Self-distancing as a path to help-seeking for people with depression

Journal Pre-proof Self-distancing as a path to help-seeking for people with depression Sara M. Hollar, Jason T. Siegel PII:

S0277-9536(19)30695-1

DOI:

https://doi.org/10.1016/j.socscimed.2019.112700

Reference:

SSM 112700

To appear in:

Social Science & Medicine

Received Date: 29 January 2019 Revised Date:

14 November 2019

Accepted Date: 23 November 2019

Please cite this article as: Hollar, S.M., Siegel, J.T., Self-distancing as a path to help-seeking for people with depression, Social Science & Medicine (2019), doi: https://doi.org/10.1016/ j.socscimed.2019.112700. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd.

Running Head: SELF-DISTANCING AND SEEKING HELP FOR DEPRESSION

Self-Distancing as a Path to Help-Seeking for People with Depression

Sara M. Hollar Jason T. Siegel Claremont Graduate University

Corresponding Author: Sara M. Hollar 150 E 10th St, Claremont, CA 91711 [email protected]

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Introduction Depression affects approximately 20% of Americans during their lifetimes, and rates appear to be increasing (Hasin et al., 2018; Kessler et al., 2005). Although depression severity can vary, symptoms are often debilitating—such as limited pleasure in things that once brought joy, persistent fatigue, and consistent negative mood (American Psychiatric Association, 2013). Impairment increases as depression deepens—people experiencing severe depression report overall functioning one full standard deviation below the national mean (Hasin et al., 2018). Depression is treatable (Collado, Lim, & MacPherson, 2016) and evidence suggests that treatment rates are increasing. In a nationally representative sample, nearly 70% of people who had experienced depression in their lifetime eventually sought some type of treatment (Hasin et al., 2018). However, this leaves 30% of people untreated, and the average delay between depression onset and start of treatment can reach 47 months (Hasin et al., 2018). In one survey, only 35% of people with severe depressive symptomology reported seeing a mental health professional in the past year (Pratt & Brody, 2014). Unlike many other diseases—where severity predicts help-seeking—studies typically find an inverse relationship between depression severity and help-seeking intentions (e.g., Huntley & Fisher, 2016). Accordingly, scholars have investigated methods to understand and increase help-seeking among those with depression (e.g. Thompson, Sugg, & Runkle, 2018). Some efforts to increase help-seeking have been successful (Beaudoin, 2008; Siegel & Thomson, 2017), but others have not been able to significantly improve help-seeking attitudes (Dueweke & Bridges, 2017; see Gulliver, Griffiths, Christensen, & Brewer, 2012 for a review of help-seeking interventions). Most troubling, some interventions have made participants with depression less likely to seek help (e.g., Batterham, Calear, Sunderland, Carragher, & Brewer, 2016; Lienemann, Siegel, &

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Crano, 2013). These mixed results show the importance of taking into account barriers to helpseeking (e.g. stigma, Henshaw, Durkin, & Snell, 2016; Klik, Williams, & Reynolds, 2019) as well as the cognitive processes underlying depression when developing help-seeking interventions (Siegel, Lienemann, & Rosenberg, 2017). Beck’s Cognitive Theory of depression (CTD; Beck, 1967, 1974; Rush & Beck, 1978) provides a framework for understanding both the cognitive changes brought about by depression, and the challenges faced by those seeking to increase help-seeking. The CTD holds that individuals with depression experience a persistent depressogenic schema in which cognitions are negatively biased. According to Beck, the salience of negative information leads to patterns of thought that are labeled in the CTD as the cognitive triad, which refers to pervasive and lasting negative views of oneself, the world, and the future. The theory holds that “the more severe the depressive state, the more frequent and pervasive the negative self-referent automatic thoughts and the more prominent the negativity processing bias” (Clark, Beck & Alford, 1999, p. 168). Illustrative of these biases’ influence on help-seeking cognitions, Lienemann and Siegel (2016) found that higher levels of depressive symptomatology were associated with more negative attitudes, expectations, and intentions regarding help-seeking. In a review building upon Beck’s theorizing, Wisco (2009) concludes there is substantial evidence that “depressive thought is more negative for self-relevant than for externally-focused content” (Wisco, 2009, p. 382). In line with this thinking, some research on depression indicates that negative self-referent information processing both predicts and maintains depression over time (Black & Pössel, 2013; Pyszczynski & Greenberg, 1987). So powerful is the negative bias toward self-relevant information in people with depression that reflecting on positive and happy memories about the self can result in worsened mood for this population (Joormann & Siemer,

SELF-DISTANCING AND SEEKING HELP FOR DEPRESSION 2004; Keeler & Siegel, 2016). Although the negative bias toward self-relevant information provides a partial explanation for the challenges faced by scholars seeking to increase helpseeking, it also provides an opportunity. If interventions encouraging help-seeking could minimize the perceived self-relevance of a message, then it could maximize the likelihood of success. In line with this line of thinking, Siegel, Lienemann, and Tan (2015) scripted messages guided by the overheard communication technique (Walster & Festinger, 1962) to appear as if addressed to individuals without depression (e.g., “Do you know someone who is feeling distressed?”) instead of people with depression (e.g., “Are you feeling distressed?”). In two studies, the overhead communications were more successful at increasing help-seeking intentions among people with heightened depressive symptomatology than the direct messages. Siegel and Thomson (2017) also have found success by using a positive emotion infusion of the other-focused emotion of elevation—an emotion that occurs when someone witnesses another act in a morally outstanding manner to someone besides the self. Participants who were induced to feel elevation reported increased levels of help-seeking intentions. Further support for the potential utility of approaches that minimize self-relevance is found in the therapeutic realm by Wisco (2009), who described how "when challenging automatic thoughts, cognitive therapists will often urge a client to consider what he would think if the same situation happened to a friend, with the rationale that we're easier on others than we are on ourselves” (p. 389). In line with these approaches, we assess whether self-distancing offers a path for increasing helpseeking among people with heightened depressive symptomatology. Self-Distancing Self-distancing, or reviewing information from a third-party perspective, can be a

