Self-Stigma of Seeking Help Scale (SSOSH)

Abstract

The Self-Stigma of Seeking Help Scale (SSOSH) is a widely utilized, 10-item psychometric instrument developed by David L. Vogel, Nathaniel G. Wade, and Shawn Haake in 2006 to assess the internalized stigma an individual experiences when contemplating or engaging in professional psychological services. While public stigma reflects the broader societal stereotypes, prejudice, and discriminatory attitudes directed toward people who seek mental health care, self-stigma represents the internalization of these negative societal appraisals, resulting in diminished self-esteem, perceived inadequacy, and subjective loss of personal worth. The SSOSH operationalizes this psychological mechanism through a unidimensional construct evaluated on a 5-point Likert response scale ranging from 1 (strongly disagree) to 5 (strongly agree). Psychometric investigations across diverse clinical, non-clinical, collegiate, military, and cross-national populations have confirmed that the SSOSH exhibits robust psychometric integrity. Internal consistency reliability typically yields Cronbach’s alpha (α) coefficients between .86 and .91, accompanied by solid two-month test-retest reliability (r = .72). Confirmatory factor analyses consistently substantiate a unidimensional factor structure, demonstrating strong measurement invariance across biological sex and varying cultural contexts. The scale demonstrates profound convergent validity through inverse associations with attitudes toward seeking professional psychological help and actual counseling utilization, while exhibiting discriminant validity from general self-esteem, generalized self-efficacy, and global psychological distress. As an empirically sound and concise instrument, the SSOSH serves as a cornerstone measure in counseling psychology, clinical assessment, behavioral health research, and public health intervention design aimed at ameliorating barriers to psychological treatment.

Keywords

Self-Stigma of Seeking Help Scale, SSOSH, mental health stigma, internalized stigma, help-seeking behavior, counseling attitudes, psychological barriers, psychometrics, scale validation, clinical assessment

Authors

The Self-Stigma of Seeking Help Scale was developed and validated by a team of researchers in counseling psychology based at Iowa State University:

• David L. Vogel, Ph.D. – Professor of Psychology, Department of Psychology, Iowa State University, Ames, Iowa, United States. Dr. Vogel’s empirical program centers on the social-cognitive processes that facilitate or hinder psychological help-seeking, with a primary focus on public stigma, internalized self-stigma, gender role socialization, and health communication interventions.
• Nathaniel G. Wade, Ph.D. – Professor of Psychology and Director of Training, Department of Psychology, Iowa State University, Ames, Iowa, United States. Dr. Wade specializes in group psychotherapy, forgiveness interventions, and the intersection of social stigma, interpersonal processes, and therapy utilization.
• Shawn Haake, M.S. – Department of Psychology, Iowa State University, Ames, Iowa, United States. Co-investigator and psychometrician involved in the initial instrument development, item generation, and structural validation of the SSOSH.

Further cross-cultural validation and structural modeling extensions of the instrument were conducted in collaboration with international researchers, notably Patrick Ian Armstrong, Ph.D., Pei-Chun Tsai, Ph.D., and Ashley H. Hackler, M.S.

Purpose

The primary purpose of the Self-Stigma of Seeking Help Scale (SSOSH) is to quantify the degree to which an individual internalizes societal stigmas regarding psychological counseling, leading to a perceived reduction in self-worth, personal agency, or self-respect if they were to seek professional psychological assistance. For decades, mental health epidemiologists observed a persistent discrepancy between the high prevalence of psychiatric morbidity and the low rates of treatment utilization across global populations. While structural barriers (such as financial constraints, lack of health insurance, and provider scarcity) play an undeniable role, psychological and attitudinal barriers frequently represent the most potent impediments to service engagement.

Prior to the introduction of the SSOSH, existing stigma instruments conflated perceived public stigma (the belief that society devalues individuals who seek psychological help) with self-stigma (the application of those devaluing beliefs to oneself). This theoretical conflation hindered researchers from identifying the precise psychological mechanisms that deter individuals in distress from pursuing care. Empirical studies demonstrated that perceived public stigma alone often fails to directly predict help-seeking intentions; rather, public stigma operates indirectly by fueling internalized self-stigma. The SSOSH was specifically constructed to address this gap by isolating the self-evaluative threat inherent in seeking therapy.

In clinical, counseling, and applied research settings, the SSOSH fulfills several vital functions:

• Identification of High-Risk Non-Seekers: Clinical outreach programs in university counseling centers, military organizations, and primary care settings utilize the SSOSH to identify subpopulations that harbor high levels of internalized shame, enabling tailored outreach that normalizes distress.
• Intervention Evaluation: Public health campaigns and pre-therapy orientation programs targeting help-seeking attitudes deploy the SSOSH as an outcome measure to assess whether psychoeducational or narrative-based interventions successfully reduce self-stigmatizing beliefs.
• Theoretical and Structural Equation Modeling: Researchers employ the scale within path-analytic models to test mediators and moderators linking distal sociocultural variables (e.g., traditional masculinity ideology, cultural collectivism, family social norms) to proximal behavioral outcomes (e.g., scheduling a clinical intake, adhering to psychotherapy).

