- Email: [email protected]
The relationship between perfectionism and mental illness stigma
Personality and Individual Differences 126 (2018) 66–70
Contents lists available at ScienceDirect
Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
The relationship between perfectionism and mental illness stigma a,⁎
a
a
T
b
Amy Shannon , Joel O. Goldberg , Gordon L. Flett , Paul L. Hewitt a b
Department of Psychology, York University, 4700 Keele St., Toronto, ON, M3J 1P3, Canada Department of Psychology, University of British Columbia, 1912-2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
A R T I C L E I N F O
A B S T R A C T
Keywords: Perfectionism Perfectionistic self-presentation Stigma Mental illness beliefs Treatment seeking
Despite experiencing higher levels of psychological distress, individuals with high levels of perfectionism are more reluctant to seek treatment for psychological issues and they are often treatment resistant when in treatment. Mental illness stigma has been shown to be a significant barrier to treatment seeking in other populations and it stands to reason that it may play a key role for individuals with high levels of perfectionism as well. As such, the primary goal of this study was to discern whether individuals who differ along the continuum of various types of perfectionism also differ in terms of mental illness beliefs in ways that suggest awareness of and concern about being stigmatized. In addition, we examined links between perfectionism and attitudes towards seeking help and self-stigma for seeking help. A sample of 140 university students completed the Multidimensional Perfectionism Scale and the Perfectionistic Self-Presentation Scale and separate measures of mental illness beliefs, help-seeking attitudes, and self-stigma for seeking help. Analyses found that perfectionistic self-presentation was associated with unfavorable mental illness attitudes overall. Our results suggest that targeted interventions to reduce mental illness stigma should be tailored to address the beliefs and concerns of perfectionistic people who are vulnerable to distress.
1. Literature review 1.1. Mental health and stigma in universities University students are a subset of the population that is at increased risk for psychological distress (Adlaf, Demers, & Gliksman, 2005). Transitioning from high school to university has been shown to be an especially stressful time that is often accompanied by marked increases in psychological distress (Conley, Kirsch, Dickson, & Bryant, 2014). However, the rates of help-seeking for university students who are experiencing psychological distress are low (Eisenberg, Golberstein, & Gollust, 2007). There are many reasons why individuals may elect not to seek help for their psychological distress. However, the stigma surrounding mental illness and accessing mental health services appears to be a key factor that leads some individuals to neglect treatment (Clement et al., 2015). Studies have shown that mental illness stigma is prevalent (Cook & Wang, 2010) and this stigma is a barrier to accessing mental health services (Bowers, Manion, Papadopoulos, & Gauvreau, 2013). 1.2. Perfectionism Members of the population that stigmatize mental illness may differ
⁎
in terms of a number of personality traits as compared to those who do not. Perfectionism is one trait that may help illuminate why groups of individuals differ in their stigmatization of certain conditions. Previous studies have documented that certain personality traits have an impact on one's perceptions of others (Brown, 2012) and on one's perception of mental health care (Hewitt, Habke, Lee-Baggley, Sherry, & Flett, 2008). Indeed, perfectionism has been linked to other types of stigma among undergraduate student populations. Cox and Hill (2018) found that trait perfectionism predicted more negative attitudes towards individuals with physical disabilities among a sample of university students. Specifically, socially prescribed perfectionism predicted anticipated increased negative affect and interpersonal stress when engaging with individuals with physical disabilities as well as increased desire to distance oneself from individuals with physical disabilities. The authors posit that socially prescribed perfectionism is related to increased susceptibility to negative emotions that often results in anticipated negative interpersonal interactions that, in turn, lends itself to social distancing coping behaviors. Given this propensity to anticipate negative interactions, it stands to reason that trait perfectionism may also be predictive of negative attitudes towards individuals with mental illness. However, the impact of perfectionism on mental illness stigma has yet to be investigated among undergraduate students. Six different types of perfectionism have been identified and are
Corresponding author. E-mail addresses: [email protected] (A. Shannon), [email protected] (J.O. Goldberg), gfl[email protected] (G.L. Flett), [email protected] (P.L. Hewitt).
https://doi.org/10.1016/j.paid.2018.01.022 Received 25 November 2017; Received in revised form 12 January 2018; Accepted 14 January 2018 0191-8869/ © 2018 Elsevier Ltd. All rights reserved.
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
characterized by different patterns of thoughts and behaviors (Hewitt et al., 2003; Hewitt & Flett, 1991). Self-oriented perfectionism is characterized by requiring perfection of oneself, socially prescribed perfectionism is defined by the perception that others require one to be perfect, other-oriented perfectionism is typified by requiring perfection from others, perfectionistic self-promotion involves the need to appear perfect, nondisplay of imperfection is characterized by the refusal to engage in any behaviour that is less than perfect, and nondisclosure of imperfection is typified by the refusal to admit any imperfection. While there is evidence that some aspects of perfectionism may be useful in certain contexts (see Stoeber & Otto, 2006 for review), perfectionism has been linked with psychological distress in undergraduate students, notably stress reactivity and depressive symptoms (Flett, Nepon, Hewitt, & Fitzgerald, 2016), anxiety (Smith, Vidovic, Sherry, Stewart, & Saklofske, 2018), and binge eating (Smith, Sherry, Gautreau, Stewart, Saklofske, & Mushquash, 2017). Furthermore, perfectionism has also been associated with lower likelihood of seeking help for psychological distress (Ey, Henning, & Shaw, 2000). Thus, perfectionism is associated with increased psychological distress yet is also linked to reluctance to seek professional help for said distress. The reason for this potentially dangerous scenario wherein perfectionism may increase an individual's risk of mental health issues while also making that individual less likely to seek help is not known for certain; however, it stands to reason that mental illness stigma may play a role.
2.2. Importance As noted above, the impact of perfectionism on mental illness stigma has not yet been investigated, however despite the paucity of prior research, it stands to reason that perfectionism may impact one's attitudes towards mental illness. It may be that associating with someone who has a mental illness or admitting that one is experiencing psychological distress and seeking assistance may violate a perfectionistic individual's need to be or to appear perfect. Illuminating the relationship between perfectionism, stigma, and attitudes towards seeking help is especially important given recent evidence that suggests that perfectionism may be a risk factor for suicides that ostensibly occur without warning (Flett, Hewitt, & Heisel, 2014). 2.3. Hypotheses It was predicted that individuals who are high on perfectionistic self-promotion would have more negative views of professional treatment for mental health issues due to research that found that those individuals who are high in perfectionistic self-promotion have negative expectations of therapy and may view it as threatening (Hewitt et al., 2008). In addition, it has been hypothesized that individuals who score high on measures of perfectionistic self-presentation have a negative image of the self (Flett, Madorsky, Hewitt, & Heisel, 2002). Consequently, these individuals were predicted to have high levels of self-stigma. Furthermore, participants who scored highly in terms of self-oriented perfectionism were expected to have more self-stigma as they hold themselves to excessively high standards and admitting that they are experiencing psychological distress may violate these standards (Hewitt & Flett, 1991). Moreover, those who score high on socially prescribed perfectionism feel as though others expect them to be perfect, and experiencing psychological distress may violate this expectation. Therefore, those who scored high on socially prescribed perfectionism were expected to score higher on perceptions of stigmatization by others for seeking help (Hewitt & Flett, 1991). In addition, it was expected that participants who were high in other-oriented perfectionism would have more negative views of individuals with mental illness as they already hold other individuals up to impossibly high standards and having a mental illness may violate these standards (Hewitt & Flett, 1991).
