Christina Sanderson Thesis Draft Final-1

CHILDHOOD TRAUMA AND PSYCHOLOGICAL SYMPTOMS PREDICT
BARRIERS TO MENTAL HEALTH CARE AMONG COLLEGE STUDENTS
By
Christina Sanderson
Submitted to the Board of Study of Psychology
School of Natural and Social Sciences
in partial fulfillment of the requirements
for the degree of Bachelor of Arts
Purchase College
State University of New York
May 2014
Accepted:
__________________________, Sponsor
Dr. Ilyse Spertus
__________________________, Second Reader
Dr. Linda Bastone

CHILDHOOD TRAUMA AND BARRIERS TO MENTAL HEALTH CARE

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Abstract
This study investigated the relationships between childhood trauma, psychological
symptoms, and barriers to seeking mental health care. It was hypothesized that all three
factors would have relationships with one another. It was also hypothesized that
psychological symptoms is a mediator of the relationship between childhood trauma and
barriers to seeking mental health care. Participants completed a questionnaire that
contained a demographics form, the Barriers to Help-Seeking Scale, the Inventory of
Attitudes Toward Seeking Mental Health Services Scale, the Childhood Trauma
Questionnaire, and a Patient Health Questionnaire. There were significant correlations
between psychological symptoms and all the barriers to care measured, as well as
psychological symptoms and childhood trauma. Childhood trauma was significantly
correlated with all barriers but one. Hierarchical regressions showed reduced partial
correlations between childhood trauma and the measured barriers to care when
psychological symptoms were introduced to the model. These findings suggest that
psychological symptoms are a mediating variable in the relationship between childhood
trauma and barriers to seeking mental health care, and that having experienced a
childhood trauma exerts its effects on barriers to care through the experience of
psychological symptoms.


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Acknowledgements
I would like to thank my Senior Project Advisor, Dr. Ilyse Spertus, for helping me
with my project, for her continual patience and endless support, and for all her time and
energy in helping me to complete this project n a timely and efficient fashion. I would
also like to thank my Second Reader, Dr. Linda Bastone for providing me with advice
and feedback throughout the year. I would also like to thank Cathie Chester, Cathy
VanBomel, and the rest of the Purchase College Counseling Center for providing me with
resources for my participants, as well as their devotion to this study and all the help they
have provided me this semester. A special thank you is due to Purchase College Faculty
for providing me with this experience to collect and analyze data, and lastly to my
participants for their time and assistance.


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Childhood Trauma and Psychological Symptoms Predict Barriers to Mental Health Care
Among College Students
Mental illness is a prevalent issue within the population of college students.
Research has shown that more than one third of college students suffer from some form
of mental health problem (Zivin, Eisenberg, Gollust, & Golberstein, 2009). The
psychological problems that have been found to be the most prevalent in a college
population include depression, anxiety, eating disorders, self-injury, and suicidal thoughts
(Zivin et al., 2009). The 2005 National Comorbidity study replication found anxiety to be
the most prevalent class of disorders among adults ages 18 to 44, followed by impulse-
control disorders, mood disorders, and substance use disorders (Kessler et al., 2005).
According to the results of this study, the lifetime prevalence of any mental disorder was
46.4%, with a higher prevalence within the younger age groups.
In addition to exploring the prevalence of mental disorders, several studies have
examined the practice of self-injurious behaviors among college students (Whitlock,
Eckenrode, & Silverman, 2006). A self-injurious behavior is any behavior that inflicts
pain on oneself without any suicidal intent. Whitlock and colleagues (2006) found that
490 of 2,875 (17%) of participants reported having practiced self-injurious behavior at
some point in their lives. Alcohol consumption and binge drinking (defined as consuming
five or more alcoholic drinks on at least one occasion) is a self-injurious behavior of
concern within a college student population. A national survey of 140 college campuses
found that nearly half (44%) of the respondents reported themselves to be binge drinkers
(Wechsler, Davenport, Dowdall, Moeykens, & Castillo, 1994). More recently,
researchers have found that binge drinking among college students has increased over


