Capstones, Theses and
Dissertations
2016
Mental Health Stigma in Religious Communities:
Development of a Quantitative Measure

TABLE OF CONTENTS
ABSTRACT iii
CHAPTER 1. OVERVIEW
The Present Study
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2
CHAPTER 2. LITERATURE REVIEW
The Impact of Stigma
Goffman’s Foundational Work on Stigma
Link and Phelan’s Four Components of Stigma
Labeling Effects and Mental Illness
Public vs. Self-Stigma
Mental Illness Stigma vs. Help-Seeking Stigma
Attitudes toward Counseling, Intentions to Seek Counseling, and Stigma
Self-Stigma of Mental Illness vs. Self-Stigma of Help-Seeking
Internalized Stigma Model
Religious Mental Health Stigma
Conclusions

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CHAPTER 3. METHODS
Participants
Measures
Procedures

CHAPTER 4. RESULTS
Attention Check
Sample 1: Exploratory factor analysis
Internal consistency reliability
Sample 2: Confirmatory factor analysis
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CHAPTER 5. DISCUSSION 53
RMHSS versus RBAMI
Limitations
Future Directions
Conclusion
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CHAPTER 6. REFERENCES
CHAPTER 7. APPRENDICES
APPENDIX A: STUDY MATERIALS
APPENDIX B: IRB APPROVAL SHEET
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ACKNOWLEDGEMENTS 86
iii
ABSTRACT
While mental health stigma is a burgeoning field of research, little work has been done on
whether mental health stigma in different subcultures is the same or different as the general
population. There is qualitative evidence that beliefs about the etiology and effective
treatments for mental illness differ in religious communities as compared to the general
population, but efforts to quantify this difference have been sparse and reflect poor
methodology. The purpose of the present study is to create and validate a measure of mental
health stigma in religious communities. Items will be generated using extant literature and
revised after expert review and piloting. In Study 1, the items were tested with 703
undergraduate students at a large Midwestern university. Exploratory Factor Analysis was
then used to determine a factor structure with good fitting items. In Study 2, items were
retested with a second sample of undergraduate students at the same university, to conduct a
Confirmatory Factor Analysis, to cross-validate the scale, and to measure convergent and
discriminate validity using several scales measuring related constructs. The outcome is a
psychometrically strong, valid self-report instrument to measure mental health stigma in
religious communities.
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CHAPTER 1. OVERVIEW
A Surgeon General report named mental illness stigma “the most formidable obstacle to
future progress in the arena of mental illness and health” (Abdullah & Brown, 2011; U.S.
Department of Health and Human Services, 1999). Considering that one epidemiological study,
the National Comorbidity Survey – Revised (NCS-R), estimated that 26.2% of adult Americans
have a diagnosable mental illness in a given year, this stigma has significant impact on the health
of Americans (Kessler, Chiu, Demler, & Walters, 2005). In a given year at most one-third of
those with a diagnosable mental disorder will seek treatment from a mental health professional
(Bathje & Pryor, 2011). While approximately 80% of all people with a mental disorder
eventually seek treatment, the median delay between first onset of the disorder and first
treatment contact is nearly ten years (Wang, Berglund, Olfson, & Kessler, 2004). Many factors
contribute to this finding, but mental health stigma is one of the most powerful factors (Bathje &
Pryor, 2011; Henderson, Evans-Lacko, & Thornicroft, 2013).
Most research on mental illness and help-seeking stigma has focused on the general
population without looking at factors that may be unique to specific subcultures. While the
general population may be hesitant to use mental health services, those in religious communities
underutilize them even more (Mayers, Leavey, Villianatou, & Barker, 2007; Ng, Nyunt, Chiam,
& Kua, 2011; Trice & Bjorck, 2006). While many factors account for this treatment gap, one
influence comes in the form of mental illness and help-seeking stigma that are unique to those
communities. Common religious beliefs, particularly among the Abrahamic traditions, indicate
that the main causes of mental illness are moral weakness, sin, or unfaithfulness with religious
practices such as praying, reading the Bible, or worshiping (Hartog & Gow, 2005; Trice &
Bjorck, 2006). In this paper, this stigma will be referred to as religious mental health stigma.
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Little research has been conducted in the area of religious mental health stigma. There
has been research conducted on attitudes of religious communities toward mental illness
including the etiology of the disorders and appropriate treatments as well as the referral behavior
of religious leaders (e.g. Farrell & Goebert, 2008; Jones, Cassidy, & Heflinger, 2012, etc.).
Researchers, however, have taken few steps to integrate religious mental health stigma into
existing research regarding mental health stigma. What research has been done has conflated
public stigma of mental illness and help-seeking. Self-stigma has not been addressed at all.
In a unique attempt to further research mental health stigma in religious communities,
Wessellmann and Graziano (2010) created a measure of religious beliefs about mental illness,
the only measure in the literature of which I am aware. They made the distinction between
religious and secular beliefs about mental illness. While this scale has many valuable elements,
there are several limitations. It has several questions that only apply to Christians, the focus is
solely on public stigma – self-stigma is not addressed. In addition, the psychometric properties
of the measure are lacking. For example, the items were not reviewed by a panel of experts nor
were they piloted, a readability analysis was not conducted, and test-retest reliability was not
assessed.
The Present Study
In the present thesis, I generate a self-report scale to measure religious mental health
stigma across two studies. In the first study items are generated using the extant literature and
then assessed for their psychometric properties. Students at a large Midwestern university
complete the measure, then exploratory factor analysis is conducted to determine what factors
emerge and to determine which items have the factor loading to justify retention. In the second
study the retained items are given to a new set of participants to test the reliability and validity of
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the measure. The creation of this measure allows researchers in the future to measure religious
mental health stigma in order to predict such outcomes as help-seeking intentions, treatment
adherence, and prejudice against those with mental illness.

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CHAPTER 2. LITERATURE REVIEW
The stigma of mental illness has been a burgeoning field of research over the past fifteen
years. Link and Phelan’s seminal article “Conceptualizing Stigma” provided a needed framework
for future mental health stigma research (2001). Mental health stigma was then broken down into
the concepts of public stigma and self-stigma (i.e. Ben-Porath, 2002; Corrigan, Kerr, & Knudsen,
2005; Vogel & Wade, 2009), and then further the stigma of mental illness and of seeking
psychological services or help-seeking stigma (i.e. Komiya, Good, & Sherrod, 2000; Tucker,
Hammer, Vogel, Bitman, Wade, & Maier, 2013). Mental health stigma in religious communities
has only been researched in a roundabout way – in a systematic review of the literature only four
of 1423 articles identified through various PsycINFO searches dealt directly with mental illness
stigma in religious communities (Mathison & Wade, 2014). That said, research on related areas
provides valuable background knowledge, such as religious beliefs about the etiology of mental
illness, accepted methods of treatment for mental illness in religious communities, religious
leaders’ understanding of and training in mental health issues, and the differences in belief across
race and ethnicity. Before breaking down the components of stigma and its manifestations in
religious communities, however, it is important to understand their impact.
The Impact of Stigma
Mental health stigma is one of the most powerful of all stigmas; its effects pervasive and
grievous (Abdullah & Brown, 2011; Bathje & Pryor, 2011; Ben-Porath, 2002). In 2007, a group
called the Behavioral Risk Factor Surveillance System (BRFSS) surveyed adults in 37 U.S.
states and territories about their attitudes toward mental illness, using the 2007 BRFSS Mental
Illness and Stigma module. Based on 2007 BRFSS data most adults with mental health
symptoms (78%) and without mental health symptoms (89%) agreed that treatment can help
5
persons with mental illness lead normal lives. Though 57% of the total sample believed that
people are caring and sympathetic to persons with mental illness, only 25% of adults who
actually experienced mental health symptoms believed so (Centers for Disease Control and
Prevention, 2010). Furthermore, 68% of Americans do not want to have a person with mental
illness marry into their family and 58% do not want one in their workplace (Mental Health
America of Eastern Missouri, 2011). People with mental illnesses often face discrimination in
employment, housing, health care, and social interaction (Bathje & Pryor, 2011). Not only does
the individual with a mental illness experiences the effects of stigma but so does their family and
friends (Corrigan, Kerr, & Knudsen, 2005; Stanford, 2007).
The effects of mental health stigma are formidable in the lives of those with mental
illness as well as their friends and family. But to know the effects is not the same as
understanding the ways in which it works. A theoretical understanding of the construct of stigma
is key in addressing stigma. The forerunners of research in mental health stigma studied stigma
as a general concept, creating a framework from which research on mental health stigma could
build.
Goffman’s Foundational Work on Stigma
Erving Goffman’s 1963 work Stigma: Notes on the Management of Spoiled Identity
broke ground for the study of stigma. He categorized stigma into three types: physical stigma,
stigma of character traits, and stigma of group identity. Physical stigma refers to physical
abnormalities such as blindness or need of a wheelchair. Stigma of character traits includes traits
such as having a record of mental disorders, imprisonment, addiction, homosexuality, suicide
attempts, or radical political behavior. Stigma of group identity refers to the stigma against the
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members of an identifiable group, for example, a particular race or religion. In contrast, he refers
to a non-stigmatized individual as a “normal.”
Goffman (1963) describes several important implications of having a stigma. He posits
that normals “believe the person with a stigma is not quite human” (p. 5). This, at its core, is
stigma – that by considering a stigmatized individual as not quite human, normals are not
required to treat such an individual with the dignity and respect owed a human. Along these lines
Goffman states, “On this assumption [normals] exercise varieties of discrimination, through
which [they] effectively, if often unthinkingly, reduce his life chances” (p.5). Because of the
negative effects of being stigmatized, an individual with a stigmatized trait will attempt to
conceal this trait if at all possible.
Here it is necessary to divide stigmatized individuals into two groups, those who are
discredited, whose stigmatized trait is immediately apparent, and those who are discreditable,
whose stigmatized trait is not immediately apparent. Those with a physical stigma and some of
those with a group stigma (e.g. as indicated by skin color or religious dress) are discredited while
those with a character trait stigma or others with a group stigma (e.g. those with an ambiguous
skin color) are discreditable. Those with a discredited stigma are prey to the discrimination
attached to their stigma immediately. Those with a discreditable stigma, on the other hand, can
conceal the trait and avoid the negative effects of stigma, but must ever be wary of the possibility
of being found out (Goffman, 1963).
Unfortunately, Goffman (1963) suggests that even if an individual can conceal a
stigmatized trait from the outside world, “the stigmatized individual tends to hold the same
beliefs about identity” that normals do (p.7). In both discredited and discreditable individuals, his
can lead to self-hatred and self-disgust because one does not see oneself as completely human.
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Shame about the stigmatized trait, therefore, can be present whether others are aware of the trait
or not. Between the expected discrimination from others and the negative self-Assessment, a
stigmatized individual may resort to isolating themselves in defense. If s/he is discreditable
rather than discredited though, s/he may choose to avoid disclosing the trait in order to avoid
discrimination. While this may save them from overt discrimination, the stigmatized individual
in effect isolates themselves by always presenting an incomplete picture of him/herself, leading
all the same to feelings of isolation (Goffman, 1963).
Goffman’s (1963) insights into stigma apply easily to mental health stigma. Mental
health stigma is a character trait stigma and a person with mental illness is discreditable. Thus,
such a person may conceal their mental illness from others in order to avoid discrimination.
However, even if s/he does, s/he is still prey to negative self-Assessments based on his/her mental
illness. As opposed to an individual that cannot escape his/her stigmatizing trait such as an exconvict, a person with mental illness can avoid both outside discrimination and negative selfAssessment by denying the fact that s/he has a mental illness at all. This has profound implications
for mental health treatment, which will be discussed at length below. First, though, it is useful to
understand the components of stigma.
Link and Phelan’s Four Components of Stigma
In their influential article “Conceptualizing Stigma” Link and Phelan (2001) described
stigma as having four components encompassing five factors: 1) labeling, 2) stereotyping, 3)
separation, and 4) status loss and discrimination. The first component, labeling, is the social
process by which any given human trait is singled out and deemed salient by a particular society.
Labeling is not only the process that attaches a name, it is the process by which that trait gains
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importance in a society. The labels “black” and “white” do not describe actual skin tones and yet
these labels have tremendous influence.
The second component of stigma consists of the link between a label and a negative
stereotype. Link and colleagues (1999) conducted a vignette study that illustrated this well.
Participants reported on their beliefs about how dangerous former mental hospital patients are
(endorsement of a negative stereotype). Then, the participants were presented with several
vignettes describing symptoms and experiences of a protagonist, half of whom were randomly
labeled as “former back-pain patients” and the other half as “former mental patients.” Then the
participants were assessed for rejecting responses toward the protagonist. When the protagonists
were labeled as former back-pain patients, endorsement of the dangerousness of mental patients
did not predict rejecting responses. However, when the protagonists were labeled as former
mental patients, endorsement of the dangerousness of mental patients was a strong predictor of
rejecting responses. It was only when the protagonist was labeled that the negative stereotype
had any effect on him/her.
The third component, separation, is the implication that there is an “us” who do not have
this label and are very different from “them” who do have the label. For example, separation is
revealed when one compares the common use of the adjective “schizophrenic” to describe a
person with schizophrenia compared to a person with hypertension, who is never called a
“hypertensive.”
The fourth component includes both status loss and discrimination. Status loss refers to
the lower levels of power and prestige held by those who are stigmatized. Status loss results in
concrete inequities within small groups, such as when individuals choose not to sit next to a
homeless person or dismiss a woman’s opinion when working on a group project. Note that
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instances such as these can easily pass without notice unless one looks for them and considers
their implications and impact. Status loss is not necessarily evident to the casual observer.
Furthermore, the significance of status loss is not held in a single instance, but in the collection
of similar instances that work to reinforce the message that one person is worth more than
another (Link & Phelan, 2001). Discrimination, both individual and systematic, is more overt.
Individual discrimination includes overt behavior such as rejecting a job application from or
refusing housing to an individual with a stigmatized trait. Institutional discrimination are the
structures within a particular institution that disadvantage a stigmatized person regardless of an
individual’s attitudes or opinions about said person. For example, the use of SAT scores works to
the advantage of those who were raised in areas with good schools and to the disadvantage of
those who go to poor schools. As white individuals by and large live in wealthier school districts
and/or have greater access to private schools and racial/ethnic minorities by and large live in
poor urban areas, the gap in quality of K-12 education results in institutionalized racism against
racial and ethnic minorities (Link & Phelan, 2001).
Labeling Effects and Mental Illness
In another influential article, Link (1987) discussed the effects of labeling specifically on
individuals with mental illness. He hypothesized that long before an individual becomes a mental
patient s/he learns how others devalue and discriminate against them. When an individual enters
psychiatric treatment and the label of “mental patient” is now applied to him/her, the individual
goes through a process of self-dAssessment and fear of rejection. Link surveyed 429 community
residents 164 psychiatric patients of the Washington Heights section of New York City who both
had and had not been labeled as mental patients and assessed their endorsement of the belief that
others devalue and discriminate against mental patients. Endorsement of those beliefs were
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associated with demoralization, income loss, and unemployment in the labeled group over the
unlabeled group (Link, 1987).
