Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS)

1. Abstract

The Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS) is a psychometrically robust, multidimensional instrument developed by Corey S. Mackenzie, W. L. Gekoski, and V. J. Knox in 2004. Created as an adaptation and theoretical extension of Fischer and Turner’s classic 1970 Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS), the IASMHS was formulated to address long-standing conceptual and psychometric limitations in measuring attitudes toward mental healthcare utilization. Grounded within Icek Ajzen’s Theory of Planned Behavior (TPB), the instrument conceptualizes help-seeking behavior as a function of cognitive-affective evaluations, normative social perceptions, and perceived behavioral control.

The IASMHS consists of 24 self-report items evaluated on a 5-point Likert-type scale ranging from 0 (disagree) to 4 (agree). Psychometric investigations yield a replicated three-factor structure comprising three distinct, clinically meaningful subscales: Psychological Openness (8 items), assessing an individual’s willingness to acknowledge psychological distress and emotional vulnerability; Help-Seeking Propensity (8 items), reflecting perceived behavioral control, perceived efficacy of psychological treatments, and willingness or intention to seek professional services; and Indifference to Stigma (8 items), measuring the degree to which an individual is unconcerned by societal prejudice, discrimination, or social devaluation associated with receiving mental health treatment. Total scores range from 0 to 96, with higher scores reflecting more positive help-seeking orientations.

Extensive psychometric evaluations have demonstrated that the IASMHS exhibits superior structural stability, high internal consistency reliability (α = .76 to .87 across subscales; full-scale α ≥ .87), and robust test-retest stability (r = .85 over a 3-week interval). It displays solid convergent, discriminant, and construct validity across diverse developmental cohorts, including community-dwelling older adults, university students, healthcare workers, and clinical samples internationally. Crucially, the IASMHS demonstrates substantial predictive validity regarding actual past service use and prospective utilization intentions, establishing itself as a premier gold-standard assessment in public health, clinical psychology, and psychiatric epidemiology.

2. Keywords

IASMHS, mental health help-seeking, psychological openness, help-seeking propensity, indifference to stigma, attitudes toward psychotherapy, theory of planned behavior, psychometrics, mental health service utilization, healthcare barriers

3. Authors

The Inventory of Attitudes Toward Seeking Mental Health Services was developed by a team of clinical psychologists and psychometricians at Queen’s University in Kingston, Ontario, Canada:

• Corey S. Mackenzie, Ph.D., C.Psych. — Professor and Director of Clinical Training, Department of Psychology, University of Manitoba; Adjunct Scientist, Riverview Health Centre, Winnipeg, Canada. His research centers on clinical geropsychology, psychiatric epidemiology, mental health literacy, and structural barriers to mental health service utilization among adults across the lifespan.
• W. L. (Lee) Gekoski, Ph.D. — Professor Emeritus, Department of Psychology, Queen’s University, Kingston, Ontario, Canada. His scholarship focused on social gerontology, developmental psychology, cognitive aging, and age-related health attitudes.
• V. Jane Knox, Ph.D. — Professor Emeritus, Department of Psychology, Queen’s University, Kingston, Ontario, Canada. Her expertise encompassed experimental psychopathology, behavioral medicine, clinical intervention strategies, and psychometric measurement.
• Heather L. Macaulay, M.A. — Department of Psychology, Queen’s University, who collaborated on the initial adaptation and statistical scale validation studies published in 2004.

Corresponding Author Contact Information: Dr. Corey S. Mackenzie, Department of Psychology, University of Manitoba, P404 Duff Roblin Building, 190 Dysart Road, Winnipeg, Manitoba, R3T 2N2, Canada. E-mail: [email protected].

4. Purpose

Despite significant advancements in evidence-based pharmacological and psychological interventions over the past several decades, the World Health Organization repeatedly documents a massive treatment gap in psychiatry: fewer than one-third of individuals meeting diagnostic criteria for mental disorders ever access professional services. This underutilization is particularly pronounced among specific demographic cohorts, notably men, racialized minorities, socioeconomically disadvantaged populations, and older adults. To understand and address this public health challenge, researchers require psychometrically sound instruments that can accurately diagnose the cognitive, emotional, and social barriers hindering service engagement.