4

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powerful emotional regulation strategy. It has been shown to promote better conflict resolution (Finkel, Slotter, Luchies, Walton, & Gross, 2013), improve reasoning about personal issues, (Grossmann & Kross, 2014) and reduce emotional reactivity to difficult situations (Kross, Duckworth, Ayduk, Tsukayama, & Mischel, 2011). Self-distancing is frequently operationalized by reflecting on an experience as if one was a fly on the wall, or watching a movie of one’s self. Much of current self-distancing research was borne from the observation that sometimes replaying past events is not adaptive and instead leads to rumination and increased negative mood (Kross, Ayduk, & Mischel, 2005). Kross and colleagues propose that recounting an event from a self-immersed perspective, as if the event were reoccurring, does not lead to adaptive outcomes. Instead, self-distancing from the emotionality of the event allows individuals to reconstrue the event and draw meaning from it, leading to better outcomes. It also leads to lowered emotional reactivity than self-immersion when recalling a memory (Ayduk & Kross, 2010) and when focusing on the future (White, Kuehn, Duckworth, Kross, & Ayduk, 2018). Self-distancing has much in common with some tactics used in current treatment of mood disorders like cognitive behavior therapy and acceptance therapy, where individuals are asked to reappraise thoughts and feelings with self-compassion, sometimes by asking what they might say to a friend in a similar circumstance, or by treating the self as a beloved friend (Diedrich, Grant, Hofmann, Hiller, & Berking, 2014). Given that the depressogenic schema exerts the greatest influence over the processing of self-relevant materials (Wisco, 2009), we considered whether using a self-distancing approach could increase the impact of help-seeking interventions seeking to influence people with depression. Kross and Ayduk (2009) found those with depression were able to take a distanced perspective, and in cases where they did so, this was associated with lower emotional reactivity. Current Studies

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The current studies adapt a common method of self-distancing and apply it to helpseeking, focusing solely on people with heightened depressive symptomatology who have not sought help for depression. As the negative automatic thoughts associated with depression are most severe when processing self-relevant information, taking the position of another was expected to minimize the negative biases associated with the disorder. Across three studies, participants were prompted to take a distanced perspective or a self-immersive perspective on a prior experience when they considered help-seeking. Studies 2 and 3, which were registered on the Open Science Framework, also included a true control condition. We hypothesized that participants who took a distanced perspective would display higher intentions to seek help, hold more positive expectations about help-seeking, and possibly would display lower levels of selfstigma. Studies 1 and 3 used writing tasks as experimental stimuli, while Study 2 used a video manipulation to approximate a public service announcement. The Institutional Review Board of Claremont Graduate University approved all study materials and procedures. Study 1 Bringing together past prompts from work by other researchers who have used distancing to improve decision making (Finkel et al., 2013; Kross & Ayduk, 2009, 2011), we developed a short writing task to bring about a distanced or immersive point of view. We hypothesized that people with depressive symptomatology would display greater intentions to seek help and higher help-seeking outcome expectations if they had responded to the distancing, rather than the immersive, task. We also included a measure of self-stigma as an exploratory variable to inform future research regarding the pathways by which distancing might impact help-seeking. Method Participants. We recruited participants through Amazon’s Mechanical Turk (MTurk). A

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separate screening survey contained the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and demographic information. The BDI-II is a commonly utilized measure for assessing depressive symptomatology (e.g., Merchand et al., 2016). There were 500 participants that completed the screening survey for $0.25: 51.6% female (n = 258), 48.0% male (n = 240), while two self-described their gender (0.4%). Of the participants who took the screener, those scoring above 13, indicating at least mild depressive symptomatology, and who reported never seeking help for depression were invited to take a follow-up survey for an additional $0.75. This resulted in a majority male sample (55.7% male, 44.3% female), as more men than women indicated no prior help-seeking. There were no respondents that qualified as univariate or multivariate outliers, and all participants wrote for at least 60 seconds in response to the prompt. The final sample for analyses was 61 participants, with 33 in the immersive condition, and 28 in the distancing condition. Of the participants included in analyses, the average score on a 7-point question asking if they consider themselves to be currently depressed from 1 (definitely not) to 7 (definitely yes) was 4.11 (SD = 1.51). See Table 1 for demographic information. There were no missing data. Procedure. Once participants gave informed consent, they were randomly assigned to the self-distancing or self-immersive condition. These prompts were adapted from prior distancing studies (Finkel et al., 2013; Kross & Ayduk, 2011). In both conditions, participants were asked to recall “a time they had been feeling down and had considered asking for help.” Then, in the self-immersive condition, they were asked to relive that moment, recall what they had been thinking, and replay the moment through their own eyes. Participants in the selfdistancing condition were asked to replay the moment, but to watch themselves from the point of