Here we see a concrete example of how stigma theory has a real world impact on those
with mental illness. In this example, we see the interplay between public stigma and self-stigma,
as was suggested by Goffman, constructs which were refined as follows.
Public vs. Self-Stigma
Public stigma. Public stigma includes the negative stereotypes, prejudice, and
discrimination of those publically labeled as mentally ill. In addition, public stigma affects more
than those with a mental illness, friends and family members and even mental health provider
groups (Corrigan, 2005). Neighborhoods with psychiatric hospitals experience its deleterious
effects, as evidenced by the not in my backyard (or NIMBY) phenomena protesting against the
building of new mental health centers in the United Kingdom and United States (Cowan, 2003;
Zippay & Sung, 2008). Public stigma threatens two central concerns for those with mental
illness, procuring and keeping gainful employment and obtaining safe and comfortable housing.
In a study conducted by Farina and Felner (1973) a male confederate interviewed at 32
businesses, all giving the same history. In half of the interviews, though, the confederate also
reported a past psychiatric hospitalization. Later analyses found that the interviewers were less
friendly and supporting when the hospitalization had been reported.
Public stigma also has contributed to the criminalization of the mentally ill (Corrigan,
2005). With the deinstitutionalization in the late 20th century in the United States, more people
with serious mental illnesses (PSMI) are being processed through the criminal justice system
rather than through psychiatric hospitals. This is not to say that PSMI are more likely to commit
crimes, but rather that they are being arrested for incidents related to their mental illnesses, such
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as public-offender crimes related to psychotic or manic episodes, and taken to jails for
processing rather than psychiatric hospitals. In addition, due to the high co-morbidity rate of
substance abuse and serious mental illnesses such as schizophrenia, many PSMI are arrested for
drug possession or public intoxication. While serious mental illness does not cause substance
abuse, per say, treating the serious mental illness is a far more constructive intervention than
imprisonment (Lurigio, 2013).
Self-stigma. Self-stigma, on the other hand, occurs when an individual with mental
illness internalizes public stigma, leading to lower self-esteem, self-efficacy, and hope for one’s
future (Corrigan, 2005; Vogel, Wade, & Haake, 2006). As suggested by Goffman “the
stigmatized individual tends to hold the same beliefs about identity” (p.7) as the general public,
namely that stigmatized individuals are less than human (Goffman, 1963). Link’s (1987) study of
labeling effects on ex-mental patients described above provides an excellent example – those
who endorsed stigmatizing beliefs about mental patients experienced worse outcomes, such as
loss of income and unemployment, than those who did not. Self-stigma also has a considerable
effect on whether an individual will seek psychological services, be compliant with treatment,
and/or continue ongoing therapy (Tucker et al., 2013). This can significantly hinder recovery
from mental illness, compounding an already troubling problem.
Furthermore, Vogel, Bitman, Hammer, and Wade (2013) found that public stigma
predicted the development of self-stigma in a longitudinal study of 448 college students in a
large Midwestern university. At time one (T1) and then again at time two (T2) three months later
they collected measures of public and self-stigma. They found that endorsed public stigma at T1
predicted self-stigma at T2, but not the other way around. This suggests that public stigma is
internalized as self-stigma over time.
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Mental Illness Stigma vs. Help-Seeking Stigma
The stigma of mental illness is certainly troubling in that it appears to reduce treatment
usage and result in other negative outcomes for people with psychological symptoms and
concerns. However, a related, but distinct, stigma also appears to play an important role in the
help-seeking process. The stigma associated with seeking psychological services is “the
perception that a person who receives psychological treatment is undesirable or socially
unacceptable” (Vogel, Wade, & Haake, 2006; p. 325). Those who were labeled as having sought
counseling or as having been hospitalized have been shown to be rated less favorably and treated
more negatively than those who were not labeled (Vogel, Wade, & Hackler, 2007). The helpseeking stigma and mental illness stigma are related in that both require that the stigmatized
individual be labeled, consistent with general stigma theory. However, help-seeking stigma is
distinct in that those who endorse the stigma believe that those who seek treatment are weaker or
less adequate than those who attempt to handle their concerns on their own or with the help of
family, friends, or community leaders (Komiya, Good, & Sherrod, 2000). Consistent with the
distinction above between public stigma and self-stigma, an individual who would seek
psychological treatment could fall prey to both stigmas. An individual may see him or herself as
less adequate or weak as a result of seeking treatment (Vogel, Wade, & Hackler, 2007).
In a study of 380 undergraduates, Ben-Porath (2002) found a difference in stigma against
those with depression symptoms and those who had both depression symptoms and had sought
help from a therapist. In this study, participants were given one of four short case vignettes that
were identical except for the presenting problem – back pain vs. symptoms of depression – and
whether the individual had sought help – from the university health center for back pain, from a
therapist for depression symptoms, or no help sought. She found that the target that had
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symptoms of depression was rated as being more emotionally unstable than the individual who
had back pain. This indicates a stigma against those with depression (i.e., mental illness stigma).
However, the target who had both symptoms of depression and had sought help from a therapist
was rated as the most emotionally unstable of the four. This indicates not only that there is a
stigma of seeking help for a mental illness (in particular depression) but also that help-seeking
stigma had an effect over and above mental illness stigma (Ben-Porath, 2002).
While it is important to understand the components of mental illness and help-seeking
stigma, there is still a need to understand the path by which stigma affects help seeking
intentions. Vogel and colleagues completed a serious of studies to help make that connection.
Attitudes toward Counseling, Intentions to Seek Counseling, and Stigma
Vogel and Wester (2003) found that one of the most proximal predictors of intentions to
seek counseling was attitudes toward counseling. Previous research had shown that approach
factors, such as lack of social support, level of distress, and previous experience with counseling,
were important indicators of attitudes toward counseling. These indicators, however, gave an
incomplete picture. The researchers therefore tested the effects of avoidance factors in addition
to approach factors. Avoidance factors included low tendency to self-disclose distressing
information, high anticipated risk associated with self-disclosure, low anticipated utility of selfdisclosure, and high tendency to self-conceal. In addition, previous research had tied these
indicators to attitudes toward counseling under the assumption that attitudes predicted the
decision to seek counseling. Vogel and Wester, however, asserted that one’s attitude may or may
not predict behavior, as one may have a positive attitude about counseling but not seek it, or have
a negative attitude and seek it anyway. They therefore measured attitudes toward seeking
counseling as well as intentions to seek counseling, reasoning that intentions would be a more
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proximal measure of behavior. In two studies with 477 college students Vogel and Wester
showed that avoidance factors predicted negative attitudes toward counseling which in turn
predicted low intention to seek counseling.
Vogel, Wade, and Hackler (2007) tied together research on public and self-stigma,
attitudes toward counseling, and willingness to seek help. In a study of 680 undergraduates at a
large Midwestern university, they used structural equation modeling to test the hypothesis that
the relationship between public stigma and willingness to seek counseling was indirectly
mediated through self-stigma and attitudes toward counseling. The results of the SEM analysis
supported their hypothesis, finding that public stigma predicted self-stigma, which negatively
predicted attitudes toward counseling, which predicted willingness to seek counseling.
Self-Stigma of Mental Illness vs. Self-Stigma of Help-Seeking
It is necessary to understand the nuanced relationship between mental illness and helpseeking stigma as well. Mental illness stigma includes the attitudes and discrimination against a
person with a mental illness. Help-seeking stigma, in contrast, is the stigma associated with the
act of seeking psychological services for that mental illness (Tucker et al., 2013). Vogel, Wade,
and Hackler (2007) found that self-stigma fully mediated the relationship between public stigma
and attitudes toward counseling. Tucker and colleagues found that it was the self-stigma of helpseeking, rather than the self-stigma of mental illness, that was the most powerful predictor of
willingness to seek help.
Internalized Stigma Model
While Tucker and colleagues helped clarify the distinction between the self-stigmas of
mental illness and seeking help, a more complete model was needed to tie together the
relationship between the public and self-stigmas of mental illness and seeking help. In a study of
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448 undergraduates, Lannin and colleagues (2015) developed a model to better explain their
relationship. Their “Internalized Stigma Model asserts that both types of stigma are related – yet
distinct – barriers to recovery” (p.82). Public stigma can lead to internalization as self-stigma for
both mental illness stigma and the stigma of seeking help. In addition, the model expands the
previous models by showing the relationship between stigma and self-esteem as well as
intentions to seek counseling. These findings are important as they have real world implications
for the development of interventions. Most interventions are currently focused only on
addressing the public stigma of mental illness. Based on this model, the most effective
interventions aimed at increasing use of mental health services may not address public stigma but
rather a more proximal predictor of intentions to seek counseling, the self-stigmas of mental
illness and seeking help and self-esteem as a result of self-stigma.
Religious Mental Health Stigma
Most research that has been conducted has focused on the general population, the studies
discussed above being no exception. There is reason to believe, however, that many religions
have their own interpretations of mental illness. Both Christianity and Judaism, for example,
believe that mental illness can be the result of ongoing sin in one’s life (Rabinowitz, 2014). That
said, the link between mental illness stigma and religion has only been indirectly drawn in the
literature. While my intention is to focus in on the Abrahamic religions (i.e. Christianity,
Judaism, and Islam), the extant literature has focused disproportionately on Christians. The
summary of research that follows will therefore apply primarily to Christians, but will attempt to
bring in findings about Judaism and Islam whenever possible.
Definitions. For the purpose of this study, Religious mental health stigma (RMHS) will
be conceptualized as the public and self-stigma of mental illness and psychological help-seeking
16
in religious communities, paying special attention to beliefs about sin and morality and
religious/spiritually-oriented beliefs about causes and treatments of mental illness. While RMHS
includes stigma found in any religion, this study will focus on assessing the stigma in the
Abrahamic religions. Religious public stigma of mental illness (RPSMI) is defined as the stigma
a religious community holds toward an individual who has been labeled as having a mental
illness. Religious public stigma of psychological help-seeking (RPSPHS) is defined as the stigma
a religious community holds toward an individual who has sought psychological services.
Religious self-stigma of mental illness (RSSMI) is defined as the religious public stigma of
mental illness that has been internalized by an individual who has been labeled as having a
mental illness. Religious self-stigma of psychological help-seeking (RSSPHS) is defined as the
religious public stigma of psychological help-seeking that has been internalized by an individual
who has sought psychological services.
The continuum of Christian beliefs about mental illness. It is important to note that
not all religious individuals, or indeed all Christians, hold the same beliefs about mental illness.
In the articles reviewed, religious individuals fell on a continuum. On one end some individuals
strongly endorsed the biomedical model of mental illness. Psychological and psychiatric
problems were viewed as illnesses and treatment was valued and encouraged when appropriate.
On the other end of the continuum some individuals strongly endorsed a spiritual or religious
conceptualization of mental illness (Hartog & Gow, 2005). Prayer, reading the Bible, and healing
ministries were examples of treatments that seemed appropriate (Borras, Mohr, Brandt,
Gillieron, Eytan, & Huguelet, 2007; Crosby & Bossley, 2012; Hartog & Gow, 2005; Leavey,
2010; Lyles, 1992; Mayers, Leavey, Villianatou, & Barker, 2007; McLatchie & Draguns, 2001;
Payne, 2009; Stanford, 2007; Trice & Bjorck, 2006). Strong spiritual or religious beliefs about
17
mental illness were in the minority and were more frequently seen in more conservative,
Pentecostal, or fundamentalist congregations (Mayes, et al., 2006; Lyles, 1992; Payne, 2009;
Stanford, 2007). Biomedical beliefs about mental illness were most common in
liberal/progressive congregations. The majority of congregations/religious individuals fell
somewhere in between, endorsing both biomedical and spiritual/religious beliefs.
This will act as an important frame of reference. The findings discussed below are not
exhaustive descriptions of the beliefs Christians hold about mental illness. As mentioned above,
religious beliefs about mental illness occur alongside secular beliefs. The following is rather
meant to reflect those beliefs that are most strongly influenced by religiosity.
Christian and Muslim beliefs about mental illness. The most fundamental difference
between secular and religious mental illness stigma is the difference in beliefs about the cause of
mental illness. Demonic influence, whether seen as demonic oppression or possession, was a
frequently cited cause that has no secular counterpart. On the other hand, whereas secular stigma
might call mental illness “personal weakness” religious stigma would call it “moral or spiritual
weakness.” Beliefs about the causes of mental illness are key to understanding beliefs about
effective treatments. If one believes one has a spiritual problem then one looks for a spiritual
solution.
Demonic influence is a hallmark of Judeo-Christian beliefs about mental illness. It is
important to note that demonic influence does not exclusively refer to demonic possession. In
one study, demonic influence was found to be presented as the oppression of the enemy, Satan,
or spirits/demons. The study quoted an author who described her own experience with
depression: “…Satan took advantage of a time when I dove off a cliff of closeness with God to
coax me into a pit of despair, confusion, and depression” (Webb, Stetz, & Hedden, 2008, p. 703).
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Demonic influence in this sense was found to be the most commonly portrayed source of
depression in a Christian’s life. Another study noted that the demonic causation of psychological
symptoms seemed like “diffuse” attempts to fit their experience into their religious framework.
This article noted that clients perceived that their disorder had a demonic causality for mental
disorders both with and without psychotic features (Pfeifer, 2000).
Still, demonic possession itself was believed to be a cause of mental illness within some
Christian communities such as Pentecostals, Catholics, and Anglicans. Deliverance, also known
as exorcism, is believed to be the appropriate way to eradicate a demon. Different communities
allow different persons to conduct the deliverance. In hierarchical churches such as the Anglican
and Catholic churches priests go through specific training to perform the ritual (Leavey, 2010).
In many Pentecostal traditions, the deliverer is someone who has demonstrated a Holy Spirit
given gift to expel demons. While many believe strongly that it is imperative to expel demons
whenever a demon possession is identified – much as many believe it imperative to take
someone who is very ill to a doctor – deliverance rituals can, at times, have unintended negative
consequences. In fact, the deliverance ritual itself can be a traumatic experience, resulting in the
victimization or re-victimization of the person receiving the deliverance. At times, injuries and
even deaths have resulted (Mercer, 2013).
Demonic possession has been named as a possible cause of psychotic symptoms in
Muslim regions, as well. One author pointed to the similarities between descriptions of demonic
possessions and some psychotic behaviors such as “They put thoughts in my mind that are not
mine” or “My feelings and movements are controlled by others in a certain way” (Irmak, 2014,
p. 775). Muslim traditional healing, or Koranic healing, is common in many cultures in the
Middle East. Koranic healers use scripture from the Koran in a healing ritual to exorcise evil
19
spirits, known as Jinn (Al-Krenawi, 1999). A faith healer in Turkey reported that three months
after expelling evil spirits patients with schizophrenia were symptom free (Irmak, 2014). It is
worthy of note that Koranic healers have a good reputation among the public and Islamic
scholars (Al-Krenawi, 1999). Prominent social work, medical, and psychological scholars have
advocated the use of Koranic healers (e.g. Irmak, 2014; Al-Krenawi, 1999).