For more than three decades, Fischer and Turner’s (1970) 29-item Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS) served as the dominant metric in this field. However, empirical studies routinely identified several critical shortcomings in the ATSPPHS: an outdated psychometric factor structure that failed to replicate across modern samples, convoluted reverse-worded phrasing, inadequate alignment with contemporary health behavior models, and an inability to decouple personal intentions from societal stigma. Mackenzie and colleagues (2004) constructed the IASMHS to rectify these deficiencies. Their primary purpose was to deliver an updated, reliable, and structurally valid measurement tool explicitly engineered to interface with modern psychosocial behavioral models.

The IASMHS serves multiple distinct research, epidemiological, and clinical functions:

• Identification of Individual-Level Barriers: In primary care and university counseling triage, the scale isolates whether an individual’s reluctance to accept a mental health referral stems from affective defensiveness (low Psychological Openness), lack of knowledge and self-efficacy (low Help-Seeking Propensity), or acute fear of social judgment (low Indifference to Stigma).
• Evaluating Public Health Anti-Stigma Campaigns: Mental health advocacy programs and municipal health authorities use the IASMHS as a pre- and post-intervention outcome metric to determine whether educational initiatives successfully decouple the perception of shame from mental illness while boosting self-referral readiness.
• Epidemiological Disparity Mapping: Public health researchers utilize the IASMHS to examine how intersectional identities—including gender role socialization, ageism, cultural orientation, and socioeconomic position—shape distinct attitudinal profiles, guiding targeted resource allocation.
• Clinical Trial Moderation Analysis: Clinical psychologists use baseline IASMHS profiles to predict client adherence, therapeutic alliance formation, and premature drop-out rates in randomized controlled psychotherapy trials.

5. Psychological Construct

The IASMHS conceptualizes “attitudes toward seeking mental health services” not as a monolithic, unidimensional inclination, but as an interrelated tripartite construct. Each dimension represents a discrete psychological domain with unique etiology, behavioral manifestations, and intervention requirements.

Psychological Openness

Psychological Openness captures an individual’s baseline capacity and willingness to acknowledge internal affective distress, recognize psychological problems, and confront unresolved emotional conflict without resorting to rigid psychological defense mechanisms (such as repression, denial, or emotional suppression). Rather than measuring external service views directly, this subscale taps an internal intrapsychic orientation: the degree to which an individual accepts psychological vulnerability as a legitimate aspect of human experience.

Individuals scoring low on Psychological Openness exhibit high affective defensiveness, rigid stoicism, and emotional avoidance. They frequently endorse statements suggesting that introspective knowledge is unnecessary (e.g., Item 7: “It is probably best not to know everything about oneself”) and believe emotional suffering should remain concealed within private boundaries (e.g., Item 1: “There are certain problems which should not be discussed outside of one’s immediate family”). Conversely, high scorers show minimal reliance on experiential avoidance, freely validating personal distress and accepting that emotional dilemmas warrant introspection.

Help-Seeking Propensity

Help-Seeking Propensity measures an individual’s perceived self-efficacy, perceived behavioral control, behavioral intention, and confidence regarding professional psychological care. It addresses both cognitive confidence in therapeutic efficacy and logistical readiness to seek care when needed. This construct explicitly translates general openness into actionable behavioral agency.

High scores indicate that a person possesses clear healthcare literacy, understands how to access care, and believes that engaging professional resources is both practical and beneficial (e.g., Item 2: “I would have a very good idea of what to do and who to talk to if I decided to seek professional help for psychological problems”; Item 8: “If I were experiencing a serious psychological problem at this point in my life, I would be confident that I could find relief in psychotherapy”). In contrast, low scores reflect institutional helplessness, skepticism regarding the utility of counseling, and an extreme reliance on self-reliance or spontaneous remission (e.g., Item 12: “Psychological problems, like many things, tend to work out by themselves”).

Indifference to Stigma

Indifference to Stigma evaluates the degree to which an individual is unencumbered by societal stigma, anticipated public devaluation, and internalized shame regarding mental health treatment. Grounded in Erving Goffman’s sociological framework and modern psychiatric stigma theories, this subscale quantifies an individual’s resilience against perceived public discrimination.

Because items are scored such that higher scores represent more positive (adaptive) attitudes, high scores denote freedom from stigma sensitivity—that is, the person is indifferent to what neighbors, peers, or colleagues might think regarding their therapy attendance (e.g., disagreement with Item 24: “I would be embarrassed if my neighbor saw me going into the office of a professional who deals with psychological problems”). Conversely, low scores denote severe vulnerability to perceived public stigma and anticipated status loss (e.g., agreement with Item 6: “Having been mentally ill carries with it a burden of shame”; Item 11: “Important people in my life would think less of me if they were to find out that I was experiencing psychological problems”).