2. The current study 2.1. Research goals The current study sought to investigate the relationship between trait perfectionism, perfectionistic self-presentation, mental illness stigma, and attitudes towards seeking help. The goal of this study was to discern whether individuals who differ along the continuum of various types of perfectionism also differ in their attitudes towards individuals with mental illness, their attitudes towards mental health treatment, and the extent of self-stigma for seeking help. This investigation focused jointly on trait perfectionism dimensions and perfectionistic self-presentation due to our particular interest in perfectionistic self-presentation. The notion of perfectionistic self-presentation was introduced by Hewitt et al. (2003) to highlight the distinction between trait perfectionism (i.e., wanting or needing to be perfect) and perfectionistic self-presentation (i.e., wanting or needing to seem perfect). To our knowledge, neither trait perfectionism nor perfectionistic self-presentation have been evaluated in terms of a possible link with negative attitudes towards mental illness and people who have some form of mental illness. An association with negative attitudes would be in keeping with the evaluative nature of many perfectionists. An association between stereotypic negative beliefs and the interpersonal aspects of perfectionism (i.e., socially prescribed perfectionism and perfectionistic self-presentation) could help explain the link that these interpersonal facets of perfectionism have with a fear of negative evaluation and anticipated interpersonal threats (see Flett & Hewitt, 2014). We also examined perfectionism and help-seeking attitudes and selfstigma given that possible links with perfectionism have received little empirical or theoretical consideration. One study linked trait perfectionism with self-stigma for seeking help in adolescents (Zeifman et al., 2015). This association needs to be re-examined with an extended joint focus on trait perfectionism and perfectionistic self-presentation. Other research suggests a link between perfectionism and negative helpseeking attitudes and orientation (e.g., Abdollahi, Hosseinian, BehPajooh, & Carlbring, P., 2017) but again this research has not typically included an emphasis on perfectionistic self-presentation despite it being reasonable to assume that people who need to seem perfect should be especially unwilling to seek help, since seeking help can be interpreted as an admission of not being perfect.
3. Method 3.1. Participants One hundred and forty English speaking university students were recruited. Participants received partial course credit for their participation. The sample was 77.9% female. The average age of participants was 19.70 (SD = 2.60). The most common self-identified ethnic category was South Asian (28.6%) followed by Middle Eastern (16.4%), Caucasian (14.3%), Black (12.1%), East Asian (12.1%), Latin American (2.9%), and multi-racial or other (5.7%). 3.2. Measures An ad hoc demographics questionnaire was used to gather data regarding participant's age, sex, and ethnicity. The following measures were administered: The Multidimensional Perfectionism Scale (Hewitt & Flett, 1991) was used to measure self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. The Multidimensional Perfectionism Scale consists of 45 questions on a 7 point Likert scale ranging from strongly disagree to strongly agree. The questions load onto three subscales that measure self-oriented, other-oriented perfectionism, socially prescribed perfectionism, respectively. 67
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
Items are scored such that higher subscale scores are indicative of greater perfectionism. Adequate test-retest reliability, and concurrent validity (Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991), as well as internal consistency (Hewitt & Flett, 1991) has been documented. The Cronbach's alphas for this study were: .87 self-oriented perfectionism subscale; .75 other-oriented perfectionism subscale; .82 socially prescribed perfectionism subscale. The Perfectionistic Self-Presentation Scale (Hewitt et al., 2003) was used to assess perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection. The Perfectionistic Self-presentation Scale consists of 27 items on a 7 point Likert scale ranging from disagree strongly to agree strongly. These items load onto three subscales that measure perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection. Higher subscale scores reflect higher levels of perfectionism. Good test-retest reliability, convergent and divergent validity as well as predictive and incremental validity for measures of psychological distress above and beyond measures of trait perfectionism alone (Hewitt et al., 2003). The Cronbach's alphas for this study were: .90 perfectionistic self-promotion subscale; .86 nondisplay of imperfection subscale; .80 nondisclosure of imperfection subscale. The Beliefs Towards Mental Illness Scale (Hirai & Clum, 2000) was used to gauge stigma towards individuals with mental illness. The Beliefs Towards Mental Illness Scale consists of 21 items on a 5 point Likert scale ranging from completely disagree to completely agree. Higher scores indicate more negative views regarding mental illness. It consists of 3 subscales measuring perceived dangerousness of individuals with mental illness, perceptions of poor interpersonal and social skills of individuals with mental illness, and perceived incurability of mental illness. It has been found to have good internal consistency, reliability (Hirai & Clum, 2000), and construct validity (Royal & Thompson, 2013). The Cronbach's alphas for this study were: .78 dangerousness of individuals with mental illness subscale; .80 perceptions of poor interpersonal and social skills of individuals with mental illness; .75 perceived incurability of mental illness. The Self-Stigma of Seeking Help Scale (Vogel, Wade, & Haake, 2006) was used to measure self-stigma associated with accessing mental health services. This scale is composed of 10 items rated on a 5 point Likert scale ranging from strongly disagree to strongly agree. Higher scores are indicative of greater self-stigma. This scale has demonstrated good test–retest reliability as well as construct, criterion, concurrent, and predictive validity (Vogel et al., 2006). In addition, it showed incremental validity in predicting both attitudes towards and intent to seek psychological help (Vogel et al., 2006). The Cronbach's alpha for this study was .80 with item 4 deleted. The Attitudes Towards Seeking Professional Psychological Help Scale Shortened Form (Fischer & Farina, 1995) was used to assess stigma regarding professional treatment for psychological distress. The scale consists of 10 statements rated on a 4 point Likert scale ranging from disagree to agree. Higher scores are indicative of more positive attitudes towards seeking help. This scale has demonstrated good construct and concurrent validity, test-retest reliability, and internal consistency (Hatchet, 2006). The Cronbach's alpha for this study was .77. The Perceptions of Stigmatization by Others for Seeking Help Scale (Vogel, Wade, & Ascheman, 2009) was used to measure individuals' perception of the stigma other hold for seeking help for psychological distress. This scale instructs participants to imagine how people they interact with would act towards or perceive them if they sought counseling. Responses are recorded on a 5 point Likert scale ranging from not at all to a great deal. This scale has been found to have good internal consistency, concurrent validity, construct validity, and test–retest reliability (Vogel et al., 2009). The Cronbach's alpha for this study was .84.
Table 1 Bivariate correlations between variables for the total sample. Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
−0.12 0.05 0.21⁎ 0.12 0.13 −0.03
0.01 0.04 0.19⁎ 0.21⁎ 0.04 0.02
−0.12 −0.1 0.14 0.33⁎⁎ 0.15 0.01
−0.19⁎⁎ 0.16 0.33⁎⁎ 0.24⁎⁎ 0.15 −0.02
−0.03 0.29⁎⁎ 0.25⁎⁎ 0.15 0.20⁎ 0.05
−0.11 0.32⁎⁎ 0.30⁎⁎ 0.17⁎ 0.16 −0.07
Note: SOP = self-oriented perfectionism, OOP = other-oriented perfectionism, SPP = socially prescribed perfectionism, PSP = perfectionistic self-presentation, NP = nondisplay of imperfection, NI = nondisclosure of imperfection. ⁎ Indicates p < .05. ⁎⁎ indicates p < .01.
3.3. Procedure After informed consent was obtained, participants completed the demographics questionnaire, and the six measures listed above. 4. Results Table 1 displays correlations between the variables. Since the sample was predominately female, the pattern of correlations was also depicted by sex (see Tables 2 and 3). Tables 1 through 3 illustrate that the pattern of correlations identified in the total sample holds for female but not male participants. Table 4 displays the means and standard deviations of all variables for the total sample as well as by sex. A statistically significant difference on the nondisclosure of imperfection subscale was identified such that female participants scored significantly higher than male participants. 4.1. Regression analyses Hypotheses were tested using a series of regression models. Multiple linear regression indicated that perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection predict selfstigma, R2 = .12, F(3,132) = 5.98, p = .001. Simple linear regression analyses indicated that nondisplay of imperfection predicted attitudes towards seeking help, R2 = .04, F(1, 136) = 4.98, p = .027, self-oriented perfectionism predicted selfstigma, R2 = .05, F(1, 134) = 6.32, p = .013, socially prescribed perfectionism predicted perceptions of stigmatization by others, R2 = .11, F(1, 133) = 16.19, p < .001, and other-oriented perfectionism significantly predicted the belief that individuals with mental illness have poor social skills, R2 = .21, F(1,135) = 5.95, p = .016, but not the belief that individuals with mental illness are dangerous, R2 = .02, F (1,134) = 1.60, p = .807, or that mental illness is incurable, R2 < .01, F(1,134) = .21, p = .651. 5. Discussion The current study uniquely examined the extent to which trait perfectionism and perfectionistic self-presentation were associated with Table 2 Bivariate correlations between variables among for female participants.