Beliefs about the causes of mental illness have serious theological implications for many
Christians. A popular doctrine posits that if one has enough faith, prays or is prayed for correctly,
reads the Bible dutifully, and regularly attends worship services then one will have a sound
mind, free of fear and emotional problems (Webb, Stetz, & Hedden, 2008). A set of beliefs
termed the “emotional health gospel” (Carlson, 1998, p. 29). When an individual does
experience emotional problems, people with these beliefs might conclude that they are not living
a good Christian life. What a mental health professional would call a mental disorder is therefore
interpreted as spiritual failure. As a note, these beliefs were more common for depression and
anxiety than for disorders that were seen as having a clearer biological basis such as
schizophrenia in samples in Australia, California, and in various Christian self-help bestsellers
(Hartog & Gow, 2005; Trice & Bjorck, 2006; Webb, Stetz, & Hedden, 2008).
An inventive qualitative analysis of 14 Christian self-help bestsellers by Webb, Stetz, and
Hedden (2008) gave a revealing depiction of the emotional-health gospel. This article sought to
better understand how mental illness was portrayed by Christian media, focusing on bestselling
books. The popularity of these books reveals their influence; for example, Joyce Meyer’s
Battlefield of the Mind has sold 3 million copies and Joel Osteen’s Your Best Life Now has sold
over 4 million (Amazon.com). Failure as a Christian was a commonly noted cause of depression.
Authors warned that ‘‘If you do not pray, you will either be habitually depressed or obsessed
20
with your own ego…’’ and ‘‘…sometimes depression is caused by our own sin” (Webb, et al.,
2008, p. 704). Negative emotions, such as anger, ingratitude, or guilt were another commonly
cited cause. One author went as far as to say that ‘‘intolerance, agitation, short temperedness
mark our behavior. Clinical depression, a mental health problem largely caused by pent-up
anger, becomes a real possibility’’ (Webb, et al., 2008, p. 705). Prayer, self-discipline, and
willpower were portrayed as bulwarks to keep out depression. One author stated, ‘‘It’s even
possible to live without negative emotions. God will take them off us like a thick blanket if we
ask him to. But we have to pray’’ (p. 706.) Another asserted that ‘‘if you are depressed you have
to understand that nobody is making you depressed… You are choosing to remain in that
condition’’ (p. 706). The authors of this study note that the representations of depression in these
books are gross oversimplifications. There is no acknowledgement of the biopsychosocial
complexities found in decades of research on the disorder. Recovery from depression was
portrayed as a quick, if not immediate, process – not one that can last weeks or even years.
Although most Christians, even those in Pentecostal or conservative communities,
believed there was some biomedical component to mental illness (Matthews, 2008; Trice &
Bjorck, 2006), religious beliefs about mental illness still impact psychological help-seeking. In a
study of Protestant Christians in the Southeastern United States, 18.9% of 540 participants
agreed that “emotional/mental/relationship problems such as depression, anxiety, intense grief,
loneliness, thoughts of self-harm or substance abuse problems are solely religious/spiritual in
nature” (Royal & Thompson, 2012, p. 197). Even among those who did not endorse this item it
was common to believe that a person should only go to a mental health professional as a last
resort (Royal & Thompson, 2012). Several studies reported that Christians believed that the
primary treatment should come from the church or individuals associated with the church (e.g.
21
Crosby & Bossley, 2012; McLatchie & Draguns 2001; Royal & Thompson, 2012). After all, a
spiritual problem requires a spiritual solution. The treatment could be through pastoral or church
staff counseling or, in rarer cases, through spiritual healing ministries (Huang, Shang, Shieh, Lin,
& Su, 2011; Leavey, 2010; Lyles, 1992). Spiritual health ministries may include deliverance
rituals such as those discussed above, but may also be activities that involve miraculous healing
through prayer in church services or meetings or through multi-session, biblically-based
programs (Village, 2005). Studies on referral behavior of Christian clergy have shown them open
to referring congregants to mental health professionals, especially those that identify as Christian
themselves, but rarely doing so (e.g. Jones, Cassidy, & Heflinger, 2012). Competing beliefs
about mental illness causes and treatments accounts for some of this discrepancy, but research
has shown that clergy by and large have little, if any, education on identifying and treating
mental illness (Farrell & Goebert, 2008; Jones, Cassidy, & Heflinger, 2012; VanderWaal,
Hernandez, & Sandman, 2012).
Christian clergy and mental illness. Thirty-nine percent of Americans with a serious
personal issue turn to leaders in their religious community in times of need – even when their
crisis is directly tied to a mental illness (Taylor, Ellison, Chatters, Levin, & Lincoln, 2000). In
this way, clergy serve an important role in mental health treatment as frontline mental health
workers. In a sample of 235 college students in Southeast Texas, men were significantly more
likely to seek help from a religious advisor than women, who were more willing to seek
psychological help (Crosby & Bossley, 2012). In contrast, one study found that 71% of the 98
Protestant church leaders felt inadequately trained to recognize mental illness (Farrell & Goebert,
2008). Another study found that less than half of their sample of 179 clergy in the New York and
Connecticut had any clinical pastoral education (Moran, Flannely, Weaver, Overvold, Hess, &
22
Wilson, 2005). Even the knowledge of available mental health services is lacking (Jones,
Cassidy, & Heflinger, 2012; Taylor, Ellison, Chatters, Levin, & Lincoln, 2000).
In one study by Farrell and Goebert (2008), members of the clergy were given two
vignettes to read – one describing an individual in a manic state typical of Bipolar Disorder and
the other in depressive episode seen in Major Depressive Disorder. The clergy were asked to
identify symptoms of mental illness and to decide whether they would refer these individuals to
mental health professionals or provide counsel themselves. Nearly 40% of those who admitted to
having inadequate training to recognize mental illness indicated they would counsel the
individuals described in these vignettes (Farrell & Goebert, 2008). This discrepancy is
disconcerting, especially considering that medication prescribed by a physician is strongly
recommended in managing the manic episodes of Bipolar Disorder and/or to prevent future
manic episodes (Butcher, Hooley, & Mineka, 2014). This study found that ministers with as little
as 5 hours of mental health training were more likely to be adequately prepared to identify
mental illness (Farrell & Goebert, 2008).
Reasons that Christians are more likely to seek help from religious advisors are varied.
One reason is that seeking help from religious advisors carriers less stigma than seeking help
from mental health professionals (Crosby & Bossley, 2012). Another reason is that Christians
may be concerned that the mental health professional would discredit or undermine their faith or
that the experience would weaken their faith (Mayers, et al., 2007). For this reason, even when
clergy did refer congregants to a mental health professional they would generally send them to
one known to be Christian (Mayers, et al., 2007; McLatchie & Draguns 2001; Moran, et al.,
2005). However, a qualitative study in London found that even when Christians were initially
hesitant about seeking secular-based therapy they still found it helpful. In fact, most reported that
23
the experience strengthened their faith whether or not there was a match in the spirituality or
religious affiliation between therapist and client (Mayers, et al., 2007). This indicates that mental
health professionals can facilitate treatment in a way that respects and even promotes spiritual or
religious well-being; something many Christians do not expect. This result notwithstanding,
there is still a need to incorporate religion into diversity training for mental health professionals
(Crosby & Bossley, 2012). This might be especially salient for counseling religious minorities
who may harbor more negative views of counseling and experience greater stigma.
Race and ethnicity. Abdullah & Brown (2011) noted that race had a major effect on
mental health stigma. Ethnic and cultural minorities generally hold stronger stigmatizing beliefs
than do Caucasians, though – as with white Christians – there is a wide range of beliefs. People
from primarily Black and Hispanic churches, particularly more conservative and Pentecostal
ones, tended to endorse more spiritual etiologies and spiritual treatments for mental illness than
those from primarily white churches (Cinnirella & Loewenthal,1999; Leavey, 2010; Lyles, 1992;
Payne, 2009). Reasons behind this tendency are multifaceted, ranging from lower levels of
education, immigrant status, lack of access to mental health care, higher levels of religiosity, and
concerns about racial differences between the clinician and the client (Caplan, et al., 2011; Lyles,
1992). Among many immigrants, a dual system of beliefs has been found – that of mainstream
Western medicine and that of religious or traditional folk-beliefs (Caplan, et al., 2011).
Along these lines, immigrants from developing countries tend to endorse
religious/spiritual explanations for mental illness. African immigrants to the United Kingdom
reported high beliefs in demonic possession and demonic influence and low endorsement of
psychological or medical causes and treatments for the mentally ill. Exorcism/deliverance was
frequently believed to be the most appropriate treatment among clergy (Leavey, 2010). A study
24
on attitudes toward mental illness in Benin City, Nigeria was indicative of mental health stigma
in some African cultures. Eighty percent of the 107 Nigerians who completed the surveys
preferred that those with mental illness be in residential facilities outside of their vicinity even
though 63% agreed that mental hospitals were more akin to prisons than a place for treatment. It
was also believed that those with mental illness should be treated like children by 68% of the
sample. The influence of Pentecostal beliefs was evident as over 50% of the clergy identified as
such (Igbinomwanhia, James, & Omoaregba, 2013). Other samples have indicated large
proportions of Pentecostals in African immigrants as well (Leavey, 2010).
In a similar vein, a higher percentage of Protestant African American congregations are
conservative and/or Pentecostal than white congregations. One study found that of 51 African
American churches in California surveyed, 35% of African American churches were
conservative, 33% of were Pentecostal, and 22% were non-denominational (another Christian
group that can tend to be conservative). Only 10% were mainline protestant – churches that more
frequently endorse the biomedical model of mental illness (Payne 2009). In the study, African
American pastors were far more likely to endorse items like ‘‘Depression is hopelessness that
happens when one does not trust God’’ and ‘‘Depression is due to a lack of faith in God’’ than
European American pastors. Furthermore, European Americans were 6 times more likely to
agree that “Depression is a biological mood disorder’’ than African American pastors (Payne,
2009, p.361).
In addition, African American clergy – who are particularly important figures in many
African American circles – have wary attitudes regarding mental health services. One study of
African American pastors in the New Haven area of Connecticut indicated about half of the 99
interviewed had received specialized training for pastoral counseling for use with serious
25
problems. They also were willing to exchange referrals with secular mental health professionals
in their area, but tended to have a lack of information on available services. Even among these
pastors, though, about half agreed or strongly agreed that those with severe depression or anxiety
could cure themselves if they put their mind to it (Young, Griffith, & Williams, 2003).
Interviews with clergy in another study revealed strong faith in religious coping. One pastor
reported, “A person with a strong spiritual balance can almost take more than a person without it
because their spiritual balance will help them cope.” Another stated, “I guarantee you, bring me
anybody with whatever problem, and it will be gone in six months…if they follow the Word”
(Lyles, 1992). Worthy of note is that African American clergy conduct more pastoral counseling
than European American clergy, in part because of higher rates of poverty and limited access to
services (Young, Griffith, & Williams, 2003).
Poverty and access were not the only barriers to referrals to mental health professionals,
however. Many pastors felt uncomfortable referring congregants because they believed the
professional would not respect their religious beliefs. Another salient factor was that they were
concerned that a professional (usually assumed to be non-black) would not be able to relate to
blacks or might even be prejudiced against them. In a striking example, one black woman had
seen two white therapists of the same religious background but had not disclosed previous sexual
abuse from her parents because she was concerned that “white people assume that black people
can’t control their sex drives and I didn’t want to be stereotyped.” While this may or may not
have been what the therapists actually believed, the client did not feel safe discussing issues
regarding race (Lyles, 1992). A study of clergy referral attitudes and behavior in Michigan
likewise reported that over half of the African American clergy (n=22) indicated they were likely
or very likely to refer a congregant to a mental health professional of the same ethnicity rather
26
than one of a different ethnicity (VanderWaal, Hernandez, & Sandman, 2012). It seems then that
the low utilization of mental health services by African American Christians is influenced both
by a tendency toward more conservative or Pentecostal sects of Christianity and a concern about
racism in treatment.
While Hispanic immigrants experience significant barriers to access such as status as an
undocumented immigrant, lack of insurance, and language barriers, these factors may not be
enough to explain the exceptionally low level of help-seeking. To give an example of the rate of
help-seeking, in the Los Angeles Epidemiologic Catchment Area (ECA) study only 11% of
Mexican Americans who had experienced a mental disorder in the last six months sought any
kind of mental health treatment compared to 22% of whites with mental disorders (USDHHS,
2001). Religion, in particular Christianity, is a significant part of Hispanic culture. In one study
90% of a sample of 177 Hispanic adults recruited from a primary care office in Queens, NY was
Christian (Caplan, et al., 2011). More than half of Hispanic Christians identity as charismatic or
Pentecostal (Caplan, et al., 2011). Furthermore, religiosity was significantly correlated with
higher endorsement of the perceived stigma of seeking help for depression from friends,
coworkers, and family. The use of complementary or alternative medicine is commonplace in
Hispanic communities. This includes prayer as well as the use of traditional healing practices
such as curanderismo, a form of folk medicine with spiritual healing and the maintenance of
harmony and balance with nature. Estimates of use of alternative medicine in the Mexican and
Mexican American population from range from 50-75% (Caplan, et al., 2011).
Limited research has been done with Asian immigrants to the United States, but what
research has been done points to low endorsement and utilization of mental health services.
Research on the referral behavior of Asian American clergy in California indicated low rates of
27
referrals to mental health professionals. In fact, only 27% of the 103 clergy sampled could name
even a single provider or mental health agency to use as a referral (Yamada, Lee, & Kim, 2012).
Clergy were far more likely to refer a congregant to a general practitioner rather than a mental
health professional. Knowledge of mental illnesses and possible treatment options appear to
increase the likelihood of a referral, findings that were also found in African American
populations (Yamada, Lee, & Kim, 2012). A study with an elderly population in Singapore
found that even though religious individuals, including Christians, were more likely to have a
mental disorder, they were less likely to use mental health treatment (Ng et el., 2011). In a study
of Christian clergy in Singapore, the most commonly endorsed etiology of mental illness was a
Traditional Christian one. This included descriptions such as “lack of obedience to scripture,”
and “failing to have their minds renewed by God’s word,” and “sin.” Etiologies from mainstream
Western medicine such as poor coping and organic etiologies were also endorsed, but not as
strongly (Matthews, 2008). The above findings indicate that although less is understood about
the reasons behind the phenomena it is clear that this population is wary of mental health
treatment.
Negative implications. Negative beliefs about mental health in religious communities
can have serious implications. On the more mild side, negative beliefs can lead to ignorance of
the mental health needs of church members and a lack of Helpance from the church for families
with mental illness (Farrell & Goebert, 2008, Leavey, Loewenthal, & King 2007; Rogers,
Stanford, & Garland, 2012). In addition, these beliefs can lead to led to non-adherence with
psychiatric treatment, increasing the risk of relapse and hospitalization, and lack of medical
treatment for those with severe mental illness. This lack of consistent care can result in an
increase in high risk symptoms such as suicidal ideation and behavior and psychotic or manic
28
episodes (Borras, Mohr, Brandt, Gillieron, Eytan, & Huguelet, 2007; Mitchell & Romans, 2003).
In rare but significant cases Christian church members were discouraged and even forbidden to
take psychiatric medication and/or were told they did not have a mental illness despite having a
diagnosis from a mental health professional (Stanford, 2007).