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view of a neutral third-party, and attempt to fill their thoughts with the thoughts of an objective person. In both conditions, participants were asked to write their thoughts for one minute. Participants then completed scales asking about help-seeking intentions, help-seeking outcome expectations, and self-stigma of seeking help. The survey ended with a debriefing page that thanked participants and provided depression resources. Outcome Measures. We included measures to assess help-seeking intentions, expectations, and stigma. General Help-Seeking Questionnaire (GHSQ). Participants indicated how likely they would be to seek help from potential sources on a 7-point Likert scale (1 = extremely unlikely, 7 = extremely likely; Wilson, Deane, Ciarrochi, & Rickwood, 2005). The sources included were: a romantic partner, close friend, parent, other family member, counselor/psychologist, psychiatrist, and doctor/general practitioner (α = .77, M = 4.21, SD = 1.25, skew = -0.71, SEskew = 0.31, kurtosis = 0.33, SEkurtosis = 0.60). Help-Seeking Outcome Expectations (HSOEs). This 9-item instrument (Siegel, Lienemann, & Tan, 2015) measured participants perceptions of outcomes associated with helpseeking on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree) with items like "Seeking help for depression will make a positive difference" (α = .90, M = 5.23, SD = 1.08, skew = -0.39, SEskew = 0.31, kurtosis = -0.45, SEkurtosis = 0.60). Self-Stigma of Seeking Professional Help. This 7-item scale measured level of agreement with items like “Seeking psychological help would make me feel less intelligent” (Vogel, Wade, & Haake, 2006). Participants responded on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree; α =.92, M = 3.55, SD =1.39, skew = 0.48, SEskew = 0.31, kurtosis = -0.26, SEkurtosis = 0.60).

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Results Hypotheses were tested through a series of ANCOVAs, with age, BDI-II, and a binary measure of gender as covariates. In these analyses, no covariates were significant. Alternative analyses without covariates are available in the supplementary materials. When covariates were not included in the model, the pattern of results was the same. General Help-Seeking Questionnaire. After controlling for the covariates, participants in the self-distancing condition (M = 4.64, SE = 0.22) had significantly higher intentions to seek help than those in the immersive condition (M = 3.84, SE = 0.20), F(1, 56) = 6.93, p = .011, ηp2 = .11, 95% CI [.19, 1.41]. Help-Seeking Outcome Expectations. After controlling for the covariates, there was no significant difference between the groups (distancing: M = 5.40, SE = 0.21; immersive: M = 5.09, SE = 0.19), F(1, 56) = 1.24, p = .271, ηp2 = .02, 95% CI [-0.25, 0.89]. Self-Stigma of Seeking Professional Help. After controlling for the covariates, there was no significant difference between the groups (distancing: M = 3.50, SE = 0.27; immersive: M = 3.60, SE = 0.25), F(1, 56) = 0.08, p = .779, ηp2 = .001, 95% CI [-0.850, 0.641]. Exploratory Analyses In response to a reviewer’s insightful comment, we coded the qualitative responses to the experimental writing tasks. Based on our assumptions that self-distancing would reduce negative biases, we assessed whether participants in the self-distancing condition were less likely than those in the immersive condition to write a response devoid of positive content. The responses were ordered by ID number and stripped of information regarding the participant’s level of depressive symptomatology and condition prior to coding. The two authors independently read all responses, coding for the presence of any positive thoughts within the response. An example

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of a response coded as being void of positive content is, “I was tired of living my horrible life and just wanted it to end. I thought about getting help, but I didn’t want to. I knew they couldn’t do anything to improve my life.” Initial agreement was acceptable (κ = .63, 86.67% agreement). The nine discrepancies were resolved through discussion. Of the 28 respondents in the distancing condition, none wrote a response coded as void of positive content—compared to 48.5% (n = 16) of the 33 participants in the immersive condition. A chi-square analysis indicated this difference was statistically significant, χ2(1) = 18.40, p < .001. Cramer’s V = .55. Discussion Participants in the self-distancing condition had significantly higher intentions to seek help than those in the immersive condition. No significant differences in HSOEs, or self-stigma were detected. Although only one hypothesis was supported, we were encouraged by the strong result in for the intentions measure, particularly given the effect size (ηp2 = .11). Although the qualitative investigation was post hoc, these exploratory analyses revealed significant differences by condition. No participants in the self-distancing condition wrote a response coded as void of positive content, which suggests that distancing may prevent the automatic negative cognitive biases present when people with depression think about the self (Wisco, 2009). Study 2 With the goal of testing the utility of self-distancing as a means of increasing helpseeking in a format that would be more suitable for mass distribution, we developed a short video based on the writing prompts from Study 1. We hypothesized that participants who viewed the self-distancing video would have higher intentions to seek help and higher HSOEs than participants who viewed a self-immersive video or those who did not view any video. Self-