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time. A study on college students found that the number of participants who reported
consuming five or more alcoholic drinks on at least one occasion had increased from
41.7% in 1999, to 44.7% in 2005 (Hingson, Zha, & Weitzman, 2009).
While a range of mental health problems and self-injurious behaviors among
college students have been reported in the literature, studies also suggest an increase in
severity and complexity of such behaviors has occurred over the last several years. In an
article examining his findings from a national survey administered to University
counseling directors, Gallagher (2012) reported that in 1988, 56% of college counseling
directors noted an increase in the severity of psychological symptoms within their clients;
by 2011, this number had risen to 90%. Severity of depression has also been
accompanied by increased suicidal ideation among college students (Garlow et al., 2008).
Further, the percentage of college students being hospitalized for a mental health problem
nearly doubled from 2001 to 2011 (Gallagher, 2012). In sum, college students experience
a number of mental health problems ranging from anxiety and mood disorders to self-
injurious behavior including alcohol abuse, with some evidence suggesting the
prevalence and severity of symptoms may be on the rise.
Despite the prevalence and severity of mental health problems among college
students, research suggests only a small number of students seek mental health treatment
(Zivin et al., 2009; Gallagher, 2012). In a two year longitudinal study, Zivin et al. (2009)
reported that among those students with a mental health problem at both baseline and
follow up, less than half received treatment during that time period. Garlow et al. (2008)
found that of the students demonstrating moderately severe depressive symptoms, to
severe depressive symptoms, 85% were not receiving any form of psychiatric or


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psychological treatment. There are several reasons why students who need psychological
help are not receiving it. Researchers suggest that those who are not seeking treatment
may not be aware of the severity and complexity of psychological symptoms and their
impact on functioning (Corrigan, 2004). In other words, not all individuals experience
and interpret mental illness and help-seeking in the same way; some people may have a
more difficult time seeking treatment than others. The reasons as to why individuals in
need of psychological care do not seek the necessary treatment are a topic of interest
within the field. A larger body of research more closely examines the specific reasons as
to why certain individuals do not seek treatment for mental health problems.
Research has sought to gain a better understanding of why individuals in need of
psychological care may be reluctant to seek treatment. Gulliver et al. (2010) reviewed
published qualitative and quantitative studies that examined what prevents (barriers) and
supports (facilitators) adolescents and young adults from seeking mental health care.
Although there were few studies that explored what facilitated young adults to seek
treatment, studies did suggest that increased confidence and trust in their provider
(Wilson & Deane, 2001), a positive past history with a mental health provider (Wilson &
Deane, 2001), and social support and encouragement from family and friends to seek
treatment (Downs & Eisenberg, 2012) all increased the likelihood of individuals to seek
care. There were several studies that examined perceived barriers to seeking treatment.
The most often reported barriers to seeking mental health care among young adults were
stigma, embarrassment, the need for self-reliance, confidentiality and trust issues, and not
having enough insight about mental health services or psychological symptoms (Downs
& Eisenberg, 2012; Held & Owens, 2012; Murray, Heflinger, Suiter, & Brody, 2011;


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Prins, Meadows, Bobevski Graham, Verhaak, van der Meer, Penninx, & Bensing, 2011;
Wilson & Deane, 2012). Some research has also shown lack of accessibility to be a
barrier (Lehavot, Der-Martirosian, Simpson, & Sadler, 2013). However, many colleges
provide their students with free services in their mental health clinics, so it is expected
that lack of access to services would not be as great of an issue within this population.
Research tends to show stigma to be a common barrier to seeking mental health
care. Some of the literature breaks up stigma into separate constructs: public stigma, and
personal stigma. Dickstein, Vogt, Handa, and Litz (2010) define public stigma as the
general population’s perceptions of individuals who seek mental health treatment, and
they define personal stigma (also known as self-stigma) as an individual’s negative self-
perceptions related to seeking mental health treatment. Studies that explore public stigma
are less consistent predictors as a barrier of mental health care use (Held & Owens, 2012).
However, studies that explore personal stigma (self-stigma) are more consistent
predictors as a barrier of mental health care use (Vogel, Wade, & Hackler, 2007). A study
on college students examined the mediating effects of personal stigma (self-stigma)
associated with seeking counseling and attitudes toward seeking counseling (Vogel, et al.,
2007). Vogel et al., (2007) found that the perceived public stigma significantly predicted
personal stigma, and personal stigma predicted attitudes toward seeking counseling,
which then predicted willingness to seek counseling. The researchers note that these
findings support the modified labeling theory, which involves discrimination towards the
mentally ill (public stigma), which leads to negative consequences for people’s self-
esteem (personal stigma) if they are labeled either by themselves or others as having a
mental illness. Another study examined veterans and also explored public and personal