Measures of religious mental health stigma. In an effort to prevent these negative
consequences, more research needs to be conducted on the nature and the effects of mental
health stigma in religious communities. In order to reliably measure mental health stigma in
religious communities, a psychometrically sound scale is key (Heppner, Wampold, & Kivlighan,
2008, p.228). Although Wessellmann and Graziano (2010) created a scale to measure this
construct, the Religious Beliefs about Mental Illness (RBAMI) scale, its scale construction and
psychometric properties make its validity questionable. That said, its uniqueness in the literature
warrants a brief overview of their findings.
The RBAMI scale made a distinction between religious and secular beliefs about mental
illness. Religious beliefs are related to secular beliefs, but differ in significant ways. Secular
beliefs about mental illness were broken down into fear/danger, controllability, and anger.
Fear/danger described the fear individuals had of those with mental illness due to perceived
unpredictability or dangerousness. Controllability referred to how much individuals believed that
those with mental illness were responsible for their condition and could control their symptoms
and reactions. Anger was simply how angry an individual felt toward those with mental illness.
Religious beliefs were broken down into two factors: morality/sin and spiritually-oriented causes
and treatments. The morality and sin factor referred to beliefs that mental illness was the result of
immorality, sin, or failure to adhere to religious practices and principles. Spiritually-oriented
causes and treatments encompassed beliefs that demonic influence was largely responsible for
29
mental illness and that prayer or working with religious advisors was the appropriate course of
treatment. The morality and sin factor was the most salient, accounting for 71% variance in the
findings. The spiritually-oriented causes and treatments factor accounted for 12% of the
variance. A difference in attitudes toward depression and schizophrenia was found. Persons with
schizophrenia were found to evoke more fear and depression was found to be considered more
controllable (Wesselmann & Graziano, 2010). Unfortunately, the theoretical and psychometric
limitations of the RBAMI scale make these conclusions tentative at best.
First, the items in the scale are limited by Christian-centric language. The authors offer
items that only pertain to Christianity, although they claim to be assessing the broader category
of “religion.” This is a significant drawback to a scale that purports to assess beliefs about
mental illness that are informed by other religions, such as Islam or Judaism. Another drawback
is that there are no items that take into consideration particularly salient aspects of other
religions. For example, in Judaism there is a strong belief that God doesn’t give one anyone more
trials than one can handle. While many Jews find this belief helpful, it could lead to stigma
against mental illness should one feel that one cannot psychologically or emotionally handle a
situation through their religion. In Islam there is strong belief that struggles in this life are
Allah’s way of testing his followers, so seeking psychological/psychiatric help is equivalent
failing the test spiritually. In addition, there is overlap in Christian perceptions of mental illness
with Judaism or Islam. In Judaism, like in Christianity, there is a conception that mental illness is
indicative of sin (Rabinowitz, 2014, p. 248). In Islam, like some more conservative Christian
communities, there exists a conception that jinn, similar to demons, can harass or possess
individuals and that symptoms of mental illness are the effects of such activity (Hedayat-Diba,
30
2014, p.302). Were the RBAMI scale worded in a more inclusive way, it could apply to all
Abrahamic religions rather than just Christianity.
Second, the RBAMI purports to be a measure of stigma but does not cover the various
types of stigma. First, the scale only assesses public stigma, there are no questions that measure
self-stigma. Bathje and Pryor (2011) found that these two aspects of stigma play different roles
in attitudes toward seeking mental health counseling. Furthermore, the measure does not take
into account the distinction between mental illness stigma and help-seeking stigma as
emphasized by Tucker and colleagues (2013). In fact, only one of the sixteen items even
addresses help-seeking behaviors. Considering that the self-stigma of help-seeking is a stronger
predictor of attitudes toward seeking help than the self-stigma of mental illness, items assess
self-stigma should be paramount. Also, no distinction is made between inpatient and outpatient
therapy; the wording of the items only references outpatient therapy. Despite the fact that the
stigma of seeking outpatient therapy and the threat to one’s status, self-esteem, etc. is very real,
the stigma of inpatient hospitalization may be far worse. In a qualitative study Roe and Ronen
(2003) examined the experiences of individuals who had hospitalized on a psychiatric unit.
Clients reported that after being hospitalized they found who would actually be willing to
support them and who would not. One client described it well when she said that after the
hospitalization some “think that you are a mental case and you are crazy, and they won’t ever
talk with you again.” Many clients described how being hospitalized made their self-esteem
plummet to the extent that they judged how well they were doing by how long they were able to
go without being hospitalized. Because the RBAMI does not address these aspects of mental
health stigma, it gives an incomplete picture of stigma in religious communities.
31
Third, the RBAMI scale lacks psychometric validity. The items were generated without
the use of focus groups or consultation with other experts in the field, steps recommended by Lee
and Lim (2008) in order to check construct validity. This step alone might have alleviated the
omissions detailed above. In addition, the items were not pilot tested before scale validation was
conducted in order to assess for readability. Furthermore, the test-retest reliability of the measure
was not measured, making it impossible to know if the data collected from the survey reflects the
participants’ attitudes toward mental illness in general or only at a certain point in time. Because
of this neglect of the recommended procedures for scale construction, use of the RBAMI for
further research is cautioned.
Conclusions
Mental health stigma in religious communities is pervasive and powerful. While it looks
similar to general mental health stigma, there are significant differences such as the perceived
interplay between sin and morality and mental illness as well as religious beliefs about the
etiology of and effective treatments for mental illness. This is an area that has received scant
attention in the research literature. What research does exist has been primarily qualitative or
descriptive. There is a need for research that attempts to use quantitative methods to measure and
further study the effects of stigma as well as, one day, reliably measure change in stigmatizing
attitudes as a result of interventions. Only one article exists, to my knowledge, which has
attempted to measure religious mental health stigma in a systematic way; by creating a scale. The
use of this scale, due to theoretical and psychometric limitations, however is cautioned against.
In order to address this hole in the literature, it is the purpose of the present study to
create a psychometrically strong scale integrating mental health stigma research with religious
beliefs about mental illness.
32
CHAPTER 3. METHODS
Participants
Participants of Sample 1 were 704 undergraduate students who were enrolled in 100- and
200-level psychology and/or communications studies classes at Iowa State University who
signed up to be part of the SONA participant pool and volunteered to be part of a screening
survey for the semester. The sample was 57% female (n = 704; with n = 302 males and n = 1
with no response) and were racially/ethnically 83.1% European American or White (n = 585),
3.7% Latino American (n = 26), 3.4% Asian American/Pacific Islander (n = 24), 3.2% African
American or Black (n = 23), 1.6% multi-racial American (n = 11), 0.4% Native American (n =
3), and 2.8% International Students (n = 20). For year in school, 55.8% were in their first year of
college (n = 393), 25.9% in their second year (n = 182), 10.9% in their third year (n = 77), and
7.1% were in their fourth year or beyond (n = 50). Students who were part of Sample 2 were not
included in this sample.
In Sample 2, 326 undergraduate students who were also enrolled in 100- and 200-level
psychology and/or communications studies classes at Iowa State University participated. The
sample was 60.5% female (n = 197), 38.6% male (n = 126), and 0.9% transgender or gender
non-conforming (n = 3). As far as race/ethnicity, the sample was 81.4% European
American/White (n = 265), 0.9% African American/Black (n = 3), 4.7% Latino/Hispanic
American (n = 15), 9.3% Asian or Asian American (n = 30), 0.3% Native American (n = 1),
1.2% Middle Eastern or Arab (n = 4), 1.9% Biracial American (5 individuals were
Caucasian/African American and 1 was African American/Asian), and 0.3% “other” (n = 1).
Eight percent of the sample were international students (n = 26). The mean age was 19.5 with a
range of 18-32. For reported religion, 67.8% (n = 221) reported they were Christian with 39.9%
33
of the sample Protestant (n = 130) and 23.9% Catholic (n = 78) with 4.0% identifing as Christian
but not reporting their affiliation (n = 13), 12.3% no religious affiliation (n = 40), 1.5% Muslim
(n = 5), 0.3% Jewish (n = 1), 4.0% Buddhist (n = 13), 8.6% Agnostic (n = 28), 9.2% Atheist (n =
30), 0.6% Pagan (n = 2), 0.3% Hindu (n = 1), 0.3% Taoist (n = 1), 0.6% Spiritual but not
religious (n = 2), and 2.5% other, not specified (n = 8).
Measures
Religious Beliefs about Mental Illness (RBAMI). This 16-item scale, designed by
Wesselmann and Graziano (2010), has a two-factor structure (see Appendix A). The first factor
is Sin/Moral Responsibility and the second Spiritually-Oriented Causes/Treatments. The RBAMI
was designed to measure themes believed to be involved in religious beliefs about mental illness
such as demon possession, unrepentant sin, and prayer. Items include statements such as,
“Persons suffering from mental illness are being tormented by the Devil” and “Moral weakness
is the main cause of mental illness” (Wesselmann and Graziano, 2010, p.410). Items are rated on
a 5-point Likert-scale from 1 (strongly disagree) to 5 (strongly agree). Five items are reversed
scored so that higher scores reflect less endorsement of religious beliefs about mental illness.
Both Factor 1 (nine items, α = .88) and Factor 2 (seven items, α = .72) had acceptable reliability.
This measure was first normed using undergraduates at a Midwestern university (n = 142), then
cross-validated using a more diverse sample (n = 232) gathered through various internet means.
The second sample included individuals from 14 countries. Cronbach’s alpha for the present
study was 0.89 for factor 1 and 0.80 for factor 2.
Religious Commitment Inventory-10 (RCI-10). Worthington and colleagues (2003)
developed this 10-item inventory to measure religious commitment in religious and nonreligious
communities and in various religious traditions such as Christianity, Islam, and Buddhism. Items
34
include statements such as “My religious beliefs lie behind my whole approach to life.” Items are
rated on 5-point Likert-scale from 1 (not true at all of me) to 5 (totally true of me). The internal
consistency for the full scale was reported as .93 and the 3-week test-retest reliability was .87.
Evidence for construct validity was demonstrated by a moderate correlation (r = .54, p < .003)
with endorsement of the salvation value in Rokeach’s Value Survey (in an overwhelmingly
Christian sample) as well as frequency of religious activities (r = .72). Evidence for discriminate
validity was demonstrate by low, nonsignificant correlations to morality and a single item
measure of spirituality as exemplary human characteristics (r = .09 and r = .10; Worthington, et
al., 2003). Cronbach’s alpha for the present study was .95.
Knowledge Test of Mental Illness (KTMI). Michaels and Corrigan (2013) developed this
14-item faux knowledge test (i.e., error-choice test) as a measure of mental illness stigma that
circumvents endorsement of items that are considered socially preferable but do not reflect the
participant’s actual attitudes. The instructions support this illusion:
This is a test of your knowledge about mental illness. The questions on the test are taken
from findings of scientific research. You are not expected to have read the research
reports, but by using your experience and general knowledge you should be able to pick
the correct answer. Some people will do much better than others because of their training
in medicine, rehabilitation, or psychology. Read each question carefully and select the
response you consider to be the correct answer. THERE IS NO PENALTY FOR
GUESSING. There is no limit for the completion of this test, but you should work as
rapidly as you can.
Items include statements or questions purporting to assess knowledge of mental illness, as
reflected by the title of the questionnaire. One such item is, “People with severe mental illness
cannot maintain private residences.” The participant is then required to choose whether the item
is “true” or “false.” In other items, the participant is required to choose the “correct” choice. One
such item is, “The divorce rate among the general population is about 50%. What is the divorce
rate among people who experience mental illness?” The participant must choose either “Greater
35
than 70%” or “Less than 50%.” The National Comorbidity Study found that 48.2% of
respondents diagnosed with a psychiatric disorder before or during their first marriage
subsequently divorced, suggesting that the divorce rate among those with mental illness is less
than 50%, comparable to that of the general population (as cited in Michaels & Corrigan, 2013).
A choice of “greater than 70%,” then, indicated more negative attitudes toward those with mental
illness (Michaels & Corrigan, 2013). Cronbach’s alpha for the present study was .95.
The KTMI demonstrates construct validity through its positive relationship with the
Attribution Questionnaire (r = .25 to .47, p < 0.05) and inverse relationships with the SelfDetermination Scale (r = -.31 to -.40, p < 0.05) and the Empowerment Scale (r = -.34 to -.49, p <
0.05). No significant relationships were observed with self-stigma measures (recovery,
empowerment). Test-retest reliability in the initial paper ranged from 0.50 to 0.70 (Michaels &
Corrigan, 2013).
Stigma Scale for Receiving Psychological Help (SSRPH). Komiya, Good, and Sherrod
(2000) developed this 5-item, unidimensional scale to measure the public stigma of seeking
psychological services. Items are rated on a 5-point Likert scale from 1 (strongly disagree) to 5
(strongly agree) and the scores are summed so that higher scores indicate higher public stigma of
seeking psychological services. Items include statements such as, “Seeing a psychologist for
emotional or interpersonal problems carries social stigma.” The SSRPH demonstrates construct
validity through its correlation with attitudes toward seeking psychological services (r = -.40, p <
.001), and, in line with other research of the stigma of seeking psychological services, women’s
scores (M = 5.10, SD 2.88) were significantly lower than men’s (M = 6.86, SD = 3.03, F(1,282)
= 26.3, p < .0001). It has acceptable internal consistency (α = .72). Cronbach’s alpha for the
present study was .81.
36
Beliefs about DAssessment-Discrimination (DD). Link (1987) developed this 12-item
scale to measure how much a person believes that the general public will devalue and
discriminate against a person with a mental illness, connoting the public stigma of mental illness.
As discussed in the literature review, dAssessment occurs when an individual experiences status
loss whereas discrimination include the negative consequences of increased social distance.
Items are scored on a 6-point Likert scale from 1 (strongly agree) to 6 (strongly disagree). Half
the items are reverse coded such that higher scores indicate more public stigma against mental
patients. Items reference a “mental patient” or an individual who has entered a mental hospital
such as “Most people would willingly accept a former mental patient as a close friend.” A final
score is calculated by summing the scores, then dividing by the number of items answered. It
was first normed using a sample of 429 community residents and 164 psychiatric patients in the
Washington Heights section of New York City, as described in the literature review (Link,
1987). The DD shows adequate internal consistency overall (α = .76; Link, Cullen, Struening,
Shrout, & Dohrenwend, 1989). Support for convergent validity comes from the measure’s
moderate correlation with demoralization in repeat-treatment mental health patients (r = .48;
Link, 1987). Evidence of discriminant validity comes primarily from the scale’s face validity
and its low, nonsignificant correlation with measures of compliance (Link, 1987; Tucker et al.,
2013). Cronbach’s alpha was .85 in this sample.
Self-Stigma of Seeking Help (SSOSH). This 10-item questionnaire has a unitary factor
structure and measures the decrease in self-esteem and self-efficacy resulting from being labeled
as a seeker of psychological help (Vogel & Wade, 2009). Items are rated on a 5-point Likert
scale from 1 (strongly disagree) to 5 (strongly agree) and include statements such as, “Seeking
psychological help would make me feel less intelligent.” The SSOSH demonstrates good
37
construct validity through correlations with intentions to seek counseling, attitudes toward
counseling, and the public stigma for seeking help (Vogel et al., 2006). It has been shown to
distinguish between those who seek help and those who do not. Finally, the SSOSH
demonstrates discriminant validity through its zero-order, non-significant correlation with selfesteem (r = .06; Vogel et al., 2006), and demonstrates acceptable test-retest reliability over a
period of 2 months (α = .72) and has high internal consistency (α = .89; Tucker et al., 2013).