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stigma was again included as an exploratory variable. This study was pre-registered on the Open Science Framework (https://osf.io/r45uw). Method Participants. Data collection procedures were identical to Study 1. Of the 2,806 participants who completed the screener survey, 57.8% were female, 41.3% were male, and 0.6% self-described with another gender identity. Those who indicated they had never sought help for depression, and who scored over 13 on the BDI-II were invited to the follow-up survey. As outlined in our OSF registration, we excluded 22 participants for not viewing the video for the full runtime, and 16 participants for failing an attention check item. One participant was a multivariate outlier. Additionally, although not part of our pre-registration, we noticed five respondents’ age changed between the screening and the experimental survey beyond what was chronologically possible (this did not occur in the data for Study 1). These participants were excluded from the data set as well, leaving 297 participants in the analysis. We provide the analyses including outliers and participants with mismatched age in the supplementary material. The conclusions did not differ regardless of the inclusion of these participants. Of the participants included in analyses, the mean score on a measure asking if they considered themselves to be currently depressed was 3.99 (SD = 1.78) on a 7-point scale from definitely not to definitely yes. See table 1 for demographic information. There were no instances of missing data, except for the likely help source outcome measure described below. Procedure. First, participants viewed a test video and answered two multiple-choice questions. Participants who correctly answered these attention check items were then randomly assigned to either the self-distancing condition, self-immersive condition, or the control condition. Those in the control condition immediately received the measures, while all others

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viewed a short video asking them to think about a time they had thought about help-seeking from a distanced or immersive perspective. Participants then responded to outcome measures, answered demographic questions, and received a debriefing page with depression resources. Outcome Measures. Multiple measures of help-seeking intentions were included to allow a broader view of effects. We also measured HSOEs and self-stigma. Overall Help-Seeking Scale. This three-item scale asked participants to report their helpseeking intentions in a general sense, rather than from specific sources, with items like “I would be willing to seek help for my depression” (α = .91, M = 4.23, SD = 1.53, skew = -0.24, SEskew = 0.14, kurtosis = -0.75, SEkurtosis = 0.28). General Help-Seeking Questionnaire. This measure was identical the one used in Study 1 (α = .73, M = 3.92, SD = 1.29, skew = -0.03, SEskew= 0.14, kurtosis = -0.36, SEkurtosis = 0.28). Likely Help Source Intentions. In the screening survey, we asked participants if they believed they were currently depressed. Those who indicated that they did were asked to choose from the source from whom they would be most likely to seek help. The list of sources was taken from the GHSQ. After the experimental survey, we isolated their intentions to seek help from their self-reported most likely source (M = 5.58, SD = 1.65 skew = -1.26, SEskew = 0.14, kurtosis = 0.77, SEkurtosis = 0.29). We felt this may be a more accurate measure of specific help-seeking intentions, as there may be some sources in the GHSQ that are poor sources of aid to some individuals (e.g., estranged parents). Eight participants did not consider themselves depressed, and therefore, they are missing data for this outcome variable and not included in analyses of this variable. Help-Seeking Outcome Expectations. This measure is the same as the one used in Study 1 (α = .84, M = 5.14, SD = 0.89, skew = 0.01, SEskew = 0.14, kurtosis = -0.16, SEkurtosis = 0.28).

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Self-Stigma of Seeking Professional Help. This scale was the same as in Study 1 (α = .92, M = 3.76, SD = 1.26, skew = -0.07, SEskew = 0.14, kurtosis = -0.57, SEkurtosis = 0.28). Results We report results of a series of ANCOVAs with age, a binary measure of gender, and the BDI-II as covariates, and with outliers excluded. The two participants who did not select a binary gender identity are not included in this analysis, but in accordance with our pre-registration, alternative analyses with these participants, without covariates, and with outliers are available in the supplementary materials. In all cases, the pattern of results and significance were the same. Help-Seeking Intentions. For the 3-item scale that asked about help-seeking in general, there was no significant effect of condition, F(2, 288) = 2.01, p = .14, ηp2=.01 (immersive: M = 4.01, SE = 0.16; distancing: M = 4.26, SE = 0.16; control: M = 4.44, SE = 0.15). None of the covariates were significant. For the GHSQ, there were also no significant differences between the immersive (M = 3.76, SE = 0.13), distancing (M = 4.02, SE = 0.14), and control (M = 4.00, SE = 0.13) conditions, F(2, 288) = 1.21, p = .30. ηp2 =.008, and no significant covariates. There was also no significant effect for the single item measure of help-seeking from the most likely source of help, F(2, 280) = 0.22, p = .80, ηp2 = .002 (immersive: M = 5.51, SE = 0.17; distancing: M = 5.57, SE = 0.17; control: M = 5.66, SE = 0.16), with gender as a significant covariate. Help-Seeking Outcome Expectations. There were no significant differences between the immersive (M = 5.08, SE = 0.09), distancing (M = 5.24, SE = 0.09), or control (M = 5.10, SE = 0.08) conditions on HSOEs: F(2, 288) = 0.853, p = .43, ηp2 = .006, with BDI-II as a significant covariate. Self-Stigma of Seeking Professional Help. There were no significant differences between the groups regarding the self-stigma, F(2, 288) = 0.37, p = .69, ηp2 = .003, (immersive:

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M = 3.85, SE = 0.13; distancing: M = 3.70, SE = 0.13; control: M = 3.72, SE = 0.12). The covariates were not significant. Exploratory Analysis The a priori hypotheses were not supported. However, we considered the possibility that the effectiveness of distancing on help-seeking outcomes may depend on depression severity, as people with more severe symptoms would be most affected by the negative bias that is symptomatic of depression and would therefore benefit most from a technique that ameliorates such bias. Additionally, some research indicates that help-seeking messages have differential effects based on the perceiver’s level of depression (Lueck, 2018). For example, data charts from Siegel et al. (2015) suggest that mistargeted messages were most beneficial to participants with severe depression, and previous findings on self-distancing have shown that the benefits of distancing increase linearly with level of depression (Kross & Ayduk, 2009). To explore the possibility of such a pattern here, we ran hierarchical linear regressions to test the impact of the BDI-II, beyond the effect of the covariates and conditions tested via ANCOVAs, and to test for possible interactions between condition and the BDI-II. Entered into the model in step one were age, a binary measure of gender, and two dummy-coded variables that test the two treatment conditions (distancing, and immersive) in contrast to the control condition. In step two, we entered the centered score on the BDI-II (Aiken & West, 1991). In step three, we entered interaction terms between the treatment conditions and BDI-II. Although it would have been of interest to test this interaction in Study 1, we lacked sufficient power to do so. Help-Seeking Intentions. A regression with age, gender, BDI-II, dummy coded conditions, and the interaction terms did not predict the measure of general help-seeking intentions (R2 = .022, F(7, 286) = 0.924, p = .488). The only significant predictor was the