Psychological Construct

The construct measured by the SSOSH is self-stigma associated with seeking psychological help. In psychometric literature, this construct is defined as the reduction in an individual’s self-esteem or self-worth that occurs when the individual perceives themselves as weak, inadequate, incompetent, or socially unacceptable because they utilize or consider utilizing mental health services.

Self-stigma represents an internal psychological process characterized by distinct cognitive and affective features:

• Cognitive Appraisal of Threat to Self-Regard: Individuals scoring high on self-stigma view the act of consulting a therapist not as a proactive, problem-solving measure, but as concrete evidence of cognitive or emotional failure. Items such as "Seeking psychological help would make me feel less intelligent" operationalize the cognitive distortion that personal problem-solving ability is antithetical to seeking guidance from a professional.
• Affective Experiences of Inadequacy and Shame: Unlike public stigma, which evokes fear of external social rejection or discrimination, self-stigma evokes internally generated feelings of inferiority, personal degradation, and shame. Items such as "I would feel inadequate if I went to a therapist for psychological help" tap into the visceral self-reproach experienced by the individual.
• Erosion of Self-Confidence and Agency: The construct encompasses the anticipation that utilizing help will permanently compromise one’s self-concept and independence. Reverse-scored items such as "My self-confidence would NOT be threatened if I sought professional help" measure the presence of psychological resilience and the capacity to perceive help-seeking as congruent with personal agency.

It is clinically and theoretically paramount to distinguish self-stigma from related but distinct constructs. Public stigma is externally focused ("Others will judge me if I see a therapist"), generalized self-esteem reflects a global affective orientation toward the self across all life domains, and attitudes toward seeking professional psychological help reflect cognitive evaluations of the utility and effectiveness of psychotherapy. Self-stigma specifically captures the self-evaluative cost: "What does it say about me if I need therapy?"

Theoretical Framework

The theoretical architecture of the SSOSH is firmly anchored in the sociocognitive models of mental illness stigma advanced by Patrick W. Corrigan, integrated with cognitive appraisal theory (Richard Lazarus & Susan Folkman) and the modified labeling theory of Bruce Link and colleagues.

Corrigan’s Progressive Model of Self-Stigma

Corrigan formulated a four-stage hierarchical model explaining how societal prejudice transforms into private self-hatred:

1. Awareness: The individual becomes aware of prevailing cultural stereotypes depicting individuals who seek therapy as emotionally defective, volatile, or hopelessly incompetent.
2. Agreement: The individual cognitively endorses these cultural stereotypes as legitimate, rational, and objectively true.
3. Application: When experiencing distress, the individual applies these endorsed stereotypes directly to the self ("I need therapy; therefore, I am defective").
4. Harm to Self-Esteem: The direct application results in psychological harm, producing drops in self-efficacy, feelings of self-loathing, and what Corrigan famously coined the "why try" effect (why try to seek treatment, improve my life, or set goals if I am inherently damaged?).

The SSOSH directly operationalizes the third and fourth stages of this framework: the catastrophic application of mental health stereotypes to personal self-identity and the resulting threat to self-regard.

Cognitive Appraisal and Stress-Coping Theory

In accordance with Lazarus and Folkman’s stress and coping model, entering psychotherapy can be cognitively appraised either as a challenge (an adaptive coping mechanism) or as a profound threat (an indictment of personal capacity). When an individual perceives seeking help as a core threat to self-integrity, the ego mobilizes defensive avoidance behaviors. Consequently, avoidance of psychological treatment serves as an immediate, maladaptive defense mechanism to preserve fragile self-esteem at the expense of long-term symptom relief. The SSOSH quantifies this specific perceived ego threat.

Validity

The psychometric validation of the SSOSH across original development studies (Vogel, Wade, & Haake, 2006) and subsequent international investigations has established exceptional construct, convergent, discriminant, and predictive validity.

Construct and Convergent Validity

In the seminal 2006 validation samples involving collegiate and community cohorts, the SSOSH exhibited robust, theoretically expected correlations with established constructs:

• Perceived Public Stigma: Correlated positively with the Stigma Scale for Receiving Psychological Help (SSRPH; Komiya et al., 2000), showing moderate coefficients (r = .46 to .48), confirming that while self-stigma relates to public stigma, the two are empirically separable.
• Attitudes Toward Seeking Help: Correlated strongly and negatively with Fischer and Turner’s Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; r = -.53 to -.63), demonstrating that higher self-stigma leads to marked aversion toward psychological services.
• Intentions to Seek Counseling: Correlated negatively with the Intentions to Seek Counseling Inventory (ISCI; Cash et al., 1975), yielding coefficients ranging from r = -.30 to -.44 across both vocational and psychological distress domains.
• Disclosure Expectations: Associated positively with anticipated risks of disclosing personal information to a counselor (r = .40) and negatively with anticipated utility of emotional disclosure (r = -.32).