Cronbach’s alpha for the present study was .91.
Self-Stigma of Mental Illness (SSOMI). Tucker, et al (2013) developed this 10-item
scale to measure the self-stigma of being labeled as having a mental illness. This scale was
developed as a parallel to the Self-Stigma of Seeking Help (SSOSH) Scale. Items are rated on a
5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and include statements such
as “If I had a mental illness, I would be less satisfied with myself.” Half the items are reverse
scored such that higher scores represent greater self-stigma associated with having a mental
illness. Evidence for convergent validity was demonstrated through it strong, positive correlation
with the modified Self-Stigma of Depression (SSD) Scale (r = .73, p < .001). Discriminant
validity for the SSOMI comes from its small, negative correlation with self-esteem (r = -.25, p <
.001). It has high internal consistency, with Cronbach’s alpha being .91 in the original study
(Tucker et al., 2013). Cronbach’s alpha for the present study was .92.
Attitudes toward Seeking Professional Psychological Services – Short Form (ATSPPSSF). Fischer & Farina (1995) developed this 10-item questionnaire as a revision of the original
29-item ATSPPS (Fischer & Turner, 1970) to measure attitudes toward seeking help. The
revised version correlates strongly (r = .87) with the original, suggesting that the two are
measuring the same construct. Items are rated on a 4-point Likert-scale from 0 (disagree) to 3
38
(agree) and include items such as “A person should work out his or her own problems; getting
psychological counseling would be a last resort.” Half of the items are reverse-scored such that
higher scores denote higher agreement with seeking psychological services. Evidence of
convergent validity comes from correlation of the short form with the use of professional
psychological services (r = .39). Test-retest reliability after 1 month was good (r = .80) as was
internal consistency (r = .84; Tucker et al., 2013). Cronbach’s alpha in the present study was .77.
Intentions to Seek Counseling Inventory (ISCI). Cash, Begley, McCown, & Weise
(1975) developed this 17-item inventory to measure how likely respondents were to seek
psychological services should they experience any of the presenting concerns listed such as
depression, loneliness, or difficulties dating. Items are rated on 6-point Likert-scale from 1 (very
unlikely) to 6 (very likely). Responses are summed with higher scores indicating a greater
likelihood of seeking help for those presenting concerns. Evidence for convergent validity comes
from its ability to detect differences in college students’ intentions to seek psychological services
when clinicians are presented as more or less physically attractive. Additionally, the ISCI relates
to the perceived significance of a presenting concern and to attitudes toward seeking help (r =
.36; Kelly & Archer, 1995; Tucker et al., 2013). Cronbach’s alpha in the present study was .90
Marlowe-Crowne Social Desirability Scale (MCSD). Social desirability is especially
important to measure in stigma research as with other research on prejudice and discrimination.
Tourangeau and Yan (2007) reported that individuals underreport racist attitudes in survey
research. Much of mental health stigma theory comes from prejudice and discrimination research
including that based on racism (e.g. Goffman, 1963; Link & Phelan, 2001). It follows, then, that
attitudes against individuals with mental illness would also be underreported. Along these lines,
Michaels and Corrigan (2013) reported that in stigma research an individual may endorse a more
39
socially acceptable answer than one that reflects their ‘true’ beliefs in order to escape social
opprobrium. Henderson and colleagues found that, in doing research on mental health stigma,
data collection method was important in controlling for social desirability and acquiescence bias.
They reported that online self-report surveys are “clearly preferable” to face-to-face interviews
(Henderson, Evans-Lacko, Flach, & Thornicroft, 2012; p.153). In their study, for example, they
found that whereas 12.2% of the online sample reported having a mental illness, only 4.6% of
the face-to-face interview participants did so (Henderson, et al., 2012).
The most widely used social desirability scale was originally developed by Crowne and
Marlowe (1960) based on items from the Minnesota Multiphasic Personality Inventory. It has a
true-false response format to questions such as, “I sometimes feel resentful when I don’t get my
way.” It was originally purported to have two factors, social desirability bias and acquiescence
bias. Loo and Thorpe (2000) found that these two factors only accounted for 17.3% of the
variance, leaving a significant amount of the variance unaccounted for. While several shortened
versions have been developed, Loo and Thorpe recommend using the full, original version as the
shortened versions focused on only these constructs. The full, 33-item version will therefore be
used in this study. Internal consistency reliability analyses in Loo and Thorpe’s study was
adequate (α = .64 – .78; 2000). Cronbach’s alpha was .71 in the present study.
International Personality Item Pool – Neuroticism Scale (IPIP-N). Goldberg (1999)
developed the International Personality Item Pool as a broad-bandwidth personality inventory
with items in the public domain with items measuring the Big-Five factor markers. There are two
versions of the full inventory, one with 50-items and the other with 100. For the purposes of this
study we will only use the 10-item neuroticism scale pulled from the 50-item version. Items are
rated on a 5-point Likert-scale from 1 (very inaccurate) to 5 (very accurate). Five of the items
40
are keyed in the positive direction and five in the negative direction (e.g., “Often feel blue” and
“Seldom feel blue”). The scale has an internal consistency of .86 (Goldberg et al., 2006) and
correlates highly (r = .83) with the neuroticism subscale of the NEO-Five Factor Inventory
(Gow, Whiteman, Pattie, & Deary, 2005). Cronbach’s alpha for the present study was .87.
Attention Checks. Random responses from even 5% of participants can have a significant
impact on observed correlations (Credé, 2010). It is highly recommended that researchers make
every attempt to identify and eliminate such random responders (Osborne & Blanchard, 2011;
Tucker, 2013). The present study will identify random responding by requiring the participant to
answer correctly both of two items prompting a specified response (e.g., “Please select Strongly
Disagree for this item”).
Religious/ Spiritual affiliation, familiarity with mental illness, and demographic
questionnaire. Participants are asked to report their age, gender, religious/spiritual affiliation,
and frequency of attendance to religious/spiritual meetings, services, or events. Participants are
also asked their familiarity with mental illness by selecting all that apply of the following
choices: none, media (books, movies, TV, etc.), taken a class, personal experience (self),
personal experience (family member), or personal experience (other: please specify). If the
participants select any of the “personal experience” options, they are asked to report with which
mental illness(es) they are familiar.
Procedures
After receiving approval from the IRB committee at Iowa State University, procedures of
the scale construction followed those recommended by Heppner, Wampold, and Kivlighan
(2008).
41
Item generation. Items were generated based on existing items in the RBAMI, SSOSH,
SSOMI, ATSPPS-SF, and SSRPH as wells as on information found through the literature
review. Items integrated religious beliefs about mental illness and psychological help-seeking
and items based on general stigma research. Items represented initially were categorized into
four groups: religious public stigma of mental illness (RPSMI), religious public stigma of
psychological help-seeking (RPSPHS), religious self-stigma of mental illness (RSSMI), and
religious self-stigma of psychological help-seeking (RSSPHS). Items were also included that
reflect the sin/morality and spiritually-oriented causes/treatments factors as measure by the
RBAMI. Lily Mathison and Nathaniel Wade reviewed the items and added additional items to
help cover all of the elements of the construct. Then two experts, one in help-seeking stigma and
scale validation and one in quantitative psychology, specifically scale construction, reviewed the
items and directions. Both offered suggestions and items and the directions were revised as
appropriate. Then, the items and directions were reviewed for readability by a freelance editor
and writer with 15 years of editing experience.
Expert panel review. A panel of nine experts in the areas of religion (Christianity and
Judaism), religious counseling, and mental health stigma reviewed the items generated for the
scale. This panel assessed the items for content validity and had the option of generating
additional items and suggesting topics or domains that still needed to be covered, though no
additional topics were suggested. At each step, items were revised, deleted, or added as
recommended by Heppner et al. (2008).
Experts had experience with a religious community and had expertise in the field of
mental health and/or mental health stigma. When asked which religion they were most familiar
with, four reported Judaism and four Christianity (one did not answer the question). Of those
42
who reported they were familiar with Christianity, one reported being familiar with the church of
Latter Day Saints. Of the eight that reported their education level, five held a doctor of
philosophy in Psychology, Human Development, or Behavioral Neuroscience, one held a
Masters in Counseling Psychology, and two held a Bachelors in Psychology (both were graduate
students in a doctoral Counseling Psychology program). Occupations of the reviewers included
tenure-track or tenured professor, staff psychologist at a university counseling center, and
graduate student. After the expert panel reviewed the items and directions and their comments
were reviewed and incorporated, there were 44 items for testing.
Readability analyses. Two readability analyses were conducted. The first was the Flesch
Reading Ease formula (Flesch, 1948), which used the average number of words per sentence and
the average number of syllables per word to calculate a number between 0-100, with higher
numbers signifying easier reading. The RMHSS received a score of 50.6 using this formula. The
second measure was the Flesch-Kincaid Grade level index (FKG; Flesch 1979), which also used
the average number of words per sentence and average number of syllables per word to calculate
the reading level to a U.S. grade-school level. The RMHSS was considered to be at a grade level
of 10.0 using this scale. Because reading researchers have criticized objective readability
formulas for being simplistic (Lenzner, 2014), the items were also subjectively assessed for
readability by a professional editor and by experts reviewing the items. This included
suggestions for rewording items to make them simpler or more understandable and reformatting
to make the scale easier to read.
Sample 1. In the first study, 704 student participants completed an online survey during
mass-testing of SONA participants in early September 2015. Data collected included informed
consent, the items of the RMHSS created during the previous steps, university emails, and
43
student IDs. Sample 1 included participants who only completed mass-testing and were not a
part of Sample 2 (described below).
Sample 2. During the semester, SONA participants had the opportunity to complete the
questionnaire packet, which was provided as an online study through SONA starting at the end
of September 2015 and continuing into January 2016. All SONA participants over the age of 18
were eligible whether they participated in mass-testing or not. This was called Sample 2 and
includes 326 participants. The questionnaire packet included the full set of items from the new
measure of religious mental health stigma as well as the Religious Beliefs about Mental Illness
scale (RBAMI; Wesselmann and Graziano, 2010), Stigma Scale of Receiving Psychological
Help (SSRPH; Komiya, Good, and Sherrod, 2000), Knowledge Test of Mental Illness (KTMI;
Michaels and Corrigan, 2013), Beliefs about DAssessment-Discrimination (DD; Link, 1987)
scale, Self-Stigma of Seeking Help (SSOSH; Vogel & Wade, 2009) scale, Self-Stigma of Mental
Illness (SSOMI; Tucker, Hammer, Vogel, Bitman, Wade, & Maier, 2013) scale, Attitudes
Toward Seeking Professional Psychological Help – Short Form (ATSPPH-SF; Fischer & Farina,
1995), Intentions to Seek Counseling Inventory (ISCI; Cash, Begley, McCown, & Weise, 1975),
Marlowe-Crowne Social Desirability Scale (MCSD; Crowne & Marlowe, 1960), International
Personality Item Pool- Neuroticism Scale (IPIP-N; Goldberg, 1999), Religious Commitment
Inventory-10 (RCI-10; Worthington, Wade, Hight, Ripley, McCullough, Berry, Schmitt, Berry,
Bursley, & O’Connor, 2003), and Religious/ Spiritual affiliation, familiarity with mental illness,
and demographic questionnaire (demographic questionnaire).
After data were collected for both Samples 1 and 2, the email IDs and student IDs were
compared for the two data sets. If the participant was found to be in both data sets, their data was
deleted from Sample 1. There were 11 participants in Sample 2 who did not report either their
44
student ID or their email ID. These were deleted from Sample 2 to ensure that there was no
possibility of a participant whose data was in Sample 1 also being in Sample 2. (See Table 1
below.)
Table 1. Overview of Samples for the Scale Construction and Examination

Sample Sample Name N Scales Test/Analyses
1 Mass-Testing (MT) Only 704 RMHSS EFA

2 Full Questionnaire (FQ)
Only (not MT)
326 All Scales CFA
Validity/Reliability

45
CHAPTER 4. RESULTS
Attention check. Participants who answered either or both of the two attention checks
incorrectly were eliminated from the sample for analysis purposes. T-tests were used to evaluate
if there was a significant difference between the demographics of those who did answer the
attention checks correctly and those who did not. There was no difference between the groups in
terms of ethnicity, religion, whether or not they were international students, or age. There was a
significant difference between the gender of those who answered the attention check correctly
and those who didn’t, with men being more likely to incorrectly answer them (p = .001).
Sample 1: Exploratory factor analysis. Using data from Sample 1, I conducted an
exploratory factor analysis (EFA) as recommended by Heppner et al. (2008) with principle axis
factoring extraction and a Direct Oblimin (oblique) rotation. Principle axis factoring was chosen
over principle components analysis per the recommendations of Howard (2016) and
Worthington and Whittaker (2006). An oblique rotation was determined to be the most
appropriate as, according to stigma theory, any factors found would most likely be correlated and
oblique rotation allows for this possibility (Howard, 2016; Worthington & Whittaker, 2006).
Direct Oblimin was chosen as the oblique rotation as it was suggested as the most preferred over
Promax by Howard (2016). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was
0.97. KMO values range from 0 to 1, with higher numbers indicating better sampling adequacy.
Howard (2016) recommends that the KMO should be above .60 before performing an EFA, as
this indicates that latent factors may be present and an EFA may be performed.
The number of factors to retain was determined by Cattell’s scree test, in which one looks
at a plot of the Eigenvalues of each factor and identifies where the “elbow” of the plot resides.
All factors above that point are retained while those below are discarded (DeVellis, 2003). In the
46
case of the RMHSS, the elbow was determined to start at factor three. Factors one and two were,
therefore, retained while factors three and below were not.
In terms of retaining items, Tabachnick and Fidell (2013) recommend a minimum factor
loading of .32, whereas Howard cites 0.40 as a “good” factor loading (2016). Howard further
recommends use of the .40-.30-.20 rule, namely that satisfactory items will load onto their
primary factor above 0.40, load onto alternative factors below 0.30, and demonstrate a difference
of 0.20 between their primary and alternative factor loadings (2016).
Worthington and Whittaker recommend that the length of the scale be considered along
with internal consistency of the scale scores in determining the number of items to retain (2006).
As there were two factors, it was considered that 5 items per factor would be a good number, as
the objective was to create a short measure, so long as all of the main theoretical components of
the concept were assessed. The top 5 items in the two factors were therefore retained. (See Table
1.) Upon closer inspection of the items chosen for the first factor, I determined that two of the
items were redundant with other items. I then deleted these items and chose the two items with
the next highest factor loadings in their stead. In addition, upon inspection of the chosen 10 items
I discovered that a key concept from the literature was missing: the concept of demon/spirit
attack/possession/oppression. As this item still had an acceptable factor loading (.78), I included
it in the scale as an 11th item. Factor 1 accounted for 43.31% of the variance while factor 2
accounted for 26.12%.