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immersive condition, (B = -0.431, SE = 0.12, 95% CI [-0.86, -0.05] t = -1.99, p = .047), indicating that when all other predictors in the model are held constant, participants in the immersive condition scored -0.43 points lower on the measure of general help-seeking intentions than those in the control group. The model with the GHSQ also did not fit the data well (R2 = .021, F(7, 286) = .860, p = .538). None of the variables significantly predicted scores on the GHSQ. The regression for the Likely Help Source was also a poor fit, R2 = .036, F(7, 278) = 1.48, p = .18. Gender was the only significant predictor (B = .52, SE = 0.20 95% CI [-0.14, 0.91] t = -2.66, p = .008, indicating that, when all other predictors were held constant, women had scores 0.52 higher on this measure than men. Help-Seeking Outcome Expectations. After controlling for the main effects of covariates and condition in step one, adding the BDI-II was a significant improvement to the model in step two, F change(1, 288) = 5.240, p < .023, R2 = .04, R2 change =.02. Adding the interaction terms in step three was not a significant improvement from step two, F change(2, 286) = .823, p = .44, R2 = .04, R2 change = .006), and did not significantly fit the data F(7, 286) = 1.78, p = .09). Step 2, with age, gender, condition and BDI-II, is the best fitting equation (F(5, 288) = 2.17, p = .057). In this model, when the other predictors are held constant, each one-point increase in the BDI-II decreases HSOE scores by -0.014 (B = -0.014, SE = 0.006, 95% CI (-0.03, -0.002) t = -2.29, p = .023). Self-Stigma of Seeking Professional Help. A regression with age, gender, BDI-II, dummy coded conditions, and the interaction terms did not fit the data (R2=.022, F(7, 286) = .911, p = .498). No variables in the equation significantly predicted self-stigma scores. Discussion No hypotheses were supported in this study. Exploratory analyses testing if the

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manipulation was more successful at different levels of depression severity were also not significant, as the predictors did not explain significant variance in the outcomes. We considered three interpretations of these findings: 1) the video was not powerful enough to require watchers to undertake the relatively cognitively effortful task of distancing as the writing prompt did, 2) that respondents did not pay attention to the video, which would have been effective had they done so, or 3) self-distancing is not an effective way to increase help-seeking. We felt it most important to rule out the third possibility, so we returned to the writing prompt to re-test whether the results of Study 1 replicated in a larger sample. Study 3 The goal of Study 3 was to re-establish that self-distancing can impact on help-seeking by replicating Study 1 in a larger sample and to add a true control group. This study was preregistered on the Open Science Framework (https://osf.io/t658d). We hypothesized that participants who were in the self-distancing condition would display higher intentions to seek help and more positive HSOEs than participants in the immersive or control conditions. We also included a measure of self-stigma, to continue exploring this variable in relation to selfdistancing. Method Participants were recruited from MTurk with a screening survey containing the BDI-II and questions about their depression history. Of the 5,894 participants who completed the screening survey, 56.5% were female, 42.9% were male, and 0.4% self-described with another gender identity. Those who scored above 13 and who reported not seeking help for depression were invited to the experimental survey. As in the previous studies, a greater percentage of men than women met these criteria. As outlined in our pre-registration, participants were excluded

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from analysis if they failed an attention check item, or if they failed to respond to the prompts. Again, we found some participants whose age changed from the screening survey to the main study, so we removed these nine participants from analyses. There were also eight additional outliers in the data set that were not included in the analyses. Supplemental materials are available that report the results when these participants are included. For the 574 participants included in analyses, the mean score on a 7-point question asking if they considered themselves depressed was 3.75 (SD = 1.69). See Table 1 for demographic information. There were no missing data. After the informed consent, participants were randomized into the distancing condition, immersive condition, or control condition. The prompts were identical to ones used in Study 1. Participants viewed the same outcome measures as in Study 1, plus an additional single item help-seeking measure that asked participants how likely they would be to seek help from at least one source. The GHSQ demonstrated borderline reliability (α = .67, M = 3.96, SD = 1.16, skew = -0.14, SEskew = 0.10, kurtosis = -0.31, SEkurtosis = 0.20). The single item measure had a mean score of 4.93, and a standard deviation of 1.62 (skew = -0.55, SEskew = 0.10, kurtosis = -0.44, SEkurtosis = 0.20). The measure of HSOEs demonstrated adequate reliability (α = .86, M = 5.29, SD = 0.91, skew = -0.29, SEskew = 0.10, kurtosis = -0.05, SEkurtosis = 0.20), as did the self-stigma measure (α = .88, M = 3.73, SD = 1.10, skew = -0.01, SEskew = 0.10, kurtosis = -0.07, SEkurtosis = 0.20). Participants also responded to demographic items and received a debriefing page that included depression resources. Results A series of ANCOVAs were conducted to test our hypotheses. We report here the results with age, a binary measure of gender, and BDI-II as covariates, and with univariate and