Discriminant Validity

To verify that the SSOSH does not merely capture general negative self-concept or affective distress, discriminant analyses were conducted against standard personality and psychiatric indices:

• Global Self-Esteem: Correlated only modestly with the Rosenberg Self-Esteem Scale (r = -.11 to -.22), confirming that the SSOSH measures a situational, help-seeking-specific threat rather than baseline trait self-worth.
• Generalized Self-Efficacy: Displayed low correlations with general self-efficacy scales (r = -.14), showing that feeling capable in everyday tasks does not protect against help-seeking self-stigma.
• Psychological Distress Severity: Correlated minimally with depressive and anxiety symptom severity on the Symptom Checklist-90-Revised (SCL-90-R) and the Patient Health Questionnaire-9 (PHQ-9) (r values typically between .05 and .16), proving that endorsement of self-stigma is independent of current psychopathology levels.

Predictive and Behavioral Validity

Crucially, longitudinal investigations by Vogel, Wade, and Hackler (2007) and Vogel et al. (2013) demonstrated behavioral predictive validity. In structural equation models, the SSOSH fully mediated the relationship between public stigma and willingness to seek counseling. Furthermore, in longitudinal clinical tracking designs, students who scored high on the SSOSH at the beginning of an academic semester were significantly less likely to attend an intake appointment at university mental health clinics over a two-month tracking window, even when controlling for high levels of subjective psychological distress.

Cross-Cultural Validity

Vogel et al. (2013) conducted a comprehensive cross-national validation study across six nations: the United States, Taiwan, the United Kingdom, Turkey, Greece, and Israel. The 10-item SSOSH maintained structural integrity across all six cultural cohorts, validating its cross-cultural metric and scalar invariance when translated and adapted appropriately.

Reliability

The SSOSH has undergone extensive testing for both internal consistency and temporal stability across diverse populations, repeatedly surpassing standard psychometric thresholds.

Internal Consistency Reliability

Across validation and replication samples, the SSOSH demonstrates high internal consistency:

• In the initial scale construction samples (Vogel et al., 2006), Cronbach’s alpha coefficients were reported at α = .86 (Sample 1, N = 591 university undergraduates), α = .89 (Sample 2, N = 219), α = .87 (Sample 3, N = 209), and α = .91 (Sample 4, N = 175).
• Subsequent studies among specific subpopulations have reported comparable coefficients: military veterans (α = .89; Wade et al., 2011), rural community residents (α = .88; Brenner et al., 2018), and racial/ethnic minority college students (α = .87 to .90; Nam et al., 2013).
• McDonald’s hierarchical omega (ω) has routinely ranged from .87 to .92, reinforcing that the scale exhibits high composite reliability without being contaminated by multidimensional residual variance.

Test-Retest Reliability

The temporal stability of the SSOSH was assessed across a two-month interval in a non-clinical sample (Vogel et al., 2006, Sample 4). The test-retest correlation coefficient was r = .72 (p < .001), indicating moderate-to-high temporal stability. This coefficient reflects the theoretical expectation that while self-stigma represents a relatively stable cognitive schema, it retains sufficient state-dependent malleability to respond to educational interventions or therapeutic reframing.

Factor Analysis

The dimensional structure of the SSOSH was evaluated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) during the initial psychometric validation process and in subsequent independent structural replications.

Exploratory Factor Analysis (EFA)

In the initial scale development study, an initial pool of candidate items was administered to an undergraduate cohort (N = 591). Principal axis factoring with promax rotation was utilized to explore underlying latencies. Both the Kaiser-Guttman eigenvalue-greater-than-one rule and the Cattell scree test revealed a sharp discontinuity after the first factor:

• Eigenvalues: Factor 1 had an eigenvalue of 4.42, explaining 44.2% of the total item variance, whereas Factor 2 yielded an eigenvalue of only 0.89, falling well below the retention threshold.
• Factor Loadings: All 10 retained items demonstrated robust primary factor loadings on the single construct, ranging from .52 to .78, with no significant cross-loadings. The item-total correlations ranged from .43 to .71.