6. Theoretical Framework

The IASMHS is theoretically anchored at the convergence of behavioral health decision-making models, social cognition, and sociological stigma frameworks. Primarily, the scale maps directly onto Icek Ajzen’s (1985, 1991) Theory of Planned Behavior (TPB), which posits that actual health behavior is proximal to behavioral intention, which is guided by three core determinants: attitude toward the behavior, subjective norms, and perceived behavioral control.

By ensuring that its three subscales align with the three dimensions of the TPB, the IASMHS allows health psychologists to evaluate which specific cognitive-normative channel inhibits a population from forming a behavioral intention to access healthcare services.

Secondarily, the IASMHS draws from Ronald Andersen’s Behavioral Model of Health Services Use. Andersen categorizes healthcare utilization predictors into predisposing factors (socio-demographic characteristics, health beliefs, and cultural values), enabling resources (access to providers, knowledge of clinics, financial capacity), and need factors (perceived severity of illness). The IASMHS captures the interplay between predisposing cognitive values (Psychological Openness), perceived enabling factors and personal resources (Help-Seeking Propensity), and social structural impediments (Indifference to Stigma).

Finally, the scale incorporates sociopsychological conceptualizations of social stigma developed by Erving Goffman (1963) and expanded into mental health by Corrigan (2004) and Link et al. (1989). Mental health stigma operates at two levels: public stigma (social prejudice, stereotyping, and discrimination enacted by the external environment) and self-stigma (the internalization of public devaluation, culminating in reduced self-esteem and self-efficacy). The IASMHS specifically operationalizes an individual’s subjective vulnerability to both dimensions, recognizing that fear of label-induced devaluation serves as one of the most insidious obstacles to professional care-seeking.

7. Validity

The IASMHS has undergone rigorous validation across diverse populations, establishing strong construct, convergent, discriminant, and criterion-related validity.

Construct and Factorial Validity

In the foundational validation study by Mackenzie, Knox, Gekoski, and Macaulay (2004), construct validity was confirmed through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). CFA in an independent community sample demonstrated that the proposed three-factor oblique model fit the empirical data significantly better than competing unidimensional or orthogonal alternatives. Standard goodness-of-fit indices supported structural integrity (χ²/df ≤ 2.1, CFI = .93, RMSEA = .052), with all 24 items displaying substantial and statistically significant standardized factor loadings (> .40) onto their designated constructs.

Convergent Validity

Convergent validity has been extensively demonstrated through correlations with established legacy instruments and theoretically related psychological constructs:

• ATSPPHS Correlation: The IASMHS total score correlates very strongly with Fischer and Turner’s original ATSPPHS (r = .87, p < .001), indicating that the adapted instrument preserves the core conceptual breadth of help-seeking attitudes while providing cleaner subscale delineation.
• General Help-Seeking Intentions: The Help-Seeking Propensity subscale demonstrates robust positive correlations with the General Help-Seeking Questionnaire (GHSQ) (r = .61 to .68, p < .001), confirming that this subscale reliably mirrors immediate intention to consult formal healthcare providers.
• Stigma Metrics: The Indifference to Stigma subscale exhibits substantial negative correlations with the Perceived Devaluation-Discrimination Scale (PDD) (r = -.58, p < .001) and the Self-Stigma of Seeking Help (SSOSH) scale (r = -.64, p < .001). Individuals who score high on Indifference to Stigma consistently report lower anticipated shame and less internalized stereotype endorsement.
• Emotional Intelligence and Alexithymia: Psychological Openness shows significant negative correlations with the Toronto Alexithymia Scale (TAS-20) (r = -.45, p < .001) and significant positive associations with emotional expression, confirming that this dimension captures genuine affective receptivity rather than superficial compliance.

Discriminant Validity

The IASMHS demonstrates solid discriminant validity against unrelated personality and clinical constructs. Correlations with the Marlowe-Crowne Social Desirability Scale remain uniformly low to negligible (r = .06 to .14), demonstrating that respondent answers are not artifacts of social desirability bias. Furthermore, the subscales correlate weakly with global neuroticism, general cognitive aptitude, and somatic symptom reporting, demonstrating that attitudes toward professional help-seeking operate independently of baseline psychiatric symptom intensity.

