fears have been measured with concern for how a mental health professional will treat the individual, fear about what the mental health professional will think of the individual if she or he seeks help, and fear of being coerced by the counselor. One study found that these types of fears can lead to the delay or avoidance of seeking help (Amato & Bradshaw, 1985); two studies found that individuals who do not use mental health services have the highest level of treatment fears (Kushner & Sher, 1989; Pipes, Schwarz, & Crouch, 1985). However, the role of treatment fears is complicated, because not all studies have shown consistent results. Deane and Chamberlain (1994), for example, found that treatment fearfulness predicted intentions to seek professional help. Yet Deane and Todd (1996) found that treatment fears were not uniquely predictive of help seeking when other factors (e.g., social stigma) were included in the analysis. One reason for this discrepancy may be that treatment fears affect intent to seek help differently depending on the type of problem examined. Treatment fears seem to have a greater effect on individuals dealing with such issues as (a) academic problems (Cepeda-Benito & Short, 1998), (b) interpersonal problems (Vogel et al., 2005), and (c) drug/alcohol problems (Vogel et al., 2005), but have less of an effect for other issues, such as emotional problems or thoughts of suicide (Deane & Todd, 1996). Clearly, treatment fears are an important avoidance factor, but more information is needed about their role relative to other factors.

Fear of Emotion

Researchers have identified a fear of having to discuss painful emotions as another reason that some individuals avoid seeking counseling (Komiya et al., 2000). Seeking help from another person often involves strong emotions, and clients may fear having to experience painful emotions. Indeed, even after seeking help, many clients withhold emotions they have been afraid to express to a counselor (Kelly, 1998). In a study examining emotional expression specifically, Komiya et al. (2000) found that reluctance to seek counseling was greater for individuals who were not open about their emotions. Similarly, persons who were less skilled at dealing with emotions have also been found to be less likely to seek help, in general, as well as less likely to seek help from a mental health professional for concerns about suicide (Ciarrochi & Deane, 2001). Vogel and Wester (2003) found that expectations of having to express emotions to a therapist affected individuals' help-seeking attitudes and intentions. In addition, although concerns about expressing specific emotions did not affect help-seeking attitudes, overall willingness to express emotions was related to individuals' attitudes toward seeking professional help. Finally, Vogel et al. (2005) found that expectations about emotional expression affected not only help-seeking attitudes and intentions but also actual help-seeking behavior. People who had experienced a distressing event, as compared with those who had not, were more likely to endorse concerns about the potential risks of expressing emotions to a counselor. Thus, although only a few studies have directly examined emotional expression, it seems to be a particularly important factor to consider in reaching out to individuals who are experiencing a psychological problem.

Anticipated Utility and Risk

The role of a person's initial expectations about counseling can influence her or his decision about whether to seek professional help (Tinsley, Brown, de St. Aubin, & Lucek, 1984). In particular, the anticipated utility of and risks associated with seeking therapy have been suggested as two of the most important influences on a person's decision to seek counseling (Vogel et al., 2005; Vogel & Wester, 2003). Anticipated utility refers to the perceived usefulness or lack thereof regarding seeking services from a counselor. Researchers (e.g., Tinsley et al., 1984) have suggested that individuals who do not seek counseling services may have lower expectations about the benefits of seeking help than do individuals who seek such services. Anticipated risk, on the other...

NOTE: All illustrations and photos have been removed from this article.



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