While the two factors both refer to religious mental health stigma broadly, Factor 1 deals
more with personal religious beliefs about mental health care while Factor 2 refers to religious
community beliefs about mental illness in particular. The full title for Factor 1 will therefore be
Personal Religious Beliefs about Mental Health Care and be called “Personal” for short. On the
47
other hand the full title for Factor 2 will be Religious Community Beliefs about Mental Illness
and be called “Community” for short.
Internal consistency reliability. Cronbach’s alpha was calculated to measure the
internal consistency reliability of the scores on the scale. It was 0.83 for Sample 1. A
correlational analysis was conducted with the Marlowe-Crowne Social Desirability scale to
measure the extent that social desirability is measured by the new scale. As hypothesized, the
correlation was small at .17 (p = .002).
Sample 2: Confirmatory factor analysis. Next, the data from Sample 2 were analyzed
to test the reliability and validity of the scores on the new scale. Internal consistency reliability
was examined again with Cronbach’s alpha and was determined to be 0.82 for Sample 2. Using
data from Sample 2, I tested construct validity by calculating correlations between the scores on
the new scale and scores on existing scales including the RBAMI, SSRPH, KTMI, SSOSH, DD,
SSOMI, ATSPPH-SF, ISCI, MCSD, IPIP-N, and RCI-10. Table 3 illustrates the measures used
for validity and the correlations found.
Using data from Study 2, I conducted a confirmatory factor analysis (CFA) to compare
four models (see Table 4). Model 1 was a single-factor model, assuming that the items measure
one construct, which was called religious mental health stigma (RMHS). Model 2 was a twofactor orthogonal model (which does not allow the two factors to correlate) based on the factor
structure from the EFA. Model 3 was a two factor Oblique model (which allows the two factors
to correlate). Model 4 was a two factor bifactor model, assuming that the items measure two
constructs as found in the EFA, but at the same time measure a single construct, RMHS.
CFA Model Comparisons were employed to decide on the best fitting model. Global fit
indexes were also examined. These included the comparative fit index (CFI), Tucker-Lewis
48
Index (TLI), Root Mean Square Error of Approximation (RMSEA), and the Standardized Root
Mean Square Residual (SRMS) with cutoffs for the CFI and TLI > .95 and the RMSEA and
SRMS <.06 as suggested by Hu and Bentler (1999). The results were then examined to
determine which model best balanced parsimony with fit (using chi-square difference tests). It
was determined that the best fitting model was the two factor bifactor model, as shown in figure
1 below.
Analyses of Variance (ANOVA) were used to determine if differences in responses on
the RMHSS exist between racial/ethinic, religious affiliation, international/domestic, and gender
groups. The means between different genders and religious affiliations were tested using
ANOVAs and were not significantly different. However, race/ethnicity (European American
versus minority groups) and international/domestic were. As the number of minorities in any one
group was – unfortunately – too small to test differences between groups, the mean difference
between European Americans and minority groups on the RMHSS was found. There was a
significant difference (F = 14.65, df = 320, p < .001) with the mean for minority groups (24.87,
SD = 5.84) higher than that for European Americans (21.72, SD = 5.72). As for international
versus domestic there was a significant difference (F = 24.75, df = 322, p < .001) with
international students’ mean (21.83, SD = 5.60) being higher than domestic students’ (27.58, SD
= 6.28). A Pearson correlation was used to determine if there was a significant relationship
between age and the RMHSS; there was no significant correlation, although this is not surprising
given the restricted range on age in the current sample.
Finally, a Pearson’s correlation was used to estimate the test-retest reliability using those
participants who participated in both Mass-Testing and SONA (Sample 1 + Sample 2).
Unforunately, there were very few participants who completed both data collection (n = 32). The
resulting correlation (r = .34) was non-significant.
49
Table 2
Loadings on Factors 1 and 2 for RMHSS items.
Item Factor 1
Loading
Factor 2
Loading
35. I would feel as if I were failing religiously if I got help from a mental health
professional. .89
26. I would feel less devoted to my religion if I took psychiatric medication. .87
28. Taking psychiatric medication would feel like giving up on God or the divine. .86
43. Getting help from a mental health professional is against my religious or
spiritual beliefs. .85
16. If I struggled with a mental illness, it would be a result of my own sin. .84
38. Taking psychiatric medication would feel like giving up on my religion. .83
12. If I had a mental illness I would think that I had not been following my religious
beliefs devotedly. .83
14. I would feel less devoted to my religion if I went to a therapist for psychological
help. .81 -.12
23. If I had a mental illness I would be afraid that I was not on the right religious path. .81
37. A person who is devoted to their religious beliefs and practices would not have
psychological difficulties. .81
29. Mental illness results from the sins or wrongs an individual has committed. .80
18. If I was diagnosed with a mental illness I would worry that I might not gain access
to the afterlife (i.e. heaven). .79
40. A person with a mental illness is being attacked, oppressed, or possessed by
spirits (e.g. demons, jinn, dybbuk). .78 .13
32. Getting help from a mental health professional is against my religious community’s
beliefs. .78 -.23
22. If I had a mental illness I would feel rejected by God or the divine. .77 -.17
25. I would feel inadequate if I went to a therapist for psychological help instead of God
or the divine.
.76 .18
19. Seeking a therapist for psychological help should be a last resort, only to be used
after seeking help from one’s religion. .72 .27
6. Seeing a mental health professional would feel like giving up on God or the divine. .72 -.14
36. The only mental health provider a member of my faith should see is one who shares
my religious beliefs. .71 .23
31. God or the divine only gives me situations I can handle, so there is no need for me to
seek help from a mental health professional. .67 .32
4. If I had a mental illness I would feel that I was not doing the will of God or the
divine.
.67 -.13
10. If I were struggling emotionally or mentally I would think I was being influenced by
demons or evil spirits. .66 .16
34. Mental illness is the result of sin being in the world. .65 .21
9. Taking psychiatric medication is against my religious community’s beliefs. .64 -.25
41. Seeking a therapist for psychological help is only appropriate for very serious
problems; otherwise, one should seek help from one’s religion. .63 .36
33. Prayer is a better treatment for mental illness than mental health care. .61 .53
11. A person should work out his or her own problems with the help of God or the
divine instead of seeking mental health care. .60 .46
50
Table 2 continued
42. I would be afraid to tell people in my religious community if I were taking
psychiatric medication.
.60 .22
39. Most people in my religious community would think less of a person with mental
illness. .59 -.38
30. If I were experiencing a serious emotional crisis reading my religious text (e.g.
Bible, Koran, Torah) would be more effective than seeking mental health care. .58 .48
15. I would never tell people in my religious community if I struggled with a mental
illness. .58 -.29
13. I would be afraid to tell people in my religious community if I went to a therapist for
psychological help. .57 -.24
2. Getting help from a mental health professional is somewhat inappropriate for
religious people regardless of what the problem is. .57
44. I would feel more comfortable talking with a religious leader about my problems
than a mental health professional. .52 .50
20. Most single people in my religious community would be reluctant to marry an
individual with mental illness. .33 -.17
8. If I were experiencing a serious emotional crisis I would be confident that I could find
relief by spending more time in prayer. .20 .68
5. Most people in my religious community would believe that a person with a
mental illness were just as devoted to their religion as any other person in that
community.
-.22 .65
17. Most people in my religious community would be willing to accept a person
with mental illness as a close friend. -.21 .64
1. Most people in my religious community would treat a person with mental illness
just as they would treat anyone else. -.15 .59
27. A person should first turn to their religious beliefs and practices if they feel like they
have an emotional or mental health concern. .49 .55
3. Most people in my religious community believe that having a mental illness is a sign
of personal failure. .45 -.55
7. Most people in my religious community would willingly accept a religious leader
who had a mental illness. -.13 .55
24. Most people in my religious community would accept a person with mental
illness as a children’s religious teacher. .50
21. Getting help from a mental health professional could help me spiritually. .34

51
Table 3
Correlations between the RMHSS and Other Measures.
Measure Acronym RMHSS RMHSS1
RMHSS2
RBAMI1
RBAMI2
Religious Mental Health
Stigma Scale – Full
RMHSS — .79** .77** .54** .32**
Religious Mental Health
Stigma Scale – Personal
RMHSS-1 .79** — .24** .73** .54**
Religious Mental Health
Stigma Scale – Community
RMHSS-2 .77** .24** — .14* .01
Religious Beliefs about Mental
Illness, Factor 1
RBAMI-1 .54** .73** .14* — .67**
Religious Beliefs about Mental
Illness, Factor 2
RBAMI-2 .32** .54* .01 .67** —
Stigma Scale of Receiving
Psychological Help
SSRPH .32** .21** .30** .09 -.07
Knowledge Test of Mental
Illness
KTMI .22** .16** .19** .27** .21**
Beliefs about DAssessmentDiscrimination
DD .22** .03 .31** -.06 -.16**
Self-Stigma of Seeking Help SSOSH .40** .31** .32** .18** .14*
Self-Stigma of Mental Illness SSOMI .22** .13* .22** .08 .02
Attitudes Toward Seeking
Psychological Help
ATSPPHSF
.34** .34** .19** .32** .32**
Intentions to Seek Counseling
Inventory
ISCI -.08 -.02 -.11* -.02 -.05
Marlowe-Crowne Social
Desirability Scale
MCSD .17** .22** .05 -.08 -.14*
Neuroticism Scale IPIP-N .13* .12* .09 .02 -.04
Religious Commitment
Inventory-10
RCI-10 -.04 -.27** .21** .35** .49**
** Correlation is significant at the 0.01 level (2-tailed)
*Correlation is significant at the 0.05 level (2-tailed)
52
Table 4
Goodness-of-Fit Indicators for the Competing Models of the 11-item RMHSS
Model df χ² CFI TLI RMSEA(CI) SRMR AIC
One General
Factor
44 489.85 .69 .61 .18 [.16, .20] .15 8156.23
Two Factor
Orthogonal
44 145.68 .93 .91 .08 [.07, .10] .11 7812.05
Two Factor
Obilque
43 126.82 .94 .93 .07 [.06, .09] .05 7795.20
Two Factor
Bifactor
33 77.36 .97 .95 .06 [.05, .08] .03 7765.74
Note: RMHSS = Religious Mental Health Stigma Scale; CFI = Comparative Fit Index; RMSEA
= Root-Mean Square Error of Approximation; CI = 90% Confidence Interval for RMSEA;
SRMR = Standardized Root-Mean-Square Residual; AIC = Akaike’s Information Criterion
Figure 1
Two Factor Bifactor Model
53
CHAPTER 5. DISCUSSION
An 11-item quantitative measure of mental health stigma in Christian and Jewish
communities was developed over the course of this study. The extant literature has focused on
qualitative and descriptive research, with only one article doing any quantitative research on the
topic. The measure of religious mental health stigma developed in this study had strong
psychometric support. In addition, the measure incorporates theory on public stigma and selfstigma of mental illness and help-seeking and is more applicable to religions other than
Christianity. The goal was to develop a psychometrically sound measure of mental health stigma
in Jewish and Christian communities and, considering internal consistency, goodness of fit
indeces, and measures of external validity, it appears that, overall, this goal was accomplished.
RMHSS versus RBAMI
While the RMHSS was intended to replace the RBAMI in use, it appears that the two
scales may be measuring different constructs based on correlations between the scales. This
indicates that, depending on the goal of a study, the RMHSS or the RBAMI may be an
appropriate fit. The below table summarizes the relationships between the RMHSS, each of its
factors and the two RBAMI factors. As indicated on the table, the overall RMHSS correlates
moderately with the two RBAMI factors. Looking at each RMHSS factor, the first factor
correlates strongly with the two RBAMI factors but the second only weakly correlates with the
first RBAMI factor and does not correlate at all with the second. This indicates that there is some
overlap between the RMHSS Factor 1 and the RBAMI, but the second appears to be picking up
on something the RBAMI is not. Factor 2 of the RMHSS looks at perceived opinions of one’s
religious community. This, apparently is not accounted for in the RBAMI.
Looking at the correlations between the RBAMI and RMHSS and the other scales, the
RMHSS, in this sample, performs better overall relating to established stigma scales. For
54
example, the RMHSS has significant correlations with the SSRPH and the SSOMI while the
RBAMI does not. This indicates that the RMHSS accounts for both the public stigma of seeking
psychological help and the self-stigma of mental illness better than the RBAMI. In fact, the
RMHSS significantly correlates in some way to all of the stigma scales. It makes sense that the
RMHSS would correlate with the stigma scales better than the RBAMI, as the items were
constructed specifically to incorporate existing stigma theory while the RBAMI was not.
One area where the RBAMI appears to have out-performed the RMHSS is in its factors’
weak or zero-level correlations with the IPIP-N and the MCSD. The RMHSS full scale and
factor 2 correlate significantly, albeit weakly, with both (Factor 1 is not related to either scale).
Nonsignificant correlations between the RMHSS and the IPIP-N and MCSD would indicate that
the new religious stigma scale is not related to neuroticism and socially-desireable responding.
The RMHSS and RBAMI also related to another scale differently – the Religious
Commitment Inventory (RCI-10). This scale was included as a measure of external validity and
it was hypothesized that there would be a positive correlation between the RCI-10 and the
RMHSS. While there was, indeed, a positive correlation between the two RBAMI factors and the
RCI-10, there was no significant correlation between the full RMHSS. However, when looking
at the correlations between the RMHSS Factors 1 and 2 and the RCI-10, this makes sense as
Factor 1 is positively correlated with it whereas Factor 2 is negatively correlated. This is
particularly interesting because Factor 2 of the RMHSS was the factor that had no correlation
with the two RBAMI scales, indicating that it captures a construct that the RBAMI does not. It
appears that as perceptions of mental health stigma in a religious communities increase, religious
commitment decreases. This relationship seems to indicate that, for whatever reason, people that
55
are more committed to their religion perceive that their religious community holds less
stigmatizing beliefs about mental illness and mental health care.
It is notable, however, that in looking at the full RMHSS, the two RMHSS factors and the
two RBAMI factors, only RMHSS factor 2 correlated with the scale that included items that
measured perceptions of the religious community. Using structural equation modeling, Vogel
and Wester (2003) found that the most proximal predictor of intentions to seek counseling was
attitudes toward seeking counseling. Furthermore, the Internalized Stigma Model (Lannin, et al.,
2015) suggests that the self-stigma of seeking help and mental illness were closer predictors of
intentions to seek counseling than were public stigma. It is therefore possible that, given their
significant correlations with other stigma measures but not the ISCI, the RMHSS may represent
constructs that are more distally related to intentions to seek counseling.
One benefit of using the RMHSS over the RBAMI is that, according to the CFA
conducted in this study, it has a bifactor structure that allows the use of both its factors separately
and the full scale as a whole. In contrast, the reported factor structure for the RBAMI is a 2-
factor structure, requiring that the two factors be analyzed separately and not as a whole.
Theoretically, this is an important distinction, as this indicates that the two factors within the
RMHSS combine to create a unified construct. The RBAMI scale, with its two factors, does not
appear to measure a unified construct. In addition to the theoretical implications, this has
implications for its ease of use as well. The RMHSS can be used as a scale with two subscales or
one general scale, depending on what the user is interetested in. The RBAMI must be used as
two separate scales.