Predictive and Criterion Validity

Mackenzie et al. (2004, 2006) investigated whether IASMHS scores differentiated individuals with past mental health utilization from service-naïve individuals. Logistic regression analyses indicated that individuals who had consulted a mental health professional in the past scored significantly higher on all three subscales—most prominently on Help-Seeking Propensity (Odds Ratio = 2.45, p < .001) and Psychological Openness (Odds Ratio = 1.82, p < .01)—after controlling for age, gender, education, and current symptom severity. Prospective studies have confirmed that baseline IASMHS scores accurately predict actual clinic attendance over a 12-month follow-up window.

8. Reliability

Psychometric evaluations demonstrate that the IASMHS possesses exceptional reliability across both internal consistency and temporal stability metrics.

Internal Consistency Reliability

In the original validation cohorts (Mackenzie et al., 2004), Cronbach’s alpha coefficients demonstrated strong internal consistency across the instrument:

• Full Scale IASMHS (24 items): α = .87
• Psychological Openness (8 items): α = .76 to .82
• Help-Seeking Propensity (8 items): α = .78 to .84
• Indifference to Stigma (8 items): α = .79 to .85

Subsequent psychometric evaluations across global adaptations have replicated these values. For instance, in cross-cultural adaptations (including Chinese, Turkish, Italian, Portuguese, and Persian validations), Cronbach’s alpha for the full scale consistently falls between .84 and .90, with subscale alphas rarely dropping below .74. McDonald’s omega (ω) coefficients, which offer a more robust estimate of reliability under conditions of tau-inequivalence, mirror these results (ω ≥ .86 for the total score).

Test-Retest Stability

Temporal stability was established by administering the scale to an undergraduate cohort across a 3-week test-retest interval. Pearson product-moment correlations demonstrated high longitudinal reliability:

• Full Scale Test-Retest Coefficient: r = .85 (p < .001)
• Psychological Openness: r = .74 (p < .001)
• Help-Seeking Propensity: r = .81 (p < .001)
• Indifference to Stigma: r = .86 (p < .001)

These figures illustrate that while help-seeking attitudes can shift in response to major life events, therapeutic interventions, or educational campaigns, they remain remarkably stable personality-adjacent attitudinal constructs under baseline conditions.

9. Factor Analysis

The factorial architecture of the IASMHS was developed through a two-phase psychometric design involving Exploratory Factor Analysis (EFA) followed by Confirmatory Factor Analysis (CFA) across distinct independent cohorts.

Exploratory Factor Analysis (EFA)

Starting with an initial pool of candidate items derived from the ATSPPHS and newly authored statements targeting behavioral control and modern stigma forms, Mackenzie et al. (2004) executed an EFA using principal axis factoring with oblique (promax) rotation, reflecting the theoretical expectation that dimensions of help-seeking attitudes covary. The screen plot and Kaiser-Guttman criterion (eigenvalues > 1.0) unambiguously confirmed three distinct factors, which collectively accounted for 42.8% of the total variance.

Items were selected based on three strict criteria: (a) factor loading ≥ .40 on the primary factor, (b) cross-loadings ≤ .25 on non-target factors, and (c) conceptual coherence with the intended theoretical construct. This yielded the definitive 24-item scale, with exactly 8 items loading cleanly onto each of the three dimensions.

Confirmatory Factor Analysis (CFA)

The three-factor structure was subsequently tested in a diverse adult community sample using structural equation modeling. The empirical fit of the proposed three-factor correlated model demonstrated acceptable to excellent indices:

• Chi-Square / Degrees of Freedom Ratio (χ²/df): 1.94 (values < 3.0 indicate excellent fit)
• Comparative Fit Index (CFI): .934
• Tucker-Lewis Index (TLI): .925
• Root Mean Square Error of Approximation (RMSEA): .051 (90% Confidence Interval: [.043, .059])
• Standardized Root Mean Square Residual (SRMR): .054

Alternative models, including a unidimensional general factor model (χ²/df = 5.82, CFI = .621, RMSEA = .128) and a two-factor model combining Openness and Propensity (χ²/df = 3.91, CFI = .784, RMSEA = .094), exhibited poor fit and were rejected. Standardized path coefficients (item loadings) on primary factors ranged between .42 and .79 (all p < .001). Inter-factor correlations revealed moderate positive associations: Psychological Openness correlated with Help-Seeking Propensity at r = .48, and with Indifference to Stigma at r = .34; Help-Seeking Propensity and Indifference to Stigma correlated at r = .39. These moderate correlations indicate that while the three subscales share variance as components of an overarching help-seeking attitude, they remain sufficiently distinct to prevent multicollinearity and justify separate subscale scoring.