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stigma. The experiment yielded similar results: greater public stigma was significantly
associated with greater personal stigma, and personal stigma significantly predicted less
positive attitudes toward seeking mental health treatment (Held & Owens, 2012).
Personal stigma reflects internal feelings about oneself, and these feelings are typically
negative. Personal stigma alone, along with the support provided from the research,
provides further reason to examine why individuals feel as though having a mental illness
is something to be ashamed of, or why other individuals may perceive mental illness
negatively, and try to reduce these views.
Another barrier that is common within an adolescent population is the need for
autonomy, or relying on oneself to solve their problems on their own. Wilson and Deane
(2012) examined adolescents and belief-based barriers, which are person related barriers
that are formed based on beliefs such as the need for autonomy and help-seeking fears.
Their most relevant finding was that for both males and females, the need for autonomy
was a significantly stronger barrier to seeking mental health care than help-seeking fears,
such as embarrassment or trust. Also to note, white males had a significantly stronger
need for self-reliance than females (Wilson & Deane, 2012). Another study by Davies et
al., (2000) explored the attitudes college men had towards seeking treatment for health
problems in general (e.g., alcohol abuse, anger issues). They found the strongest barrier
for college men to seek treatment was the need for independence.
The feeling of a need to rely on ones self to solve problems comes with it an idea
of singularity. Individuals’ yearning to solve their problems on their own suggests that
they may not be open to allowing others attempt to help them. These individuals may be
most comfortable keeping their issues to themselves because they are able to trust


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themselves with the secrecy of their issues. As it is not seen in the literature as
prominently as the need for autonomy, a distrust of health professionals and other
caregivers has also shown to be a barrier to seeking care among adolescents (Wilson &
Deane, 2012).
While research suggests a considerable presence of psychological
symptomatology among college students, a large number of students do not seek mental
health treatment. Interestingly, as the literature has thoroughly proposed that problems
with trust, a lack of psychological openness, stigmatization associated with seeking care,
as well as a need for autonomy and self-reliance are well established barriers to care
among students research also suggests that psychological symptomatology in itself
increases the risk of experiencing such barriers.
A number of studies demonstrate that psychological symptom severity is
associated with increased vulnerability to stigma, a need for self-reliance, and trust issues
(Britt, Greene-Shortridge, Brink, Ngyuen, & Rath, 2008; Hoge, Castro, Messer, McGurk,
Cotting, & Koffman, 2004). In a sample of 203 college students, Britt et al. (2008)
measured depression and stress levels, as well as perceived stigma, and other concrete
barriers, such as lack of transportation, or financial issues. They found that students who
showed more symptoms of depression were more likely to perceive stigma and
experience other factors that prevent them from receiving care than students who showed
less symptoms of depression.
As a result of the prevalence of soldiers coming back from war with mental health
problems, considerable research has examined the impact of psychological symptoms on
barriers to care among veterans. Studies show increased psychological distress among


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veterans predicts increased barriers, particularly stigma (Hoge et al., 2004). In their
seminal study, Hoge et al. (2004) reported that soldiers and marines whose responses
were positive for psychological symptoms of a mental disorder, such as anxiety, PTSD,
or major depression, were twice as likely to report concerns about stigmatization, trust of
their caregivers, and not knowing where to find the help they need, than those whose
responses did not indicate psychological symptoms of a mental disorder.
Over the last decade, research on stigma and other barriers to mental health care
have been examined in veteran populations, specifically those exposed to combat.
Experiencing combat related traumas is often linked to certain psychological symptoms,
such as posttraumatic stress disorder (PTSD). Research shows that soldiers and marines
experience more prevalent mental health problems on post-deployment screenings than
on pre-deployment screenings (Hoge et al., 2004). Additional studies have demonstrated
that veterans who have more severe PTSD symptoms show more stigma-related barriers,
and logistic-related barriers to seeking mental health treatment than those with less severe
symptoms (Ouimette et al., 2011). These studies suggest that combat related PTSD and
other psychological symptoms as a result of combat exposure can make veterans even
more vulnerable to perceived barriers to mental health care.
The literature suggests that increased symptom severity from psychological
disorders such as depression and posttraumatic stress disorder are associated with
increased perceptions of treatment barriers among college students and veteran
populations. While the literature is consistent in showing that exposure to combat and its
effect on symptom severity leads to increased barriers, little is known about exposure to