Confirmatory Factor Analysis (CFA)

To confirm the unidimensional model, CFA was conducted on an independent sample (N = 219) using maximum likelihood estimation. The single-factor model demonstrated an outstanding fit to the empirical data:

• Chi-Square / Degrees of Freedom: χ²(35, N = 219) = 52.88, p = .027 (χ²/df = 1.51)
• Comparative Fit Index (CFI): .98 (exceeding the standard .95 cutoff)
• Tucker-Lewis Index (TLI): .97
• Root Mean Square Error of Approximation (RMSEA): .048 (90% CI [.017, .072])
• Standardized Root Mean Square Residual (SRMR): .038

Alternative two-factor models (e.g., separating positively worded and negatively worded items into methodological artifact factors) were tested; while method factors for reverse scoring slightly improved mathematical fit, researchers concluded that the single-factor substantive model provided the most parsimonious, theoretically grounded representation of the data.

Instrument / Measurement Tool

• Test Type: Self-report psychometric questionnaire; cognitive-affective appraisal scale
• Format: Paper-and-pencil, computer-administered, or web-based survey format
• Number of Items: 10 items
• Response Scale: 5-point Likert scale:
  • 1 = strongly disagree
  • 2 = somewhat disagree
  • 3 = agree and disagree equally
  • 4 = somewhat agree
  • 5 = strongly agree
• Reverse-Scored Items: Five items are positively worded (reflecting low stigma or high resilience) and must be reverse-scored prior to calculating final metrics:
  • Item 2: "My self-confidence would NOT be threatened if I sought professional help."
  • Item 4: "My self-esteem would increase if I talked to a therapist."
  • Item 5: "My view of myself would not change just because I made the choice to see a therapist."
  • Item 7: "I would feel okay about myself if I made the choice to seek professional help."
  • Item 9: "My self-confidence would remain the same if I sought help for a problem I could not solve."

  Reverse-coding key: 1 → 5, 2 → 4, 3 → 3, 4 → 2, 5 → 1.

• Scoring Procedures: After reverse-scoring Items 2, 4, 5, 7, and 9, scores can be calculated as:
  • Sum Score: Summing all 10 items (theoretical range: 10 to 50). Higher total scores indicate higher levels of self-stigma regarding psychological help-seeking.
  • Mean Score: Calculating the average across all 10 items (theoretical range: 1.00 to 5.00). Scores significantly above 3.00 denote active internalized stigma, whereas scores below 3.00 indicate relative freedom from internalized help-seeking stigma.
• Administration Time: Approximately 2 to 4 minutes.
• Target Population: Adolescents and adults (ages 14 and older) across general, college, military, and clinical populations.

Permissions & Fee and Test Year

The Self-Stigma of Seeking Help Scale was initially published in 2006 in the Journal of Counseling Psychology, copyrighted by the American Psychological Association (APA). The scale was developed with the explicit intent of advancing scientific research into mental health barriers and is openly accessible for academic, clinical, and non-commercial educational research purposes without fee.

Researchers wishing to use the SSOSH in scholarly investigations do not require formal written authorization from the primary authors or the APA, provided that appropriate scholarly attribution is maintained in all resulting publications, dissertations, and professional reports. For commercial usage, digital redistribution, or inclusion in proprietary healthcare platforms, formal permission must be requested via the American Psychological Association’s Rights and Permissions department.

References

• Brenner, R. E., Cornish, M. A., Heath, P. J., Lannin, D. G., & Vogel, D. L. (2018). Stigma, help-seeking, and suicidal ideation: The moderating role of self-compassion. Journal of Counseling Psychology, 65(3), 346–356. https://doi.org/10.1037/cou0000266
• Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://doi.org/10.1037/0003-066X.59.7.614
• Nam, S. K., Choi, S. I., Lee, J. H., Lee, M. K., Kim, A. R., & Lee, S. M. (2013). A meta-analysis of factors related to help-seeking attitudes: An examination of personal, social, and cultural factors. Journal of Counseling Psychology, 60(2), 241–257. https://doi.org/10.1037/a0030177
• Vogel, D. L., Armstrong, P. I., Tsai, P. C., Wade, N. G., Hammer, J. H., Efstathiou, G., Holoma, N. G., Miville, M. L., Moorhead, M., & Topkaya, N. (2013). Cross-cultural validity of the Self-Stigma of Seeking Help (SSOSH) scale: Examination across six nations. Journal of Counseling Psychology, 60(2), 303–310. https://doi.org/10.1037/a0032055
• Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53(3), 325–337. https://doi.org/10.1037/0022-0167.53.3.325
• Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40–50. https://doi.org/10.1037/0022-0167.54.1.40
• Wade, N. G., Vogel, D. L., Rochlen, A. B., & Scheidt, J. (2011). Men’s help-seeking: Psychological distress, gender role conflict, and the role of self-stigma. Psychology of Men & Masculinity, 12(4), 369–382. https://doi.org/10.1037/a0023880

Items of the Scale