68
Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
−0.18 0.05 0.31** 0.17 0.19 0.05
0.02 0.02 0.20* 0.21* 0.01 0.08
−0.14 0.34** 0.39** 0.21* 0.18 0.04
−0.16 0.19* 0.38** 0.29** 0.21* 0.09
−0.04 0.31** 0.22* 0.17 0.25* 0.11
−0.07 0.35** 0.23** 0.21* 0.17 −0.01
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
of Zeifman et al. (2015) that linked self-stigma with trait perfectionism but did not assess perfectionistic self-presentation. The desire to appear perfect (i.e., perfectionistic self-promotion) was associated with greater self-stigma towards seeking help for mental health difficulties and more negative attitudes towards seeking professional help for mental health difficulties in general. The concept of self-reliance may be of use in illuminating the relationship between perfectionistic self-promotion and more negative attitudes towards treatment seeking. Self-reliance has been associated with more negative attitudes towards treatment seeking (Jennings et al., 2015). Those who feel the need to present themselves in a perfectionistic manner may be higher on self-reliance as they may feel that they cannot disclose their difficulties to others as it will preclude them from being or appearing perfect. As such, they choose to rely only on themselves to manage their mental health issues. It is important to underscore that greater refusal to engage in any behaviour that is less than perfect (i.e., nondisplay of imperfection) predicted self-stigma and attitudes towards seeking help, and was associated with perceived stigmatization by others for seeking help. Seeking treatment for mental health challenges may be perceived by individuals who score highly on nondisplay of imperfection as akin to engaging in a behaviour that is less than perfect. Similarly, refusal to admit to any imperfection (i.e., nondisclosure of imperfection) was also significantly related to both self-stigma and perceived stigmatization by others. These relationships were anticipated as seeking treatment for psychological distress could be seen as admitting to imperfection. Symbolic interaction stigma (Link, Wells, Phelan, & Yang, 2015) may be of use when attempting to illuminate the relationship between perfectionistic self-presentation, self-stigma, and more negative attitudes towards seeking professional help. Individuals who score highly on perfectionistic self-presentation want to display a perfectionistic persona to others. For some of these individuals, they may feel others will reject them if they do not live up to this perfectionistic persona. Consequently, they may imagine what others would think of their seeking professional help and anticipate negative interactions with others in which they are rejected as seeking help would violate the persona. These types of imagined interactions constitute what Link et al. (2015) refer to as symbolic interaction stigma. Symbolic interaction stigma, especially anticipated rejection, is associated with the internalization of mental health stigma (Link et al., 2015). It may be that, as a consequence of this process, individuals who score highly on perfectionistic self-presentation have more negative attitudes towards seeking professional help and are less likely to do so. Taken together these findings point to a subset of the population that is at greater risk for psychological distress but also feels more stigma regarding seeking mental health treatment that, in turn, may explain why these individuals are also less likely to seek treatment. This hypothesis is plausible as stigma has been found to be a strong impediment to seeking treatment for mental health difficulties. This dynamic is especially alarming given the association and perfectionism
Table 3 Bivariate correlations between variables among male participants. Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
0.11 0.12 −0.1 −0.12 −0.07 −0.40*
−0.09 0.13 0.29 0.19 0.20 −0.24
0.05 0.32 0.57** 0.17 −0.05 −0.22
−0.28 0.08 0.16 −0.6 −0.02 −0.41*
0.02 0.16 0.35 0.15 0.03 −0.16
−0.21 0.17 0.48** 0.10 0.13 −0.23
negative beliefs about mental illness with the use of a beliefs measure that has been associated with the presence of mental illness stigma. The results with the overall beliefs measure suggested that there is a link between a tendency to put on a perfectionistic front that could mask personal symptoms of distress and a tendency to endorse negative stereotypes about mental illness. This adds to what is known about people who falsely portray themselves as perfect; these individuals tend to be using this style to hide negative aspects of themselves and their sense of being an imposter from other people (Hewitt et al., 2003). Our results raise the possibility that negative assumptions about mental illness and how people react to mental illness may be contributing to this tendency to try to seem perfect (or avoid seeming imperfect) when in public. It seems quite reasonable for people who actually suffer from mental illness to try to avoid appearing imperfect in order to ward off the anticipated negative responses and reactions of people who tend to stigmatize people with mental health problems. A more refined analysis of the components of mental illness beliefs showed that perfectionistic self-presentation and, to a lesser extent, trait perfectionism have their clearest associations with beliefs about the poor interpersonal and social skills of individuals with mental illness. Examination of the various perfectionism factors showed that it was socially prescribed perfectionism that had the strongest association with negative beliefs about the social skills of people with mental illness. These negative beliefs about interpersonal skills could, at least to some extent, reflect the salience of the self-appraisals of people who are high in interpersonal perfectionism because they tend to have negative views of their own personal capacities to act appropriately in public and it is this sense of being unable to meet social expectations that fuels much of their social anxiety (Flett & Hewitt, 2014). In this instance, people with high levels of socially prescribed perfectionism tend to feel hopeless and judged by others which is reflected by the fact that socially prescribed perfectionism predicted perceptions of stigmatization by others. Perfectionistic self-presentation was associated with more negative attitudes towards help seeking. Similarly, perfectionistic self-presentation and self-oriented perfectionism predicted self-stigma for seeking help. The obtained associations were stronger and more consistently evident with perfectionistic self-presentation, thus qualifying the results
Table 4 Means and (standard deviations) of all variables of interest with ANOVA results for sex differences. Variable
Total sample N = 141
Female n = 109
Male n = 30
F
p
η2
SOP OOP SPP PSP NP NI Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
73.75 (15.21) 60.64 (12.76) 59.21 (14.37) 45.55 (13.48) 49.79 (12.41) 26.56 (9.09) 15.97 (5.62) 9.15 (4.23) 23.36 (6.71) 18.44 (9.03) 15.36 (5.74) 9.20 (5.14)
72.67 (15.83) 59.81 (13.20) 58.35 (15.18) 45.47 (13.64) 50.38 (12.58) 27.34 (9.01) 15.89 (5.42) 9.26 (4.24) 23.83 (6.53) 18.17 (8.92) 15.48 (5.58) 9.07 (5.10)
77.67 (12.55) 63.17 (10.84) 62.25 (10.69) 46.03 (13.27) 47.37 (11.75) 23.60 (8.99) 16.27 (6.37) 8.57 (4.13) 21.62 (7.32) 19.57 (9.58) 14.97 (6.46) 9.67 (5.35)
20.53 10.63 10.63 0.04 10.38 40.05 0.01 0.63 20.49 0.56 0.18 0.31
0.114 0.205 0.204 0.840 0.241 0.046 0.746 0.429 0.117 0.457 0.670 0.578
00.02 0.01 0.01 < 0.01 0.01 0.03 < 0.01 < 0.01 0.02 < 0.01 < 0.01 < 0.01
69
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
and suicides that seemingly occur with no warning signs.