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childhood trauma and whether its effect on symptom severity also leads to increased
treatment seeking barriers.
Childhood trauma has been associated with increased psychopathology in
adulthood. Research has shown that all forms of childhood abuse, from childhood
emotional neglect to childhood sexual abuse, can have negative effects on an individual
during adulthood (Briere, Hodges, & Godbout, 2010; Van Gerko, Hughes, Hamill, &
Waller, 2005; Milligan & Andrews, 2005; Sansone, Songer, & Miller, 2005; Stuewig &
McCloskey, 2005; Spertus, Yehuda, Wong, Halligan, & Seremetis, 2003). Research has
explored the relationships between emotional abuse, emotional neglect, and sexual abuse
during childhood with accompanying distress in adulthood. Briere et al. (2010) found that
the cumulative exposure to different types of interpersonal trauma in childhood, such as
sexual abuse or physical assault, was associated with dysfunctional avoidance
characteristics, such as substance abuse, suicidality, and dissociation in adulthood.
Another study found a relationship between childhood abuse history and anxiety
disorders in adulthood (Cougle, Timapno, Sach-Ericsson, Keough, & Riccardi, 2010).
The results suggest that a greater number of anxiety disorders is associated with a greater
likelihood of a childhood abuse history. Other research has focused on the emotional
aspects of child abuse rather than the physical aspects. Spertus et al. (2003) found that
childhood emotional abuse and neglect are predictors of emotional and physical distress
as well as lifetime exposure to trauma in adult women.
The literature has also shown relationships between childhood trauma and
increased shame in adulthood. A study by Milligan and Andrews (2005) found that
participants who had been abused before the age of 17 showed correlations between three


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different shame scales. Additionally, Stuewig and McCloskey (2005) found that
participants who experienced harsh parenting in childhood had positive relationships with
proneness to shame in adulthood. Even further, childhood abuse has also been linked
with poor eating behaviors in young adulthood. Van Gerko et al., (2005) found that
participants who had an eating disorder that had been sexually abused during childhood
showed higher levels of binging and vomiting than those with an eating disorder who
were not sexually abused during their childhood.
Overall, those exposed to childhood trauma may be vulnerable to adulthood
trauma, psychological symptoms in adulthood, as well as negative feelings about the self,
like shame, or poor self-esteem. Additionally, those with a traumatic history may be less
trusting of others and as a result may feel they must rely on themselves, in turn being less
likely to seek help. It is possible these internal experiences create further barriers for
these individuals from seeking the psychological care that they need. I expect that those
with a childhood trauma history will demonstrate more of these types of barriers.
Research supporting that childhood traumas are associated with increased
psychological symptoms, gives reason to believe barriers to seeking mental health care
may not be the result of psychological symptoms alone, but they may the result of having
experienced a traumatic event during childhood. To our knowledge, there has been no
research done to determine if having experienced a traumatic event leads to increased
barriers to seeking mental health treatment. My research will explore the effect of having
experienced childhood trauma on the barriers to seeking mental health care in a college
student population. I expect childhood trauma to be associated with increased
psychological symptoms. I also expect that increased psychological symptoms will be


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associated with increased barriers. Although I expect childhood trauma to directly predict
barriers to mental health care, a model will be tested to examine the multiple
relationships among trauma history, psychological symptoms, and barriers to seeking
care. I hypothesize that the disclosure of psychological symptoms will be the channel by
which a trauma history exerts its effects on barriers. In other words, I predict that trauma
history will show its effects on barriers to seeking care through an individual’s
experience of psychological symptoms. That is, I believe psychological symptoms will
mediate the link between childhood trauma and barriers to mental health care.
Method
Participants
Thirty-six participants were recruited from a small public liberal arts state college
in the northeast of the United States. Twenty-seven women and nine men participated in
this study. Participants were between the ages of 18 and 23 (M=18.89, SD=1.21), 75%
(n=27) were female, 72.2% (n=26) reported being a freshman in college, and 44.4%
(n=16) declared a major in psychology. 61% (n=22) of participants were white, 22%
(n=8) of participants reported being more than one ethnicity, and the remaining 17%
(n=6) of participants reported being African American, Asian American, or Hispanic
American. Participants were recruited from their Introductory to Psychology course and
through their college website where they were able to sign up for a time they chose to
participate. All subjects who were students in the Introductory to Psychology class were
given class credit for their participation. Subjects who were not students in the
Introductory to Psychology class were not compensated for their participation.