Finally, in consideration of the factor structures of the RMHSS and RBAMI, the RMHSS
performed better on goodness-of-fit indeces in their respective CFA analyses. In fact, while the
56
two factor bifactor RMHSS model met the cutoffs set by Hu and Bentler (1999) for the
comparative fit index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of
Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMS), the two
factor RBAMI did not meet the cutoffs for the RMSEA or the CFI. According to the CFI, the
two factor bifactor RMHSS was a better fit for its data than the two factor RBAMI by a factor of
0.1 (RMHSS CFI = .97; RBAMI CFI = .87). This indicates that the RMHSS has a stronger, more
stable factor structure than the RBAMI.
Limitations
It is important to note some limitations of this study. First of all, the items of the RMHSS
were primarily created by two individuals who were most familiar with Protestant Christianity.
While the authors made an attempt to make the items more generally applicable to religions in
general, it is possible that they may not fit as well with other Christian groups, Judaism, Islam,
Buddhism, Hinduism, or any other religion. It may be said that this was partially assuaged by the
fact that several of the expert reviewers were familiar with different religious groups including
Reformed and Conservative Judaism and Latter Day Saints, but the fact remains that it may or
may not work as well outside of a Protestant Christian population.
Another limitation was the homogenous nature of the samples in this study. They were
primarily European American Christians (both Catholic and Protestant) in their late teens or
early twenties and all were undergraduates in a large Midwestern university in the United States.
Considering the literature has shown that racial/ethnic minorities – especially Latino and African
American individuals – tend to be more religious than white individuals, examining the RMHSS
with a more ethnically-diverse sample would be important.
57
Future Directions
There are several direction in which this study can be taken. First of all, the scale should
be cross-validated in a more diverse sample in terms of race/ethnicity, religion, geography,
education, age, and socio-economic status. A community sample, rather than a sample of
undergraduates, would be a great place to start.
Once the scale has been cross-validated in a more diverse sample, the relationships
between religious mental health stigma as measured by the RMHSS and other mental health
stigma constructs should be studied more closely. Considering that structural equation modeling
has shown that public and self-stigmas of mental illness and help-seeking are differentially
related, it is possible that RMHSS may play a role in the internalized stigma model or one similar
to it. In addition, religious stigma might play a moderating role in some contexts, such as devote
Christians considering seeking mental health care.
Finally, now that there is a measure of religious mental health stigma, it can be possible
to see if it may change over time, specifically in response to interventions which target lowering
it. Interventions would be important in order to mitigate the negative implications of high
religious mental health stigma. This can include ignorance of the mental health needs of church
members and a lack of Helpance from the church for families with mental illness (Farrell &
Goebert, 2008, Leavey, Loewenthal, & King 2007; Rogers, Stanford, & Garland, 2012). In
addition, these beliefs can lead to led to non-adherence with psychiatric treatment, increasing the
risk of relapse and hospitalization, and lack of medical treatment for those with severe mental
illness. This lack of consistent care can result in an increase in high risk symptoms such as
suicidal ideation and behavior and psychotic or manic episodes (Borras, Mohr, Brandt, Gillieron,
Eytan, & Huguelet, 2007; Mitchell & Romans, 2003). In rare but significant cases Christian
58
church members were discouraged and even forbidden to take psychiatric medication and/or
were told they did not have a mental illness despite having a diagnosis from a mental health
professional (Stanford, 2007). Interventions to decrease religious mental health stigma could
possibly lower unnecessary suffering in the lives of religious individuals.
Conclusion
The creation of the religious mental health stigma scale is an important step in
contiunuing the research in this area. First of all, it makes possible doing quantitative research in
the area – something that has been sorely lacking. In addition, in the creation of the scale, it was
discovered that there appears to be at least two distinct elements to religious mental health
stigma, personal beliefs and beliefs of the religious community. These appear to relate to other,
secular stigma scales in similar but distinct ways, including the interesting difference in how
each factor differentially relates to religious commitment. The religious community beliefs about
mental illness factor appears to be the most unique in this study, as it had no correlation with the
previously developed Religious Beliefs about Mental Illness scale. It will be important to do
future research on how these elements of religious mental health stigma relate to help-seeking
processes.
59
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CHAPTER 7. APPEDICES
APPENDIX A: STUDY MATERIALS
RMHSS – CJ
DIRECTIONS: Please read each statement and click the circle corresponding to the degree to
which you agree or disagree with the statement.
In answering, please refer to the following definitions:
For the phrase God or the divine please think of a word or phrase that best fits your concept of
the one supreme being or deity such as Yahweh, Jesus, Allah, or G-d.
Mental illness, for the purpose of this study, refers to any mental illness recognized by mental
health professionals, including but not limited to depression, anxiety, bipolar,
schizophrenia, substance use disorders, and personality disorders.
Psychiatric medication refers to any medication used to treat mental illness, including but not
limited to antidepressants (e.g. Prozac), antianxiety medication (e.g. Xanax),
antipsychotics (e.g. Seroquel), and mood stabilizers (e.g. lithium).
Mental health professional refers to any professional trained in the treatment of persons suffering
from mental illness including but not limited to psychologists, clinical social workers,
marriage and family therapists, substance abuse counselors, and psychiatrists.
Factor 1: Personal Religious Beliefs about Mental Health Care (Personal)
16. If I struggled with a mental illness, it would be a result of my own sin.
28. Taking psychiatric medication would feel like giving up on God or the divine.
35. I would feel as if I were failing religiously if I got help from a mental health professional.
37. A person who is devoted to their religious beliefs and practices would not have psychological
difficulties.
40. A person with a mental illness is being attacked, oppressed, or possessed by spirits (e.g.
demons, jinn, dybbuk).
43. Getting help from a mental health professional is against my religious or spiritual beliefs.
Factor 2: Religious Community Beliefs about Mental Illness (Community)
1. Most people in my religious community would treat a person with mental illness just as they
would treat anyone else.
5. Most people in my religious community would believe that a person with a mental illness
were just as devoted to their religion as any other person in that community.
7. Most people in my religious community would willingly accept a religious leader who had a
mental illness.
17. Most people in my religious community would be willing to accept a person with mental
illness as a close friend.
24. Most people in my religious community would accept a person with mental illness as a
children’s religious teacher.
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RMHSS – Mass Testing and SONA
DIRECTIONS: Please read each statement and click the circle corresponding to the degree to
which you agree or disagree with the statement.
In answering, please refer to the following definitions:
For the phrase God or the divine please think of a word or phrase that best fits your concept of
the one supreme being or deity such as Yahweh, Jesus, Allah, or G-d.
Mental illness, for the purpose of this study, refers to any mental illness recognized by mental
health professionals, including but not limited to depression, anxiety, bipolar,
schizophrenia, substance use disorders, and personality disorders.
Psychiatric medication refers to any medication used to treat mental illness, including but not
limited to antidepressants (e.g. Prozac), antianxiety medication (e.g. Xanax),
antipsychotics (e.g. Seroquel), and mood stabilizers (e.g. lithium).
Mental health professional refers to any professional trained in the treatment of persons suffering
from mental illness including but not limited to psychologists, clinical social workers,
marriage and family therapists, substance abuse counselors, and psychiatrists.
1. Most people in my religious community would treat a person with mental illness just
as they would treat anyone else.
2. Getting help from a mental health professional is somewhat inappropriate for religious
people regardless of what the problem is.
3. Most people in my religious community believe that having a mental illness is a sign of
personal failure.
4. If I had a mental illness I would feel that I was not doing the will of God or the divine.
5. Most people in my religious community would believe that a person with a mental
illness were just as devoted to their religion as any other person in that community.
6. Seeing a mental health professional would feel like giving up on God or the divine.
7. Most people in my religious community would willingly accept a religious leader
who had a mental illness.
8. If I were experiencing a serious emotional crisis I would be confident that I could find
relief by spending more time in prayer.
9. Taking psychiatric medication is against my religious community’s beliefs.
10. If I were struggling emotionally or mentally I would think I was being influenced by
demons or evil spirits.
11. A person should work out his or her own problems with the help of God or the divine
instead of seeking mental health care.
12. If I had a mental illness I would think that I had not been following my religious beliefs
devotedly.
13. I would be afraid to tell people in my religious community if I went to a therapist for
psychological help.
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14. I would feel less devoted to my religion if I went to a therapist for psychological help.
15. I would never tell people in my religious community if I struggled with a mental illness.
16. If I struggled with a mental illness, it would be a result of my own sin.
17. Most people in my religious community would be willing to accept a person with
mental illness as a close friend.
18. If I was diagnosed with a mental illness I would worry that I might not gain access to the
afterlife (i.e. heaven).
19. Seeking a therapist for psychological help should be a last resort, only to be used after
seeking help from one’s religion.
20. Most single people in my religious community would be reluctant to marry an individual
with mental illness.
21. Getting help from a mental health professional could help me spiritually.
22. If I had a mental illness I would feel rejected by God or the divine.
23. If I had a mental illness I would be afraid that I was not on the right religious path.
24. Most people in my religious community would accept a person with mental illness as
a children’s religious teacher.
25. I would feel inadequate if I went to a therapist for psychological help instead of God or
the divine.
26. I would feel less devoted to my religion if I took psychiatric medication.
27. A person should first turn to their religious beliefs and practices if they feel like they have
an emotional or mental health concern.
28. Taking psychiatric medication would feel like giving up on God or the divine.
29. Mental illness results from the sins or wrongs an individual has committed.
30. If I were experiencing a serious emotional crisis reading my religious text (e.g. Bible,
Koran, Torah) would be more effective than seeking mental health care.
31. God or the divine only gives me situations I can handle, so there is no need for me to seek
help from a mental health professional.
32. Getting help from a mental health professional is against my religious community’s
beliefs.
33. Prayer is a better treatment for mental illness than mental health care.
34. Mental illness is the result of sin being in the world.
35. I would feel as if I were failing religiously if I got help from a mental health
professional.
36. The only mental health provider a member of my faith should see is one who shares my
religious beliefs.
37. A person who is devoted to their religious beliefs and practices would not have
psychological difficulties.
38. Taking psychiatric medication would feel like giving up on my religion.
39. Most people in my religious community would think less of a person with mental illness.
40. A person with a mental illness is being attacked, oppressed, or possessed by spirits
(e.g. demons, jinn, dybbuk).
41. Seeking a therapist for psychological help is only appropriate for very serious problems;
otherwise, one should seek help from one’s religion.
42. I would be afraid to tell people in my religious community if I were taking psychiatric
medication.
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43. Getting help from a mental health professional is against my religious or spiritual
beliefs.
44. I would feel more comfortable talking with a religious leader about my problems than a
mental health professional.
RBAMI
Factor 1:
1. Moral weakness is the main cause of mental illness.
2. People suffering from mental illnesses are not going to their places of worship enough.
3. Mental illnesses result from an immoral or sinful lifestyle.
4. People suffer from mental illnesses because they are not sorry for their sins.
5. A person suffering from a mental illness is not relying on their faith or religious values like
they should.
6. A person suffering from a mental illness is not praying enough.
7. People have mental illnesses because someone else sinned against them.
8. Mental illnesses are a result of Original Sin.
9. A person’s relationship with God has nothing to do with their suffering from a mental illness.*
Factor 2:
10. Demons are NOT responsible for causing the symptoms of mental illness.*
11. Compared to a religious leader, a counselor/therapist would be much better at helping
someone with a mental illness.*
12. Persons suffering from mental illness are being tormented by the Devil.
13. Mental illnesses should be healed by having people pray for the afflicted person.
14. Prayer is NOT the only way to fix a mental illness.
15. God’s healing is all a person suffering from a mental illness needs—nothing else should be
relied on.
16. It is superstitious to believe a person suffering from mental illness is possessed by demons.*
RCI
1. I often read books and magazines about my faith.
2. I make financial contributions to my religious organization.
3. I spend time trying to grow in understanding of my faith.
4. Religion is especially important to me because it answers many questions about the
meaning of life.
5. My religious beliefs lie behind my whole approach to life.
6. I enjoy spending time with others of my religious affiliation.
7. Religious beliefs influence all my dealings in life.
8. It is important to me to spend periods of time in private religious thought and reflection.
9. I enjoy working in the activities of my religious organization.
10. I keep well informed about my local religious group and have some influence in its
decisions.
SSRPH
1. Seeing a psychologist for emotional or interpersonal problems carries social stigma.
2. It is a sign of personal weakness or inadequacy to see a psychologist for emotional or
interpersonal problems.
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3. People will see a person in a less favorable way if they come to know that he/she has seen
a psychologist.
4. It is advisable for a person to hide from people that he/she has seen a psychologist.
5. People tend to like less those who are receiving professional psychological help.
6. People think it is a sign of personal weakness or inadequacy to see a psychologist for
emotional or interpersonal problems.
Knowledge Test of Mental Illness
This is a test of your knowledge about mental illness. The questions on the test are taken from
findings of scientific research. You are not expected to have read the research reports, but by
using your experience and general knowledge you should be able to pick the correct answer.
Some people will do much better than others because of their training in medicine, rehabilitation,
or psychology. Read each question carefully and select the response you consider to be the
correct answer. THERE IS NO PENALTY FOR GUESSING. There is no limit for the
completion of this test, but you should work as rapidly as you can.
1. One type of psychotherapy, cognitive-behavioral therapy, has been shown to reduce the
psychotic symptoms of schizophrenia.
a. True
b. False
2. Considering people with schizophrenia, what is the average number of separate
hospitalizations for their mental illness over a one-year period of time?
a. 4 or more
b. 2 or less
3. People with severe mental illness cannot maintain private residences.
a. True
b. False
4. People with schizophrenia should be allowed to use an online dating service.
a. True
b. False
5. People with schizophrenia make up what percent of the homeless population?
a. 5%
b. 25%
6. Adolescents with schizophrenia are frequently truant from school.
a. True
b. False
7. People with severe mental illness are capable of establishing an intimate long-term
relationship of a sexual nature.
a. True
b. False
8. People with schizophrenia benefit the least from services like psychotherapy.
a. True
b. False
9. People with schizophrenia are likely to steal from their family members.
a. True
b. False
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10. Based on the capabilities of people with schizophrenia, school counselors should recommend
beginning a job-training program rather than continuing in the regular curriculum.
a. True
b. False
11. For those with serious mental illness, what percent of treatment should be dedicated to
medication compliance?
a. Greater than 80%
b. Less than 50%
12. Neglectful parenting is somewhat responsible for the beginning of a serious mental illness.
a. True
b. False
13. A person with schizophrenia is capable of being a physician or medical doctor.
a. True
b. False
14. The divorce rate among the general population is about 50%. What is the divorce rate among
people who experience mental illness?
a. Greater than 70%
b. Less than 50%
DD
Directions: Please read each statement and check the circle corresponding to the scale number
that indicates how much you agree or disagree with the statement.
1. Most people would willingly accept a former mental patient as a close friend.
2. Most people would believe that a person who has been in a mental hospital is just as
intelligent as the average person.
3. Most people believe that a former mental patient is just as trustworthy as the average
citizen.
4. Most people would accept a fully recovered former mental patient as a teacher of young
children in a public school.
5. Most people believe that entering a mental hospital is a sign of personal failure.
6. Most people would not hire a former mental patient to take care of their children, even if
he or she had been well for some time.