psychological functioning, cognitive-affective strategies, and social well-being. Emerging Adulthood, 2, 195–210. http://dx.doi.org/10.1177/2167696814521808. Cook, T. M., & Wang, J. (2010). Descriptive epidemiology of stigma against depression in a general population sample in Alberta. BMC Psychiatry, 10. http://dx.doi.org/10. 1186/1471-244X-10-29. Cox, N. C., & Hill, A. P. (2018). Trait perfectionism and attitudes towards people with disabilities. Personality and Individual Differences, 122(Supplement C), 184–189. http://dx.doi.org/10.1016/j.paid.2017.10.028. Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical Care, 45, 594–601. http://dx. doi.org/10.1097/MLR.0b013e31803bb4c1. Ey, S., Henning, K. R., & Shaw, D. L. (2000). Attitudes and factors related to seeking mental health treatment among medical and dental students. Journal of College Student Psychotherapy, 14, 23–39. http://dx.doi.org/10.1300/J035v14n03_05. Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychologial help: A shortened form and considerations for research. Journal of College Student Development, 36, 368–373. http://dx.doi.org/10.1037/prj0000131. Flett, G., Nepon, T., Hewitt, P., & Fitzgerald, K. (2016). Perfectionism, components of stress reactivity, and depressive symptoms. Journal of Psychopathology and Behavioral Assessment, 38, 645–654. http://dx.doi.org/10.1007/s10862-016-9554-x. Flett, G. L., & Hewitt, P. L. (2014). Perfectionism and perfectionistic self-presentation in social anxiety: Implications for assessment and treatment. In S. Hofmann, & P. DiBartolo (Eds.). Social anxiety: Clinical, developmental, and social perspectives (pp. 159–187). (3rd ed.). London: Elsevier. Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18, 156–172. http://dx.doi.org/10.1037/ gpr0000011. Flett, G. L., Madorsky, D., Hewitt, P. L., & Heisel, M. J. (2002). Perfectionism cognitions, rumination, and psychological distress. Journal of Rational-Emotive & CognitiveBehavior Therapy, 20, 33–47. http://dx.doi.org/10.1023/A:1015128904007. Hatchet, G. T. (2006). Additional validation of the attitudes toward seeking professional psychological help scale. Psychological Reports, 98, 279–284. http://dx.doi.org/10. 2466/PR0.98.1.279-284. Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, 456–470. http://dx.doi.org/10.1037/00223514.60.3.456. Hewitt, P. L., Flett, G. L., Sherry, S. B., Habke, M., Parkin, M., Lam, R. W., ... Stein, B, M. (2003). The interpersonal expression of perfection: Perfectionistic self-presentation and psychological distress. Journal of Personality and Social Psychology, 84, 1303–1325. http://dx.doi.org/10.1037/0022-3514.84.6.1303. Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The multidimensional perfectionism scale: Reliability, validity, and psychometric properties in psychiatric samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 464–468. http://dx.doi.org/10.1037/1040-3590.3.3.464. Hewitt, P. L., Habke, A. M., Lee-Baggley, D., Sherry, S. B., & Flett, G. L. (2008). The impact of perfectionistic self-presentation on the cognitive, affective, and physiological experience of a clinical interview. Psychiatry: Interpersonal and Biological Processes, 71, 93–122. http://dx.doi.org/10.1521/psyc.2008.71.2.93. Hirai, M., & Clum, G. A. (2000). Development, reliability, and validity of the beliefs toward mental illness scale. Journal of Psychopathology and Behavioral Assessment, 22, 221–236. http://dx.doi.org/10.1023/A:1007548432472. Jennings, K. S., Cheung, J. H., Britt, T. W., Goguen, K. N., Jeffirs, S. M., Peasley, A. L., & Lee, A. C. (2015). How are perceived stigma, self-stigma, and self-reliance related to treatment-seeking? A three-path model. Psychiatric Rehabilitation Journal, 38, 109–116. http://dx.doi.org/10.1037/prj0000138. Link, B. G., Wells, J., Phelan, J., & Yang, L. (2015). Understanding the importance of “symbolic interaction stigma”: How expectations about the reactions of others adds to the burden of mental illness stigma. Psychiatric Rehabilitation Journal, 38, 117–124. http://dx.doi.org/10.1037/prj0000142. Royal, K. D., & Thompson, J. M. (2013). A psychometric validation of the beliefs toward mental illness scale. Journal of Nursing Measurement, 21, 516–524. http://dx.doi.org/ 10.1891/1061-3749.21.3.516. Smith, M., Sherry, S., Gautreau, C., Stewart, S., Saklofske, D. H., & Mushquash, A. (2017). Are perfectionistic concerns an antecedent of or a consequence of binge eating, or both? A short-term four-wave longitudinal study of undergraduate women. Eating Behaviours, 26, 23–26. http://dx.doi.org/10.1016/j.eatbeh.2017.01.001. Smith, M. M., Vidovic, V., Sherry, S. B., Stewart, S. H., & Saklofske, D. H. (2018). Are perfectionism dimensions risk factors for anxiety symptoms? A meta-analysis of 11 longitudinal studies. Anxiety, Stress, & Coping, 31, 4–20. http://dx.doi.org/10.1080/ 10615806.2017.1384466. Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence, challenges. Personality and Social Psychology Review, 10, 295–319. http://dx. doi.org/10.1207/s15327957pspr1004_2. Vogel, D. L., Wade, N. G., & Ascheman, P. L. (2009). Measuring perceptions of stigmatization by others for seeking psychological help: Reliability and validity of a new stigma scale with college students. Journal of Counseling Psychology, 56, 301–308. http://dx.doi.org/10.1037/a0014903. Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53, 325–337. http://dx. doi.org/10.1037/0022-0167.53.3.325. Zeifman, R. J., Atkey, S. K., Zhao, W., Young, R. E., Flett, G. L., & Goldberg, J. O. (2015). When ideals get in the way of self-care: Perfectionism and self-stigma for seeking psychological help among high school students. Canadian Journal of School Psychology. http://dx.doi.org/10.1177/0829573515594372.
6. Conclusion In conclusion, this study provides a plausible explanation of why individuals with high levels of perfectionism are more reluctant to seek treatment for psychological issues as compared to their non-perfectionist peers despite experiencing higher levels of psychological distress. That is, individuals with high levels of perfectionism endorse more negative beliefs and presumably have a level of mental illness stigma that, in turn, is a significant barrier to seeking mental health support. In sum, based upon the current findings and previous literature, the following dynamic is proposed: individuals who score highly on measures of perfectionism are more likely to experience psychological distress and are also more likely to feel stigmatized when seeking help for psychological issues; this feeling of stigmatization then makes these individuals less likely to seek psychological assistance, ultimately, the result of this dynamic is significant psychological distress that is undisclosed and untreated that, in turn, leads to increased incidences of suicides in which others report an absence of warning signs. Consequently, this study points to the need for targeted interventions to reduce mental illness stigma among individuals who score highly on measures of perfectionism. These interventions will increase helpseeking behaviour that will then decrease distress and remedy this maladaptive dynamic. 7. Limitations and directions for future research There are some limitations to take into account when considering the implications of the current study. Participants in the current study were all undergraduate students and were predominately female which limits the generalizability of the findings. There is some evidence (see Table 3) that the pattern of relationships may not hold for male participants. Future research should investigate whether these findings hold for more diverse populations. Moreover, all measures were self-report which makes them particularly susceptible to social desirability. Future research would be well-served by including a measure of social desirability. Future research to investigate the efficacy of targeted interventions to reduce mental illness stigma among individuals who are high in perfectionism would be worthwhile. Specifically, targeting self-stigma among individuals who score highly on self-oriented perfectionism, perfectionistic self-promotion, nondisplay of imperfection, or nondisclosure of imperfection may increase help-seeking among these underserved populations. Moreover, targeting stigmatized beliefs about individuals with mental illness among individuals who score highly on other-oriented perfectionism may be a beneficial avenue for mental illness stigma reduction campaigns. References Abdollahi, A., Hosseinian, S., & Beh-Pajooh, & Carlbring, P. (2017). Self-concealment mediates the relationship between perfectionism and attitudes toward seeking psychological help among adolescents. Psychological Reports.. http://dx.doi.org/10. 1177/0033294117713495. Adlaf, E. M., Demers, A., & Gliksman, L. (Eds.). (2005). Canadian campus survey. Centre for Addiction and Mental Health. Bowers, H., Manion, I., Papadopoulos, D., & Gauvreau, E. (2013). Stigma in school-based mental health: Perceptions of young people and service providers. Child and Adolescent Mental Health, 18, 165–170. http://dx.doi.org/10.1111/j.1475-3588. 2012.00673.x. Brown, S. A. (2012). The contribution of previous contact and personality traits to severe mental illness stigma. American Journal of Psychiatric Rehabilitation, 15, 274–289. http://dx.doi.org/10.1080/15487768.2012.703553. Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., ... Thornicroft, G. (2015). What is the impact of mental health-related stigma on helpseeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45, 11–27. http://dx.doi.org/10.1017/S0033291714000129. Conley, C. S., Kirsch, A. C., Dickson, D. A., & Bryant, F. B. (2014). Negotiating the transition to college: Developmental trajectories and gender differences in
70
Contents lists available at ScienceDirect
Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
The relationship between perfectionism and mental illness stigma a,⁎
a
a
T
b
Amy Shannon , Joel O. Goldberg , Gordon L. Flett , Paul L. Hewitt a b
Department of Psychology, York University, 4700 Keele St., Toronto, ON, M3J 1P3, Canada Department of Psychology, University of British Columbia, 1912-2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
A R T I C L E I N F O
A B S T R A C T
Keywords: Perfectionism Perfectionistic self-presentation Stigma Mental illness beliefs Treatment seeking
Despite experiencing higher levels of psychological distress, individuals with high levels of perfectionism are more reluctant to seek treatment for psychological issues and they are often treatment resistant when in treatment. Mental illness stigma has been shown to be a significant barrier to treatment seeking in other populations and it stands to reason that it may play a key role for individuals with high levels of perfectionism as well. As such, the primary goal of this study was to discern whether individuals who differ along the continuum of various types of perfectionism also differ in terms of mental illness beliefs in ways that suggest awareness of and concern about being stigmatized. In addition, we examined links between perfectionism and attitudes towards seeking help and self-stigma for seeking help. A sample of 140 university students completed the Multidimensional Perfectionism Scale and the Perfectionistic Self-Presentation Scale and separate measures of mental illness beliefs, help-seeking attitudes, and self-stigma for seeking help. Analyses found that perfectionistic self-presentation was associated with unfavorable mental illness attitudes overall. Our results suggest that targeted interventions to reduce mental illness stigma should be tailored to address the beliefs and concerns of perfectionistic people who are vulnerable to distress.