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multivariate outliers excluded from the sample. The four participants who did not select a binary gender are not included in the ANCOVA results, but are included in the alternate analyses without covariates and with outliers available as supplementary materials to this text. Conclusions were the same regardless of inclusion. Help-Seeking Intentions. For the multi-item GHSQ, there was no significant difference between the immersive (M = 4.07, SE = 0.09), distancing (M = 3.96, SE = 0.08), and control (M = 3.87, SD = 0.08), conditions on help-seeking intentions when controlling for age, gender and BDI-II, F(2, 564) = 1.45, p = .235, ηp2 =.005. BDI-II and gender were significant covariates. There was also no significant effect for the single item measure of help-seeking intentions (immersive: M = 5.07, SE = 0.12; distancing: M = 4.98, SE = 0.12; control M = 4.81, SE = 0.11) with the same covariates of age, gender, and BDI, F(2, 564) = 1.41, p = .244, ηp2 =.005. BDI-II and gender were significant covariates. Help-Seeking Outcome Expectations. There was no significant difference between the groups (immersive: M = 5.29, SE = 0.07; distancing: M = 5.33, SE = 0.07; control: M = 5.26, SE = 0.06) on HSOEs F(2, 564) = 0.29, p = .751, ηp2 =.001 when controlling for age, gender and BDI-II. BDI-II and age were significant covariates. Self-Stigma of Seeking Professional Help. There was a significant difference between the groups regarding self-stigma, F(2, 564) = 3.06, p = .048, ηp2 = .011, when controlling for age, gender, and BDI-II. BDI-II and gender were significant covariates. In a follow-up pairwise comparison based on estimated marginal means and adjusted for multiple comparisons with a Bonferroni adjustment, the difference between the distancing (M = 3.64, SE = 0.08) and control (M = 3.87, SE = 0.07) conditions was not significant (p = .091, 95% CI [-0.025, 0.494]). There was no significant difference between the immersive (M = 3.65, SE = 0.08) and distancing

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conditions (p = 1.00, 95% CI [-0.264, 0.291]), or the immersive and control conditions (p = .133, 95% CI [-0.484, 0.042]). Exploratory Analyses Interaction. As in Study 2, we ran hierarchical linear regressions to test the impact of the BDI-II, beyond the effect of the covariates and conditions tested via ANCOVAs previously, and to test for possible interactions between condition and the BDI-II. Entered into the model in step one were age, a binary measure of gender, and two dummy-coded variables that test the two treatment conditions (distancing and immersive) in contrast to the control condition. In step two, we entered the centered score on the BDI-II (Aiken & West, 1991). In step three, we entered interaction terms between the treatment conditions and BDI-II. General Help-Seeking Questionnaire. After controlling for the main effects of covariates and condition in step one, in step two we found that adding the BDI-II was a significant improvement to the model, F change(1, 564) = 40.84, p < .001, R2 = .08, R2 change =.07. Adding the interaction terms in step three was not a significant improvement from step two, F change(2, 562) = 1.08, p = .340, R2 = .09, R2 change = .004). Neither the interaction between the distancing condition and BDI-II (B = 0.01, SE = 0.01, 95% CI [-0.01, 0.04] t = 1.04, p = .299) nor the interaction between the immersive condition and the BDI-II was significant (B = -0.01, SE = 0.01, 95% CI [-0.03, 0.02] t = -0.51, p = .613). These findings indicate that the relationship between depressive symptomatology and help-seeking intentions did not differ based on condition. Although it was not a significant improvement from step two, the third model still fit the data (R2=.09, F(7, 562) = 7.46, p < .001). In this model, higher BDI-II scores were associated with lower scores on the GHSQ, B = -0.04, SE = 0.01, 95% CI (-0.05, -0.02) t = -4.25, p < .001. Figure 1 depicts the relationship between BDI-II, condition, and the GHSQ.

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Single Item Intentions. After controlling for the main effects of covariates and condition in step one, in step two we found that adding the BDI-II was a significant improvement to the model, F change(1, 564) = 24.59, p < .001, R2 = .07, R2 change = .04. Although adding the interaction terms in step three was not a significant improvement, (F change(2, 562) = 2.45, p = .088, R2 = .08, R2 change =.01), the overall model fit the data (R =. 27, F(7, 562) = 6.65, p <.001). In the final model, higher BDI-II scores were associated with lower intentions to seek help, B = -0.05, SE = 0.01, 95% CI (-0.08, -0.03) t = -4.56, p <.001. The interaction between the distancing condition and BDI-II was significant (B = 0.04, SE = 0.02, 95% CI [.01, 0.08] t = 2.21, p = .027), indicating that in the distancing condition, the negative relationship between increased BDI-II scores and lower intention scores is weakened, compared to the control group. In contrast, the interaction between the immersive condition and the BDI-II was not significant (B = 0.02, SE = 0.02, 95% CI [-0.02, 0.05] t = -0.95, p = .343), indicating that the negative relationship between depressive symptomatology and help-seeking intentions was not affected in the immersive condition (see Figure 1). Help-Seeking Outcome Expectations. After controlling for the main effects of covariates and condition in step one, in step two we found that adding the BDI-II was a significant improvement to the model, F change(1, 564) = 20.96, p < .001, R2 = .04, R2 change =.04. Adding the interaction terms in step three was not a significant improvement from step two, (F change(2, 562) = .24, p = .786, R2 = .05, R2 change =.001), but still significantly fits the data (R = .21, F(7, 562) = 3.74, p = .001). In the final model, higher BDI-II scores were associated with lower HSOEs, B = -0.02, SE = 0.01, 95% CI (-0.04, -0.01) t = -3.27, p = .001. The interactions between the BDI-II and both the distancing condition (B = 0.01, SE = 0.01, 95% CI [-0.01, 0.03]