7. Most people think less of a person who has been in a mental hospital.
8. Most employers will hire a former mental patient if s/he is qualified for the job.
9. Most employers will pass over the applicant of a former mental patient in favor of
another applicant.
10. Most people in my community would treat a former mental patient just as they would
treat anyone.
11. Most young people would be reluctant to date an individual who has been hospitalized
for a serious mental disorder.
12. Once they know a person has been in a mental hospital, most people will take his or her
opinions less seriously.
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SSOSH
1. I would feel inadequate if I went to a therapist for psychological help.
2. My self-confidence would NOT be threatened if I sought professional help.
3. Seeking psychological help would make me feel less intelligent.
4. My self-esteem would increase if I talked to a therapist.
5. My view of myself would not change just because I made the choice to see a therapist.
6. It would make me feel inferior to ask a therapist for help.
7. I would feel okay about myself if I made the choice to seek professional help.
8. If I went to a therapist, I would be less satisfied with myself.
9. My self-confidence would remain the same if I sought professional help for a problem I
could not solve.
10. I would feel worse about myself if I could not solve my own problems.
SSOMI
Directions: People at times find that they face mental health problems. This can bring up
reactions about what mental illness would mean. Please use the 5-point scale to rate the degree to
which each item describes how you might react if you were to have a mental illness.
1. I would feel inadequate if I had a mental illness.
2. My self-confidence would NOT be threatened if I had a mental illness.
3. Having a mental illness would make me feel less intelligent.
4. My self-esteem would decrease if I had a mental illness.
5. My view of myself would not change just because I had a mental illness.
6. It would make me feel inferior to have a mental illness.
7. I would feel okay about myself if I had a mental illness.
8. If I had a mental illness, I would be less satisfied with myself.
9. My self-confidence would remain the same if I had a mental illness.
10. I would feel worse about myself if I had a mental illness.
ATTSPPH-SF
1. If I believed I was having a mental breakdown, my first inclination would be to get
professional attention.
2. The idea of talking about problems with a psychologist strikes me as a poor way to get
rid of emotional conflicts.
3. If I were experiencing a serious emotional crisis at this point in my life I would be
confident that I could find relief in psychotherapy.
4. There is something admirable in the attitude of a person who is willing to cope with his
or her conflicts and fears without resorting to professional help.
5. I would want to get psychological help if I were worried or upset for a long period of
time.
6. I might want to have psychological counseling in the future.
7. A person with an emotional problem is not likely to solve it alone; he or she is likely to
solve it with professional help.
8. Considering the time and expense involved in psychotherapy, it would have doubtful
value for a person like me.
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9. A person should work out his or her own problems; getting psychological counseling
would be a last resort.
10. Personal and emotional troubles, like many things, tend to work out by themselves.
ISCI
Instructions: Below is a list of issues people commonly bring to counseling. How likely would
you be to seek counseling/therapy if you were experiencing these problems?
Relationship difficulties
Concerns about sexuality
Depression
Conflict with parents
Speech anxiety
Difficulty in sleeping
Inferiority feelings
Difficulty with friends
Self-understanding
Loneliness
Difficulties dating
Choosing a major
Test Anxiety
Academic work procrastination
MCSD
1. Before voting I thoroughly investigate the qualifications of all the candidates.
2. I never hesitate to go out of my way to help someone in trouble.
3. It is sometimes hard for me to go on with work if I am not encouraged.
4. I have never intensely disliked anyone.
5. On occasion I have doubts about my ability to succeed in life.
6. I sometimes feel resentful when I don’t get my way.
7. I am always careful about my manner of dress.
8. My table manners at home are as good as when I eat out in a restaurant.
9. If I could get into a movie without paying and be sure I was not seen I would probably do it.
10. On a few occasions, I have given up doing something because I thought too little of my
ability.
11. I like to gossip at times.
12. There have been times when I felt like rebelling against people in authority even though I
knew they were right.
13. No matter who I’m talking to, I’m always a good listener.
14. I can remember “playing sick” to get out of something.
15. There have been occasions when I took advantage of someone.
16. I’m always willing to admit it when I make a mistake.
17. I always try to practice what I preach.
18. I don’t find it particularly difficult to get along with loud mouthed, obnoxious people.
19. I sometimes try to get even rather than forgive and forget.
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20. When I don’t know something I don’t mind at all admitting it.
21. I am always courteous, even to people who are disagreeable.
22. At times I have really insisted on having things my own way.
23. There have been occasions when I felt like smashing things.
24. I would never think of letting someone else be punished for my wrong-doings.
25. I never resent being asked to return a favor.
26. I have never been irked when people expressed ideas very different from my own.
27. I never make a long trip without checking the safety of my car.
28. Where have been times when I was quite jealous of the good fortune of others.
29. I have almost never felt the urge to tell someone off.
30. I am sometimes irritated by people who ask favors of me.
31. I have never felt that I was punished without cause.
32. I sometimes think when people have a misfortune they only got what they deserved.
33. I have never deliberately said something that hurt someone’s feelings.
IPIP-N
How Accurately Can You Describe Yourself?
Describe yourself as you generally are now, not as you wish to be in the future. Describe
yourself as you honestly see yourself, in relation to other people you know of the same sex as
you are, and roughly your same age. So that you can describe yourself in an honest manner, your
responses will be kept in absolute confidence.
Indicate for each statement whether it is 1. Very Inaccurate, 2. Moderately Inaccurate, 3. Neither
Accurate Nor Inaccurate, 4. Moderately Accurate, or 5. Very Accurate as a description of you.
1. Get stressed out easily
2. Am relaxed most of the time.
3. Worry about things.
4. Seldom feel blue.
5. Am easily disturbed.
6. Get upset easily.
7. Change my mood a lot.
8. Have frequent mood swings.
9. Get irritated easily.
10. Often feel blue.
Demographic Questionnaire
Age (in years):
Gender:
Race/Ethnicity:
80
International Student?
Yes
No
Please select which best describes your religious/spiritual beliefs (select all that apply):
Christian, Protestant
Catholic
Christian, Other (Please Specify):
Islam
Judaism
Buddhism
Agnosticism
Atheism
None
Other (Please Specify):
If you attend religious/spiritual meetings, services, or activities please specify how frequently:
Less than once per month
Once per month
2-3 times per month
Once per week
More than once per week
I used to attend religious/spiritual meetings, services, or events but do not now
I do not religious/spiritual meetings, services, or events nor have I in the past
Familiarity with mental illness (Select all that apply)
None
Taken a class
Personal experience, Self
Personal experience, Family Member
Personal experience, Other (Please Specify):
If you selected “personal experience” above, please specify with which mental illness(es):

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Materials Sent to First Two Expert Reviewers
My name is Lily Mathison and I am a doctoral student in Counseling Psychology at Iowa State
University. For my master’s thesis, I am endeavoring to create a measure of religious mental
health stigma. This information would be used in future research and/or in clinical settings to
better understand patients’ concerns and experiences. To make this measure the best it can be I
need input from experts and professionals in the fields of religion and mental health – which is
why I have contacted you. It would be extremely helpful if you would take a few moments to
review and comment on the four items listed below.
Religious Mental Health Stigma Survey
I. Please review the definitions of religious mental health stigma and comment on the
appropriateness or inappropriateness of the definition. Your insights on how these
definitions fits or do not fit with certain religious groups are particularly welcomed.
Definitions
For the purpose of this study, Religious Mental Health Stigma (RMHS) is conceptualized as the
public and self-stigma associated with mental illness and seeking psychological help in religious
communities. Of special interest are beliefs about sin, morality and beliefs about the spiritual
and/or religious causes and treatments of mental illness. While RMHS may possibly be found in
any religion, this study is limited to assessing the stigma in the Abrahamic religions (Judaism,
Christianity and Islam).
Religious public stigma of mental illness (RPSMI) is defined as the stigma that emerges from the
beliefs, practices, and/or traditions of a religious community toward individuals
considered mentally ill.
Religious public stigma of psychological help-seeking (RPSPHS) is defined as the stigma that
emerges from the beliefs, practices, and/or traditions of a religious community toward
individuals who seek and/or receive mental health care.
Religious self-stigma of mental illness (RSSMI) is defined as the religious stigma of mental
illness that has been internalized by an individual who has a mental illness, causing them
to devalue and stigmatize themselves.
Religious self-stigma of psychological help-seeking (RSSPHS) is defined as the religious stigma
of mental illness that has been internalized by an individual who seeks and/or receives
mental health care, causing them to devalue and stigmatize themselves.
Mental illness, for the purpose of this study, refers to any mental illness recognized by mental
health professionals, including but not limited to depression, bipolar, schizophrenia,
substance abuse, and personality disorders.
82
Psychiatric medication refers to any medication used to treat mental illness, including but not
limited to antidepressants (e.g. Prozac), antipsychotics (e.g. Seroquel), and mood
stabilizers (e.g. lithium).
Mental health professional refers to any professional trained in the mental health field who
provides counseling for mental illness, psychotherapy, or talk therapy. Some examples
include psychologists, clinical social workers, marriage and family therapists, substance
abuse counselors, and psychiatrists who do talk therapy.
II. Please rate the degree to which these items assess each respective facet of religious mental
health stigma, as defined above.
RHMSS
DIRECTIONS: Please read each statement and click the circle corresponding to the degree to
which you agree or disagree with the statement.
In answering, please refer to the following definitions:
God or the divine will serve as a placeholder for the word or phrase that best describes your
concept of the one supreme being or deity. Other such names may include Yahweh,
Jesus, Allah, or G-d.
Mental illness, for the purpose of this study, refers to any mental illness recognized by mental
health professionals, including but not limited to depression, bipolar, schizophrenia,
substance abuse, and personality disorders.
Psychiatric medication refers to any medication used to treat mental illness, including but
not limited to antidepressants (e.g. Prozac), antipsychotics (e.g. Seroquel) and mood
stabilizers (e.g. lithium).
Mental health professional refers to any individual who does counseling for mental illness,
psychotherapy, or talk therapy. Some examples include psychologists, clinical social
workers, marriage and family therapists, substance abuse counselors, and psychiatrists
who do talk therapy.
Religious Public Stigma Mental Illness
1. A person with a mental illness is being attacked, oppressed, or possessed by spirits (e.g.
demons, jinn, dybbuk).
2. A person who is faithful to their religious beliefs and practices would not have psychological
difficulties.
3. Mental illness results from the sins an individual has committed.
4. Mental illness is the result of sin being in the world.
5. Most people in my religious community would be willing to accept a person with mental
illness as a close friend.
6. Most people in my religious community would think less of a person with mental illness.
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7. Most single people in my religious community would be reluctant to marry an individual with
mental illness.
8. Most people in my religious community would accept a person with mental illness as a
children’s religious teacher.
9. Most people in my religious community would believe that a person with a mental illness is
just as faithful to their religion as any other person in that community.
10. Most people in my religious community would willingly accept a religious leader who had a
mental illness.
11. Most people in my religious community would treat a person with mental illness just as they
would treat anyone else.
12. Most people in my religious community believe that having a mental illness is a sign of
personal failure.
Religious Public Stigma of Psychological Help-Seeking
13. Prayer is one of the best treatments for mental illness.
14. Getting help from a mental health professional is somewhat inappropriate for religious
people.
15. A person should first turn to their religious beliefs and practices if they feel like they have an
emotional or mental health concern.
16. Getting help from a mental health professional is against my religious community’s beliefs.
17. Taking psychiatric medication is against my religious community’s beliefs.
18. A person should work out his or her own problems with the help of God or the divine.
19. Seeking a therapist for psychological help should be a last resort, only to be used after
seeking help from one’s religion.
20. Seeking a therapist for psychological help is only appropriate for very serious problems;
otherwise, one should seek help from one’s religion.
21. The only mental health provider a member of my faith should see is one who shares our
religious beliefs.
22. Secular (nonreligious) therapists do more harm than good.
23. Secular (nonreligious) therapy is not helpful because it rests on beliefs that are wrong.
24. A secular (nonreligious) therapist can be just as effective as a nonreligious therapist can.
Religious Self-Stigma of Mental Illness
25. If I was struggling emotionally or mentally I would think I was being influenced by evil
spirits (e.g. demons, jinn, dybbuk).
26. If I struggled with a mental illness, it would be a result of my own sin.
27. I would never tell people in my religious community if I struggled with a mental illness.
28. If I had a mental illness I would feel rejected by God or the divine.
29. If I had a mental illness I would feel that I was not doing the will of God or the divine.
30. If I had a mental illness I would think that I had not been following my religious beliefs
faithfully.
31. If I had a mental illness I would be afraid that I was not on the right religious path.
32. If I was diagnosed with a mental illness I would worry that I might not gain access to the
afterlife (i.e. heaven).
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Religious Self-Stigma of Psychological Help-Seeking
33. Taking psychiatric medication would feel like giving up on God or the divine.
34. Taking psychiatric medication would feel like giving up on my religion.
35. Seeing a mental health professional would feel like giving up on God or the divine.
36. Seeing a mental health professional would feel like giving up on my religion.
37. I would feel less faithful to my religion if I went to a therapist for psychological help.
38. I would feel less faithful to my religion if I took psychiatric medication.
39. I would be afraid to tell people in my religious community if I went to a therapist for
psychological help.
40. I would be afraid to tell people in my religious community if I were taking psychiatric
medication.
41. Getting help from a mental health professional could help me spiritually.
42. I would feel as if I were failing religiously if I got help from a mental health professional.
43. I would feel more comfortable talking with a religious leader about my problems than a
mental health professional.
44. I would feel inadequate if I went to a therapist for psychological help instead of God or the
divine.
45. Getting help from a mental health professional is against my religious or spiritual beliefs.
46. God or the divine only gives me situations I can handle, so there is no need for me to seek
help from a mental health professional.
47. If I were to experience a serious emotional crisis I would be confident that I could find relief
by going to my place of worship/prayer.
48. If I were experiencing a serious emotional crisis I would be confident that I could find relief
in reading my religious text (e.g. Bible, Koran, Torah).
49. If I were experiencing a serious emotional crisis I would be confident that I could find relief
by spending more time in prayer.
50. If I were experiencing a serious emotional crisis I would be confident that I could find relief
by through the prayers of a religious leader.
Other
51. All things that happen, both good and bad, are the will of God or the divine.
Open questions:
What is the first thing you would do to get help if you believed you were having a mental
breakdown?
III. Please list two or more items that are relevant to the issue of religious mental health
stigma that are not captured in the items above or reword an above item to make it
more applicable.
IV. Please list any other thoughts/concerns/ideas/etc. you might have concerning religious
stigma and mental illness.
85
APPENDIX B: IRB APPROVAL SHEET
86
AKNOWLEDGEMENTS
I would like to take this opportunity to thank those who helped me with various aspects
of conducting research and the writing of this thesis. First and foremost, I would like to thank Dr.
Nathaniel Wade for his guidance, flexibility, and encouragement throughout the process. His
energy and excitement are contagious, his insights have proven valuable, and his support has
been indispensable throughout the last few years. I would also like to thank my committee
members for their efforts and contributions to this work: Dr. Marcus Crede and Dr. David Vogel.
I would additionally like to thank Dr. Meifen Wei for her aid in running analyses and all of the
expert panelists who reviewed my scale and provided their invaluable suggestions.

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