1. Literature review 1.1. Mental health and stigma in universities University students are a subset of the population that is at increased risk for psychological distress (Adlaf, Demers, & Gliksman, 2005). Transitioning from high school to university has been shown to be an especially stressful time that is often accompanied by marked increases in psychological distress (Conley, Kirsch, Dickson, & Bryant, 2014). However, the rates of help-seeking for university students who are experiencing psychological distress are low (Eisenberg, Golberstein, & Gollust, 2007). There are many reasons why individuals may elect not to seek help for their psychological distress. However, the stigma surrounding mental illness and accessing mental health services appears to be a key factor that leads some individuals to neglect treatment (Clement et al., 2015). Studies have shown that mental illness stigma is prevalent (Cook & Wang, 2010) and this stigma is a barrier to accessing mental health services (Bowers, Manion, Papadopoulos, & Gauvreau, 2013). 1.2. Perfectionism Members of the population that stigmatize mental illness may differ
⁎
in terms of a number of personality traits as compared to those who do not. Perfectionism is one trait that may help illuminate why groups of individuals differ in their stigmatization of certain conditions. Previous studies have documented that certain personality traits have an impact on one's perceptions of others (Brown, 2012) and on one's perception of mental health care (Hewitt, Habke, Lee-Baggley, Sherry, & Flett, 2008). Indeed, perfectionism has been linked to other types of stigma among undergraduate student populations. Cox and Hill (2018) found that trait perfectionism predicted more negative attitudes towards individuals with physical disabilities among a sample of university students. Specifically, socially prescribed perfectionism predicted anticipated increased negative affect and interpersonal stress when engaging with individuals with physical disabilities as well as increased desire to distance oneself from individuals with physical disabilities. The authors posit that socially prescribed perfectionism is related to increased susceptibility to negative emotions that often results in anticipated negative interpersonal interactions that, in turn, lends itself to social distancing coping behaviors. Given this propensity to anticipate negative interactions, it stands to reason that trait perfectionism may also be predictive of negative attitudes towards individuals with mental illness. However, the impact of perfectionism on mental illness stigma has yet to be investigated among undergraduate students. Six different types of perfectionism have been identified and are
Corresponding author. E-mail addresses: [email protected] (A. Shannon), [email protected] (J.O. Goldberg), gfl[email protected] (G.L. Flett), [email protected] (P.L. Hewitt).
https://doi.org/10.1016/j.paid.2018.01.022 Received 25 November 2017; Received in revised form 12 January 2018; Accepted 14 January 2018 0191-8869/ © 2018 Elsevier Ltd. All rights reserved.
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
characterized by different patterns of thoughts and behaviors (Hewitt et al., 2003; Hewitt & Flett, 1991). Self-oriented perfectionism is characterized by requiring perfection of oneself, socially prescribed perfectionism is defined by the perception that others require one to be perfect, other-oriented perfectionism is typified by requiring perfection from others, perfectionistic self-promotion involves the need to appear perfect, nondisplay of imperfection is characterized by the refusal to engage in any behaviour that is less than perfect, and nondisclosure of imperfection is typified by the refusal to admit any imperfection. While there is evidence that some aspects of perfectionism may be useful in certain contexts (see Stoeber & Otto, 2006 for review), perfectionism has been linked with psychological distress in undergraduate students, notably stress reactivity and depressive symptoms (Flett, Nepon, Hewitt, & Fitzgerald, 2016), anxiety (Smith, Vidovic, Sherry, Stewart, & Saklofske, 2018), and binge eating (Smith, Sherry, Gautreau, Stewart, Saklofske, & Mushquash, 2017). Furthermore, perfectionism has also been associated with lower likelihood of seeking help for psychological distress (Ey, Henning, & Shaw, 2000). Thus, perfectionism is associated with increased psychological distress yet is also linked to reluctance to seek professional help for said distress. The reason for this potentially dangerous scenario wherein perfectionism may increase an individual's risk of mental health issues while also making that individual less likely to seek help is not known for certain; however, it stands to reason that mental illness stigma may play a role.
2.2. Importance As noted above, the impact of perfectionism on mental illness stigma has not yet been investigated, however despite the paucity of prior research, it stands to reason that perfectionism may impact one's attitudes towards mental illness. It may be that associating with someone who has a mental illness or admitting that one is experiencing psychological distress and seeking assistance may violate a perfectionistic individual's need to be or to appear perfect. Illuminating the relationship between perfectionism, stigma, and attitudes towards seeking help is especially important given recent evidence that suggests that perfectionism may be a risk factor for suicides that ostensibly occur without warning (Flett, Hewitt, & Heisel, 2014). 2.3. Hypotheses It was predicted that individuals who are high on perfectionistic self-promotion would have more negative views of professional treatment for mental health issues due to research that found that those individuals who are high in perfectionistic self-promotion have negative expectations of therapy and may view it as threatening (Hewitt et al., 2008). In addition, it has been hypothesized that individuals who score high on measures of perfectionistic self-presentation have a negative image of the self (Flett, Madorsky, Hewitt, & Heisel, 2002). Consequently, these individuals were predicted to have high levels of self-stigma. Furthermore, participants who scored highly in terms of self-oriented perfectionism were expected to have more self-stigma as they hold themselves to excessively high standards and admitting that they are experiencing psychological distress may violate these standards (Hewitt & Flett, 1991). Moreover, those who score high on socially prescribed perfectionism feel as though others expect them to be perfect, and experiencing psychological distress may violate this expectation. Therefore, those who scored high on socially prescribed perfectionism were expected to score higher on perceptions of stigmatization by others for seeking help (Hewitt & Flett, 1991). In addition, it was expected that participants who were high in other-oriented perfectionism would have more negative views of individuals with mental illness as they already hold other individuals up to impossibly high standards and having a mental illness may violate these standards (Hewitt & Flett, 1991).