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t = .68, p = .498), and the immersive condition (B = 0.001, SE = 0.01, 95% CI [-0.02, 0.02] t = .14, p = .886) were not significant. Figure 1 also presents these patterns. Self-Stigma of Seeking Professional Help. After controlling for the main effects of covariates and condition in step one, in step two we found that adding the BDI-II was a significant improvement to the model, F change(1, 564) = 9.15, p = .003, R2 = .05, R2 change = .02. Adding the interaction terms in step three significantly improves the model, F change(2, 562) = 4.35, p = .013, R2 = .07, R2 change =.01). In the final model, (R = .26, F(7,762) = 5.88, p < .001), higher BDI-II scores were associated with higher self-stigma, B = 0.03, SE = 0.01, 95% CI (0.01, 0.05) t = 3.75, p < .001. The interaction between the distancing condition and BDI-II was significant (B = -0.04, SE = 0.01, 95% CI [-0.04, 0.01] t = -2.95 p = .003), while the interaction between the immersive condition and the BDI-II was not significant (B = -0.01, SE = 0.01, 95% CI [-0.04, 0.01] t = -1.20, p = .229). The relationship between BDI-II and self-stigma is attenuated in the self-distancing condition so that as severity of depression increases, selfstigma does not also increase as it does in the control condition (see Figure 1). Qualitative Analysis. Again, the written responses allowed us to examine possible mechanisms by which distancing could improve help-seeking. Following the same coding procedure as Study 1, the authors coded for the existence of positive thoughts. Initial agreement in this sample was high (κ = .79; 94.2% agreement), discrepancies were resolved by discussion between the co-authors. Of the 170 respondents in the distancing condition, 7.3% (n = 13) wrote a response coded as entirely negative—compared to 25.1% (n = 43) of the 167 participants in the immersive condition. A χ2 analysis indicated this difference was statistically significant, χ2(1) = 20.68, p < .001. Cramer’s V = .24.

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Discussion The a priori hypotheses for Study 3 were not supported. There were no significant differences between the conditions on the two intention measures or HSOEs. The overall ANCOVA for self-stigma was significant, but pairwise comparisons did not show any differences between the distancing, immersive, and control conditions. Because self-distancing may be most beneficial for people experiencing severe depression, as it reduces self-relevance and sidesteps automatic negative cognitions, we investigated the interaction between depressive symptomatology and condition. The hierarchical linear regression shows that increases in BDI-II are associated with decreases in help-seeking intentions and HSOEs, and with increases in selfstigma. This pattern is expected as past research suggests that depression severity is associated with weaker intentions toward help-seeking (Siegel & Thomson, 2017). Yet, particularly noteworthy is how the impact of increased depressive symptomatology is attenuated in the distancing condition. The significant interaction between BDI-II and the distancing condition for the single-item intention measure and self-stigma indicates that the self-distancing condition had the greatest influence among those with most severe depression. People with severe depression are much more likely to endorse an intention to seek treatment and substantially less likely to endorse self-stigma statements if they are exposed to the self-distancing intervention than if they are exposed to the control condition. Additionally, analyses of the qualitative responses show a significant difference in content between the two conditions. There were three times more participants in the immersive condition who wrote a response without any positive content, compared to the distancing condition. This suggests that self-distancing may reduce the strength of the automatic negative bias toward self-relevant cognitions (Wisco, 2009) and make it possible for people experiencing

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depression to overcome automatic processing and generate positive thoughts (Hartlage, Alloy, Vazquez, & Dykman, 1993). This reduction in negativity may be a potential mechanism by which self-distancing impacts help-seeking. General Discussion Self-distancing has been shown to promote better conflict resolution (Finkel, Slotter, Luchies, Walton, & Gross, 2013), improve reasoning about personal issues (Grossmann & Kross, 2014), and reduce emotional reactivity to difficult situations (Kross, Duckworth, Ayduk, Tsukayama, & Mischel, 2011). The current research investigated whether self-distancing can increase help-seeking intentions among people with depression. Studies 1 and 3 are best understood as efficacy trials (i.e., assessments of an intervention under ideal circumstances). Getting people with depression to write about help-seeking may not be an easily applied mass approach without the trappings of interventions, but our goal was assessing whether selfdistancing could impact help-seeking expectations and intentions. Study 1 results indicated that participants in the self-distancing condition displayed significantly higher help-seeking intentions, although there were no differences between the conditions in HSOEs or self-stigma. The results of Study 3 also highlighted the potential of a self-distancing intervention, but it would be a stretch to claim evidence of anything other than potential, as a priori hypotheses were not supported. However, after reviewing previously published research (Lueck, 2018), we explored the interaction between condition and depression level. We found a change in the relationship between depressive symptomatology and outcome depending on condition. For participants who were not in the distancing condition, there was a negative association between depressive symptomatology and help-seeking intentions (as measured by the single-item measure), and a positive association between depressive symptomatology and self-stigma. Yet,