10. Instrument / Measurement Tool

• Tool Name: Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS)
• Alternative Acronym: IASMHS
• Authors: Corey S. Mackenzie, V. Jane Knox, W. L. Gekoski, and Heather L. Macaulay
• Publication Year: 2004
• Measurement Format: 24 self-report items
• Target Population: Adolescents and adults (ages 16 to 90+ years) across general community, clinical, university, and occupational settings
• Administration Time: Approximately 5 to 8 minutes
• Response Scale: 5-point Likert-type scale scored as:
  • 0 = disagree
  • 1 = somewhat disagree
  • 2 = are undecided
  • 3 = somewhat agree
  • 4 = agree
• Subscale Allocation:
  • Psychological Openness (8 items): 1, 4, 7, 9, 12, 14, 18, 21
  • Help-Seeking Propensity (8 items): 2, 5, 8, 10, 13, 15, 19, 22
  • Indifference to Stigma (8 items): 3, 6, 11, 16, 17, 20, 23, 24
• Scoring and Reverse-Scoring Protocol:
  • The IASMHS contains both positively and negatively keyed items to safeguard against acquiescence response bias.
  • Positively Scored Items (Direct): Items 2, 5, 8, 10, 13, 15, 19, 22, 23. These items are scored directly as marked: disagree = 0, somewhat disagree = 1, are undecided = 2, somewhat agree = 3, agree = 4.
  • Reverse-Scored Items: Items 1, 3, 4, 6, 7, 9, 11, 12, 14, 16, 17, 18, 20, 21, 24. These items must be recoded prior to calculation: 0 becomes 4, 1 becomes 3, 2 remains 2, 3 becomes 1, and 4 becomes 0.
  • Notice that all items on the Psychological Openness subscale (1, 4, 7, 9, 12, 14, 18, 21) are reverse-scored; on the Indifference to Stigma subscale, all items (3, 6, 11, 16, 17, 20, 24) except Item 23 are reverse-scored; and all items on the Help-Seeking Propensity subscale are directly scored.
• Interpretation of Scores:
  • Subscale Range: 0 to 32 points per subscale.
  • Total Score Range: 0 to 96 points (computed by summing all three subscales).
  • Higher scores uniformly indicate more favorable, adaptive orientations toward seeking professional mental health treatment, greater openness to psychological introspection, higher perceived behavioral efficacy, and greater resilience against public stigma.

11. Permissions & Fee and Test Year

The Inventory of Attitudes Toward Seeking Mental Health Services was originally published in 2004 in the Journal of Applied Social Psychology. The instrument is considered an open-access psychometric scale for non-commercial academic, scientific research, and clinical educational purposes. No licensing fees or formal royalties are required to administer the scale for non-commercial scholarly research, student theses, or clinical institutional triage.

Researchers and clinicians utilizing the IASMHS are required to cite the original 2004 validation paper (Mackenzie et al., 2004) in all ensuing publications, presentations, and technical reports. For commercial applications, electronic medical record (EMR) software integrations, or proprietary digital platform deployment, users should contact the primary developer, Dr. Corey S. Mackenzie, at the University of Manitoba to obtain explicit written authorization.

12. References

• Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckmann (Eds.), Action control: From cognition to behavior (pp. 11–39). Springer. https://doi.org/10.1007/978-3-642-69746-3_2
• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://doi.org/10.1037/0003-066X.59.7.614
• Fischer, E. H., & Turner, J. I. (1970). Orientations to seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35(1, Pt. 1), 79–90. https://doi.org/10.1037/h0029636
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Link, B. G., Cullen, F. T., Struening, E., Shrout, P. E., & Dohrenwend, B. P. (1989). A modified labeling theory approach to mental disorders: An empirical assessment. American Sociological Review, 54(3), 400–423. https://doi.org/10.2307/2095613
• Mackenzie, C. S., Gekoski, W. L., & Knox, V. J. (2006). Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging & Mental Health, 10(6), 574–582. https://doi.org/10.1080/13607860600641200
• Mackenzie, C. S., Knox, V. J., Gekoski, W. L., & Macaulay, H. L. (2004). An adaptation and extension of the Attitudes Toward Seeking Professional Psychological Help Scale. Journal of Applied Social Psychology, 34(11), 2410–2433. https://doi.org/10.1111/j.1559-1816.2004.tb01984.x

13. Items of the Scale (Questionnaire)