2. The current study 2.1. Research goals The current study sought to investigate the relationship between trait perfectionism, perfectionistic self-presentation, mental illness stigma, and attitudes towards seeking help. The goal of this study was to discern whether individuals who differ along the continuum of various types of perfectionism also differ in their attitudes towards individuals with mental illness, their attitudes towards mental health treatment, and the extent of self-stigma for seeking help. This investigation focused jointly on trait perfectionism dimensions and perfectionistic self-presentation due to our particular interest in perfectionistic self-presentation. The notion of perfectionistic self-presentation was introduced by Hewitt et al. (2003) to highlight the distinction between trait perfectionism (i.e., wanting or needing to be perfect) and perfectionistic self-presentation (i.e., wanting or needing to seem perfect). To our knowledge, neither trait perfectionism nor perfectionistic self-presentation have been evaluated in terms of a possible link with negative attitudes towards mental illness and people who have some form of mental illness. An association with negative attitudes would be in keeping with the evaluative nature of many perfectionists. An association between stereotypic negative beliefs and the interpersonal aspects of perfectionism (i.e., socially prescribed perfectionism and perfectionistic self-presentation) could help explain the link that these interpersonal facets of perfectionism have with a fear of negative evaluation and anticipated interpersonal threats (see Flett & Hewitt, 2014). We also examined perfectionism and help-seeking attitudes and selfstigma given that possible links with perfectionism have received little empirical or theoretical consideration. One study linked trait perfectionism with self-stigma for seeking help in adolescents (Zeifman et al., 2015). This association needs to be re-examined with an extended joint focus on trait perfectionism and perfectionistic self-presentation. Other research suggests a link between perfectionism and negative helpseeking attitudes and orientation (e.g., Abdollahi, Hosseinian, BehPajooh, & Carlbring, P., 2017) but again this research has not typically included an emphasis on perfectionistic self-presentation despite it being reasonable to assume that people who need to seem perfect should be especially unwilling to seek help, since seeking help can be interpreted as an admission of not being perfect.
3. Method 3.1. Participants One hundred and forty English speaking university students were recruited. Participants received partial course credit for their participation. The sample was 77.9% female. The average age of participants was 19.70 (SD = 2.60). The most common self-identified ethnic category was South Asian (28.6%) followed by Middle Eastern (16.4%), Caucasian (14.3%), Black (12.1%), East Asian (12.1%), Latin American (2.9%), and multi-racial or other (5.7%). 3.2. Measures An ad hoc demographics questionnaire was used to gather data regarding participant's age, sex, and ethnicity. The following measures were administered: The Multidimensional Perfectionism Scale (Hewitt & Flett, 1991) was used to measure self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism. The Multidimensional Perfectionism Scale consists of 45 questions on a 7 point Likert scale ranging from strongly disagree to strongly agree. The questions load onto three subscales that measure self-oriented, other-oriented perfectionism, socially prescribed perfectionism, respectively. 67
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
Items are scored such that higher subscale scores are indicative of greater perfectionism. Adequate test-retest reliability, and concurrent validity (Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991), as well as internal consistency (Hewitt & Flett, 1991) has been documented. The Cronbach's alphas for this study were: .87 self-oriented perfectionism subscale; .75 other-oriented perfectionism subscale; .82 socially prescribed perfectionism subscale. The Perfectionistic Self-Presentation Scale (Hewitt et al., 2003) was used to assess perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection. The Perfectionistic Self-presentation Scale consists of 27 items on a 7 point Likert scale ranging from disagree strongly to agree strongly. These items load onto three subscales that measure perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection. Higher subscale scores reflect higher levels of perfectionism. Good test-retest reliability, convergent and divergent validity as well as predictive and incremental validity for measures of psychological distress above and beyond measures of trait perfectionism alone (Hewitt et al., 2003). The Cronbach's alphas for this study were: .90 perfectionistic self-promotion subscale; .86 nondisplay of imperfection subscale; .80 nondisclosure of imperfection subscale. The Beliefs Towards Mental Illness Scale (Hirai & Clum, 2000) was used to gauge stigma towards individuals with mental illness. The Beliefs Towards Mental Illness Scale consists of 21 items on a 5 point Likert scale ranging from completely disagree to completely agree. Higher scores indicate more negative views regarding mental illness. It consists of 3 subscales measuring perceived dangerousness of individuals with mental illness, perceptions of poor interpersonal and social skills of individuals with mental illness, and perceived incurability of mental illness. It has been found to have good internal consistency, reliability (Hirai & Clum, 2000), and construct validity (Royal & Thompson, 2013). The Cronbach's alphas for this study were: .78 dangerousness of individuals with mental illness subscale; .80 perceptions of poor interpersonal and social skills of individuals with mental illness; .75 perceived incurability of mental illness. The Self-Stigma of Seeking Help Scale (Vogel, Wade, & Haake, 2006) was used to measure self-stigma associated with accessing mental health services. This scale is composed of 10 items rated on a 5 point Likert scale ranging from strongly disagree to strongly agree. Higher scores are indicative of greater self-stigma. This scale has demonstrated good test–retest reliability as well as construct, criterion, concurrent, and predictive validity (Vogel et al., 2006). In addition, it showed incremental validity in predicting both attitudes towards and intent to seek psychological help (Vogel et al., 2006). The Cronbach's alpha for this study was .80 with item 4 deleted. The Attitudes Towards Seeking Professional Psychological Help Scale Shortened Form (Fischer & Farina, 1995) was used to assess stigma regarding professional treatment for psychological distress. The scale consists of 10 statements rated on a 4 point Likert scale ranging from disagree to agree. Higher scores are indicative of more positive attitudes towards seeking help. This scale has demonstrated good construct and concurrent validity, test-retest reliability, and internal consistency (Hatchet, 2006). The Cronbach's alpha for this study was .77. The Perceptions of Stigmatization by Others for Seeking Help Scale (Vogel, Wade, & Ascheman, 2009) was used to measure individuals' perception of the stigma other hold for seeking help for psychological distress. This scale instructs participants to imagine how people they interact with would act towards or perceive them if they sought counseling. Responses are recorded on a 5 point Likert scale ranging from not at all to a great deal. This scale has been found to have good internal consistency, concurrent validity, construct validity, and test–retest reliability (Vogel et al., 2009). The Cronbach's alpha for this study was .84.
Table 1 Bivariate correlations between variables for the total sample. Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
−0.12 0.05 0.21⁎ 0.12 0.13 −0.03
0.01 0.04 0.19⁎ 0.21⁎ 0.04 0.02
−0.12 −0.1 0.14 0.33⁎⁎ 0.15 0.01
−0.19⁎⁎ 0.16 0.33⁎⁎ 0.24⁎⁎ 0.15 −0.02
−0.03 0.29⁎⁎ 0.25⁎⁎ 0.15 0.20⁎ 0.05
−0.11 0.32⁎⁎ 0.30⁎⁎ 0.17⁎ 0.16 −0.07
Note: SOP = self-oriented perfectionism, OOP = other-oriented perfectionism, SPP = socially prescribed perfectionism, PSP = perfectionistic self-presentation, NP = nondisplay of imperfection, NI = nondisclosure of imperfection. ⁎ Indicates p < .05. ⁎⁎ indicates p < .01.
3.3. Procedure After informed consent was obtained, participants completed the demographics questionnaire, and the six measures listed above. 4. Results Table 1 displays correlations between the variables. Since the sample was predominately female, the pattern of correlations was also depicted by sex (see Tables 2 and 3). Tables 1 through 3 illustrate that the pattern of correlations identified in the total sample holds for female but not male participants. Table 4 displays the means and standard deviations of all variables for the total sample as well as by sex. A statistically significant difference on the nondisclosure of imperfection subscale was identified such that female participants scored significantly higher than male participants. 4.1. Regression analyses Hypotheses were tested using a series of regression models. Multiple linear regression indicated that perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of imperfection predict selfstigma, R2 = .12, F(3,132) = 5.98, p = .001. Simple linear regression analyses indicated that nondisplay of imperfection predicted attitudes towards seeking help, R2 = .04, F(1, 136) = 4.98, p = .027, self-oriented perfectionism predicted selfstigma, R2 = .05, F(1, 134) = 6.32, p = .013, socially prescribed perfectionism predicted perceptions of stigmatization by others, R2 = .11, F(1, 133) = 16.19, p < .001, and other-oriented perfectionism significantly predicted the belief that individuals with mental illness have poor social skills, R2 = .21, F(1,135) = 5.95, p = .016, but not the belief that individuals with mental illness are dangerous, R2 = .02, F (1,134) = 1.60, p = .807, or that mental illness is incurable, R2 < .01, F(1,134) = .21, p = .651. 5. Discussion The current study uniquely examined the extent to which trait perfectionism and perfectionistic self-presentation were associated with Table 2 Bivariate correlations between variables among for female participants.