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as the Loess plots indicate (see Figure 1), in the distancing condition the relationship between depressive symptomatology and help-seeking is weakened. In the control and immersive conditions, help-seeking intentions from at least one source significantly decrease as depressive symptomatology increase—but not in the self-distancing condition. Likewise, self-stigma is positively associated with depressive symptomology for those in the control and immersive conditions, but not the self-distancing condition. In fact, in the distancing condition participants with severe depressive symptomatology respond in line with those with only mild symptomatology. The significant interaction in the distancing condition for the single-item measure of intention and self-stigma indicate that self-distancing as an intervention should not be abandoned without further exploration and development. Examining the qualitative responses from Studies 1 and 3 provided insight on the potential path through which self-distancing can influence help-seeking among people with depression. Participants in the self-distancing conditions were significantly less likely to write responses coded as being void of positive content—13 participants responding to the distancing prompt wrote a response coded as void of positive content, compared to 59 participants in the immersive conditions. This suggests that self-distancing might allow people with depression to see the positive aspects of help-seeking that are typically blocked by the negative biases of depression—possibly due to forcing more effortful rather than automatic thinking (Hartlage et al., 1993). Future research that more extensively incorporates qualitative data may better illuminate the processes through which self-distancing can influence people with depression. Limitations There are limitations to be considered when contemplating the results of the current studies. First, although the same self-distancing prompt was used in Studies 1 and 3, a different

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prompt could have caused stronger or weaker results. Moreover, all three studies relied on MTurk samples, which was particularly impactful for our understanding of Study 2. As participants completed the survey online, we cannot determine why the self-distancing video was not successful. We assumed that recording the amount of time participants spent on the page with the video would allow us to know if the video was watched fully. We realize now that there is no way of knowing which of the participants actually watched the video rather than turning away from the screen or clicking to another tab. As such, we cannot offer conclusions on the effectiveness of self-distancing videos as a strategy for increasing help-seeking. It is possible the video was ineffective at prompting distancing, and it is also possible that participants simply did not attend to the video. Further studies attempting to use a video manipulation for self-distancing would benefit from being conducted in a more controlled environment where attention is easier to direct, or from the inclusion of more manipulation checks to discern between attentive and non-attentive participants. It is also possible that the videos were unable to motivate effortful processing (Hartlage et al., 1993), which could have been responsible for the outcomes associated with the writing tasks. If so, then interventions using more interactive approaches might be warranted. Conclusions Overall, the results of all three studies should be considered in the context of other attempts to influence help-seeking outcomes among people with heightened depressive symptomatology. Although some investigations successfully persuaded people with depression, other studies have struggled to find success (see Siegel et al., 2017 for a discussion). Even more concerning is that some persuasive attempts backfire on people with heightened depressive symptomatology, resulting in negative effects (Batterham et al., 2016; Keeler & Siegel, 2016).

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Critically, self-distancing does not appear to harm people experiencing depression, and may be most beneficial for participants with the most severe symptoms. Depression researchers have reiterated the importance of testing help-seeking messages with people with depression, rather than with a general sample (Siegel, Lienemann, & Rosenberg, 2017). The results of Study 3 further this notion and support the importance of taking into account the severity, not just the existence, of depression while testing interventions (Lueck, 2018). Given the evidence that negative self-relevant cognitions are an important barrier to help-seeking (Siegel et al., 2017; Wisco, 2009), and what was learned as a result of the current studies, self-distancing deserves continued exploration as an approach for increasing help-seeking among people with depression.

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Table 1. Participant demographic information.

Age M (SD) BDI-II M (SD) Gender Female Male Decline to state/self-describe Race White Asian or Pacific Islander Hispanic Black Multiple races or self-described Education Some high school High school or GED Some college Associate degree Bachelor degree Other certificate Masters degree Doctoral degree

Study 1 (n = 61) 36.16 (11.32) 23.52 (7.89)

Study 2 (n= 297) 34.7(11.56) 23.30 (8.29)

Study 3 (n =574) 34.67 (10.51) 23.12 (9.05)

44.3% 55.7% 0.0%

50.8% 48.5% 0.7%

50.3% 49.0% 0.7%

83.6% 8.2% 4.9% 3.3% 0.0%

65.0% 11.7 4.0% 12.5% 7.8%

67.8% 11.7% 6.3% 7.0% 7.2%

0.0% 0.0% 29.5% 11.5% 34.4% 0.0% 6.6% 4.9%

0.7% 12.5% 27.3% 9.8% 37.4% 1.0% 9.1% 2.4%

1.4% 9.9% 26.7% 11.5% 36.9% 1.6% 9.9% 2.1%

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Fig. 1. Loess fit lines modeling the relationship between condition (distancing, immersive, control) and depressive symptomatology on help-seeking intentions, help-seeking outcome expectations, and self-stigma of seeking help (Study 2).

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SELF-DISTANCING AND SEEKING HELP FOR DEPRESSION Research Highlights •

Three studies examined self-distancing in people with depression.

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Self-distancing reduces likelihood of purely negative thoughts.

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Self-distancing weakens relationship between depression and help-seeking intentions.

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Self-distancing weakens relationship between depression and self-stigma.

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Self-distancing may be most effective for people with severe depression.

Sara M. Hollar: Conceptualization, Methodology, Formal Analysis, Writing-Original draft preparation Jason T. Siegel: Conceptualization, Methodology, Writing- Reviewing and Editing, Supervision