68
Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
−0.18 0.05 0.31** 0.17 0.19 0.05
0.02 0.02 0.20* 0.21* 0.01 0.08
−0.14 0.34** 0.39** 0.21* 0.18 0.04
−0.16 0.19* 0.38** 0.29** 0.21* 0.09
−0.04 0.31** 0.22* 0.17 0.25* 0.11
−0.07 0.35** 0.23** 0.21* 0.17 −0.01
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
of Zeifman et al. (2015) that linked self-stigma with trait perfectionism but did not assess perfectionistic self-presentation. The desire to appear perfect (i.e., perfectionistic self-promotion) was associated with greater self-stigma towards seeking help for mental health difficulties and more negative attitudes towards seeking professional help for mental health difficulties in general. The concept of self-reliance may be of use in illuminating the relationship between perfectionistic self-promotion and more negative attitudes towards treatment seeking. Self-reliance has been associated with more negative attitudes towards treatment seeking (Jennings et al., 2015). Those who feel the need to present themselves in a perfectionistic manner may be higher on self-reliance as they may feel that they cannot disclose their difficulties to others as it will preclude them from being or appearing perfect. As such, they choose to rely only on themselves to manage their mental health issues. It is important to underscore that greater refusal to engage in any behaviour that is less than perfect (i.e., nondisplay of imperfection) predicted self-stigma and attitudes towards seeking help, and was associated with perceived stigmatization by others for seeking help. Seeking treatment for mental health challenges may be perceived by individuals who score highly on nondisplay of imperfection as akin to engaging in a behaviour that is less than perfect. Similarly, refusal to admit to any imperfection (i.e., nondisclosure of imperfection) was also significantly related to both self-stigma and perceived stigmatization by others. These relationships were anticipated as seeking treatment for psychological distress could be seen as admitting to imperfection. Symbolic interaction stigma (Link, Wells, Phelan, & Yang, 2015) may be of use when attempting to illuminate the relationship between perfectionistic self-presentation, self-stigma, and more negative attitudes towards seeking professional help. Individuals who score highly on perfectionistic self-presentation want to display a perfectionistic persona to others. For some of these individuals, they may feel others will reject them if they do not live up to this perfectionistic persona. Consequently, they may imagine what others would think of their seeking professional help and anticipate negative interactions with others in which they are rejected as seeking help would violate the persona. These types of imagined interactions constitute what Link et al. (2015) refer to as symbolic interaction stigma. Symbolic interaction stigma, especially anticipated rejection, is associated with the internalization of mental health stigma (Link et al., 2015). It may be that, as a consequence of this process, individuals who score highly on perfectionistic self-presentation have more negative attitudes towards seeking professional help and are less likely to do so. Taken together these findings point to a subset of the population that is at greater risk for psychological distress but also feels more stigma regarding seeking mental health treatment that, in turn, may explain why these individuals are also less likely to seek treatment. This hypothesis is plausible as stigma has been found to be a strong impediment to seeking treatment for mental health difficulties. This dynamic is especially alarming given the association and perfectionism
Table 3 Bivariate correlations between variables among male participants. Variable
SOP
OOP
SPP
PSP
NP
NI
Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
0.11 0.12 −0.1 −0.12 −0.07 −0.40*
−0.09 0.13 0.29 0.19 0.20 −0.24
0.05 0.32 0.57** 0.17 −0.05 −0.22
−0.28 0.08 0.16 −0.6 −0.02 −0.41*
0.02 0.16 0.35 0.15 0.03 −0.16
−0.21 0.17 0.48** 0.10 0.13 −0.23
negative beliefs about mental illness with the use of a beliefs measure that has been associated with the presence of mental illness stigma. The results with the overall beliefs measure suggested that there is a link between a tendency to put on a perfectionistic front that could mask personal symptoms of distress and a tendency to endorse negative stereotypes about mental illness. This adds to what is known about people who falsely portray themselves as perfect; these individuals tend to be using this style to hide negative aspects of themselves and their sense of being an imposter from other people (Hewitt et al., 2003). Our results raise the possibility that negative assumptions about mental illness and how people react to mental illness may be contributing to this tendency to try to seem perfect (or avoid seeming imperfect) when in public. It seems quite reasonable for people who actually suffer from mental illness to try to avoid appearing imperfect in order to ward off the anticipated negative responses and reactions of people who tend to stigmatize people with mental health problems. A more refined analysis of the components of mental illness beliefs showed that perfectionistic self-presentation and, to a lesser extent, trait perfectionism have their clearest associations with beliefs about the poor interpersonal and social skills of individuals with mental illness. Examination of the various perfectionism factors showed that it was socially prescribed perfectionism that had the strongest association with negative beliefs about the social skills of people with mental illness. These negative beliefs about interpersonal skills could, at least to some extent, reflect the salience of the self-appraisals of people who are high in interpersonal perfectionism because they tend to have negative views of their own personal capacities to act appropriately in public and it is this sense of being unable to meet social expectations that fuels much of their social anxiety (Flett & Hewitt, 2014). In this instance, people with high levels of socially prescribed perfectionism tend to feel hopeless and judged by others which is reflected by the fact that socially prescribed perfectionism predicted perceptions of stigmatization by others. Perfectionistic self-presentation was associated with more negative attitudes towards help seeking. Similarly, perfectionistic self-presentation and self-oriented perfectionism predicted self-stigma for seeking help. The obtained associations were stronger and more consistently evident with perfectionistic self-presentation, thus qualifying the results
Table 4 Means and (standard deviations) of all variables of interest with ANOVA results for sex differences. Variable
Total sample N = 141
Female n = 109
Male n = 30
F
p
η2
SOP OOP SPP PSP NP NI Attitude towards help Stigma by others Self-stigma Poor social skills Incurable Dangerous
73.75 (15.21) 60.64 (12.76) 59.21 (14.37) 45.55 (13.48) 49.79 (12.41) 26.56 (9.09) 15.97 (5.62) 9.15 (4.23) 23.36 (6.71) 18.44 (9.03) 15.36 (5.74) 9.20 (5.14)
72.67 (15.83) 59.81 (13.20) 58.35 (15.18) 45.47 (13.64) 50.38 (12.58) 27.34 (9.01) 15.89 (5.42) 9.26 (4.24) 23.83 (6.53) 18.17 (8.92) 15.48 (5.58) 9.07 (5.10)
77.67 (12.55) 63.17 (10.84) 62.25 (10.69) 46.03 (13.27) 47.37 (11.75) 23.60 (8.99) 16.27 (6.37) 8.57 (4.13) 21.62 (7.32) 19.57 (9.58) 14.97 (6.46) 9.67 (5.35)
20.53 10.63 10.63 0.04 10.38 40.05 0.01 0.63 20.49 0.56 0.18 0.31
0.114 0.205 0.204 0.840 0.241 0.046 0.746 0.429 0.117 0.457 0.670 0.578
00.02 0.01 0.01 < 0.01 0.01 0.03 < 0.01 < 0.01 0.02 < 0.01 < 0.01 < 0.01
69
Personality and Individual Differences 126 (2018) 66–70
A. Shannon et al.
and suicides that seemingly occur with no warning signs.
psychological functioning, cognitive-affective strategies, and social well-being. Emerging Adulthood, 2, 195–210. http://dx.doi.org/10.1177/2167696814521808. Cook, T. M., & Wang, J. (2010). Descriptive epidemiology of stigma against depression in a general population sample in Alberta. BMC Psychiatry, 10. http://dx.doi.org/10. 1186/1471-244X-10-29. Cox, N. C., & Hill, A. P. (2018). Trait perfectionism and attitudes towards people with disabilities. Personality and Individual Differences, 122(Supplement C), 184–189. http://dx.doi.org/10.1016/j.paid.2017.10.028. Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical Care, 45, 594–601. http://dx. doi.org/10.1097/MLR.0b013e31803bb4c1. Ey, S., Henning, K. R., & Shaw, D. L. (2000). Attitudes and factors related to seeking mental health treatment among medical and dental students. Journal of College Student Psychotherapy, 14, 23–39. http://dx.doi.org/10.1300/J035v14n03_05. Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychologial help: A shortened form and considerations for research. Journal of College Student Development, 36, 368–373. http://dx.doi.org/10.1037/prj0000131. Flett, G., Nepon, T., Hewitt, P., & Fitzgerald, K. (2016). Perfectionism, components of stress reactivity, and depressive symptoms. Journal of Psychopathology and Behavioral Assessment, 38, 645–654. http://dx.doi.org/10.1007/s10862-016-9554-x. Flett, G. L., & Hewitt, P. L. (2014). Perfectionism and perfectionistic self-presentation in social anxiety: Implications for assessment and treatment. In S. Hofmann, & P. DiBartolo (Eds.). Social anxiety: Clinical, developmental, and social perspectives (pp. 159–187). (3rd ed.). London: Elsevier. Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18, 156–172. http://dx.doi.org/10.1037/ gpr0000011. Flett, G. L., Madorsky, D., Hewitt, P. L., & Heisel, M. J. (2002). Perfectionism cognitions, rumination, and psychological distress. Journal of Rational-Emotive & CognitiveBehavior Therapy, 20, 33–47. http://dx.doi.org/10.1023/A:1015128904007. Hatchet, G. T. (2006). Additional validation of the attitudes toward seeking professional psychological help scale. Psychological Reports, 98, 279–284. http://dx.doi.org/10. 2466/PR0.98.1.279-284. Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, 456–470. http://dx.doi.org/10.1037/00223514.60.3.456. Hewitt, P. L., Flett, G. L., Sherry, S. B., Habke, M., Parkin, M., Lam, R. W., ... Stein, B, M. (2003). The interpersonal expression of perfection: Perfectionistic self-presentation and psychological distress. Journal of Personality and Social Psychology, 84, 1303–1325. http://dx.doi.org/10.1037/0022-3514.84.6.1303. Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The multidimensional perfectionism scale: Reliability, validity, and psychometric properties in psychiatric samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 464–468. http://dx.doi.org/10.1037/1040-3590.3.3.464. Hewitt, P. L., Habke, A. M., Lee-Baggley, D., Sherry, S. B., & Flett, G. L. (2008). The impact of perfectionistic self-presentation on the cognitive, affective, and physiological experience of a clinical interview. Psychiatry: Interpersonal and Biological Processes, 71, 93–122. http://dx.doi.org/10.1521/psyc.2008.71.2.93. Hirai, M., & Clum, G. A. (2000). Development, reliability, and validity of the beliefs toward mental illness scale. Journal of Psychopathology and Behavioral Assessment, 22, 221–236. http://dx.doi.org/10.1023/A:1007548432472. Jennings, K. S., Cheung, J. H., Britt, T. W., Goguen, K. N., Jeffirs, S. M., Peasley, A. L., & Lee, A. C. (2015). How are perceived stigma, self-stigma, and self-reliance related to treatment-seeking? A three-path model. Psychiatric Rehabilitation Journal, 38, 109–116. http://dx.doi.org/10.1037/prj0000138. Link, B. G., Wells, J., Phelan, J., & Yang, L. (2015). Understanding the importance of “symbolic interaction stigma”: How expectations about the reactions of others adds to the burden of mental illness stigma. Psychiatric Rehabilitation Journal, 38, 117–124. http://dx.doi.org/10.1037/prj0000142. Royal, K. D., & Thompson, J. M. (2013). A psychometric validation of the beliefs toward mental illness scale. Journal of Nursing Measurement, 21, 516–524. http://dx.doi.org/ 10.1891/1061-3749.21.3.516. Smith, M., Sherry, S., Gautreau, C., Stewart, S., Saklofske, D. H., & Mushquash, A. (2017). Are perfectionistic concerns an antecedent of or a consequence of binge eating, or both? A short-term four-wave longitudinal study of undergraduate women. Eating Behaviours, 26, 23–26. http://dx.doi.org/10.1016/j.eatbeh.2017.01.001. Smith, M. M., Vidovic, V., Sherry, S. B., Stewart, S. H., & Saklofske, D. H. (2018). Are perfectionism dimensions risk factors for anxiety symptoms? A meta-analysis of 11 longitudinal studies. Anxiety, Stress, & Coping, 31, 4–20. http://dx.doi.org/10.1080/ 10615806.2017.1384466. Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence, challenges. Personality and Social Psychology Review, 10, 295–319. http://dx. doi.org/10.1207/s15327957pspr1004_2. Vogel, D. L., Wade, N. G., & Ascheman, P. L. (2009). Measuring perceptions of stigmatization by others for seeking psychological help: Reliability and validity of a new stigma scale with college students. Journal of Counseling Psychology, 56, 301–308. http://dx.doi.org/10.1037/a0014903. Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53, 325–337. http://dx. doi.org/10.1037/0022-0167.53.3.325. Zeifman, R. J., Atkey, S. K., Zhao, W., Young, R. E., Flett, G. L., & Goldberg, J. O. (2015). When ideals get in the way of self-care: Perfectionism and self-stigma for seeking psychological help among high school students. Canadian Journal of School Psychology. http://dx.doi.org/10.1177/0829573515594372.
6. Conclusion In conclusion, this study provides a plausible explanation of why individuals with high levels of perfectionism are more reluctant to seek treatment for psychological issues as compared to their non-perfectionist peers despite experiencing higher levels of psychological distress. That is, individuals with high levels of perfectionism endorse more negative beliefs and presumably have a level of mental illness stigma that, in turn, is a significant barrier to seeking mental health support. In sum, based upon the current findings and previous literature, the following dynamic is proposed: individuals who score highly on measures of perfectionism are more likely to experience psychological distress and are also more likely to feel stigmatized when seeking help for psychological issues; this feeling of stigmatization then makes these individuals less likely to seek psychological assistance, ultimately, the result of this dynamic is significant psychological distress that is undisclosed and untreated that, in turn, leads to increased incidences of suicides in which others report an absence of warning signs. Consequently, this study points to the need for targeted interventions to reduce mental illness stigma among individuals who score highly on measures of perfectionism. These interventions will increase helpseeking behaviour that will then decrease distress and remedy this maladaptive dynamic. 7. Limitations and directions for future research There are some limitations to take into account when considering the implications of the current study. Participants in the current study were all undergraduate students and were predominately female which limits the generalizability of the findings. There is some evidence (see Table 3) that the pattern of relationships may not hold for male participants. Future research should investigate whether these findings hold for more diverse populations. Moreover, all measures were self-report which makes them particularly susceptible to social desirability. Future research would be well-served by including a measure of social desirability. Future research to investigate the efficacy of targeted interventions to reduce mental illness stigma among individuals who are high in perfectionism would be worthwhile. Specifically, targeting self-stigma among individuals who score highly on self-oriented perfectionism, perfectionistic self-promotion, nondisplay of imperfection, or nondisclosure of imperfection may increase help-seeking among these underserved populations. Moreover, targeting stigmatized beliefs about individuals with mental illness among individuals who score highly on other-oriented perfectionism may be a beneficial avenue for mental illness stigma reduction campaigns. References Abdollahi, A., Hosseinian, S., & Beh-Pajooh, & Carlbring, P. (2017). Self-concealment mediates the relationship between perfectionism and attitudes toward seeking psychological help among adolescents. Psychological Reports.. http://dx.doi.org/10. 1177/0033294117713495. Adlaf, E. M., Demers, A., & Gliksman, L. (Eds.). (2005). Canadian campus survey. Centre for Addiction and Mental Health. Bowers, H., Manion, I., Papadopoulos, D., & Gauvreau, E. (2013). Stigma in school-based mental health: Perceptions of young people and service providers. Child and Adolescent Mental Health, 18, 165–170. http://dx.doi.org/10.1111/j.1475-3588. 2012.00673.x. Brown, S. A. (2012). The contribution of previous contact and personality traits to severe mental illness stigma. American Journal of Psychiatric Rehabilitation, 15, 274–289. http://dx.doi.org/10.1080/15487768.2012.703553. Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., ... Thornicroft, G. (2015). What is the impact of mental health-related stigma on helpseeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45, 11–27. http://dx.doi.org/10.1017/S0033291714000129. Conley, C. S., Kirsch, A. C., Dickson, D. A., & Bryant, F. B. (2014). Negotiating the transition to college: Developmental trajectories and gender differences in
70