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This study was approved by the Purchase College Institutional Review Board. All
participants provided informed consent. All participants completed the questionnaires
under the supervision of the Principal Investigator. Questionnaires were separated from
their consent forms in order to maintain anonymity.
Measures and Procedure
The surveys were distributed to the participants by the Principal Investigator. All
questionnaires included a demographics form, followed by four surveys (see Appendix
A). The demographics form was used to collect the age, ethnicity, gender, religion, sexual
orientation, major, and school years of the participants, as well as their familiarity with
the on campus counseling center.
Barriers to seeking mental health care were measured by the Barriers to Help
Seeking Scale or BHSS (Mansfield, Addis, & Courtenay, 2005). The BHSS is a 31-item
questionnaire that measures five different factors: need for control and self-reliance (e.g.,
I would think less of myself for needing help), minimizing problem and resignation (e.g.,
The problem wouldn’t seem worth getting help for), concrete barriers and distrust of
caregivers (e.g., I don’t trust doctors or other health professionals), privacy (e.g., This
problem is embarrassing), and emotional control (e.g., I don’t like to talk about feelings).
Each item is rated on a 5-point Likert-type scale from 0 (not at all) to 4 (very much). Four
questions were added to the end of this questionnaire that ask about psychological
problems within the family, knowledge about past mental health care visits of family, and
the helpfulness of these services.
Attitudes toward seeking mental health care were measured by the Attitudes
Toward Seeking Mental Health Services questionnaire or IATSMHS (Mackenzie, Knox,


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Gokoski, & Macaulay, 2004). This is a 24-item questionnaire that measures three factors:
psychological openness (e.g., Psychological problems, like many things, tend to work out
by themselves), help-seeking propensity (e.g., If I believed I were having a mental
breakdown, my first inclination would be to get professional attention), and indifference
to stigma (e.g., Having been mentally ill carries with it a burden of shame). Each item is
rated on a 5-point Likert-type scale from 0 (disagree) to 4 (agree).
Childhood Trauma was measured by the Childhood Trauma Questionnaire or
CTQ (Bernstein et al., 2002). This is a 28-item questionnaire that measures 5 factors:
physical abuse (e.g., People in my family hit me so hard that it left me with bruises or
marks), sexual abuse (e.g., someone threatened to hurt me or tell lies about me unless I
did something sexual with them), emotional abuse (e.g., I thought my parents wished I
had never been born), physical neglect (e.g., I had to wear dirty clothes), and emotional
neglect (e.g., I felt loved). Each item is rated on a 5-point Likert-type scale from 1 (never
true) to 5 (very often true).
Psychological symptoms were measured by the Patient Health Questionnaire or
PTQ (Spitzer, Kroenke, & Williams, 1999). Modules 1-8 of the Patient Health
Questionnaire were included for use in this study. Module 1 covers somatoform factors,
module 2 covers depression factors, modules 3-5 cover panic and anxiety, and modules
6-8 cover eating behaviors. Modules 9 and 10 (alcohol assessment measures) were
omitted and replaced with the CAGE questionnaire (see below.) Due to an error, the
anxiety module answer column included the answer options “not at all,” “several days,”
and “more than half the days,” and did not include “nearly every day.” Due to an IRB
request, a question on suicidality was omitted from the questionnaire.


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Alcohol abuse was measured by the CAGE questionnaire (Ewing, 1984). “CAGE”
is an acronym for “Have you ever felt you should cut down on your drinking? Have
people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about
your drinking? Have you ever had a drink first thing in the morning to steady your nerves
or get rid of a hangover (eye opener)?” The CAGE was used to assess alcohol abuse
rather than the PHQ because it may give less false positives, hence more specificity in a
college student population.
Results
The means and standard deviations of the subscale scores are presented in Table 1.
Due to the small sample size total scores were used rather than subscale scores on
independent variables (e.g., total psychological symptoms vs. anxiety, depression, etc.
and total childhood trauma vs. sexual abuse, emotional abuse, etc.) to decrease the
number of analyses conducted. As a result, the independent variable for all analyses was
total childhood trauma and the mediator variable was total psychological symptoms.
Zero-order correlations were conducted to examine the relationships between
childhood trauma, psychological symptoms, and the dependent variables (help-seeking
propensity, concrete barriers and distrust of caregivers, indifference to stigma, need for
control and self-reliance, and emotional control). These are presented in Table 2.
Consistent with predictions and previous research, total childhood trauma was
significantly correlated with total psychological symptoms, r(34)=.42, p < .01. Also
consistent with predictions, as well as previous research, total psychological symptoms
were significantly correlated with all barriers to care tested. Additionally, total childhood
trauma was significantly correlated with several barriers to seeking care, emotional


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control, r(34)=.50, p < .01, concrete barriers and distrust of caregivers, r(34)=.35, p < .05,
and control and self reliance, r(34)=.40, p < .05, and help-seeking propensity, r(34)=-.59,
p < .01. The help-seeking propensity correlation is negative because the factors are
scored in a reversed fashion; less help-seeking propensity indicates more barriers to
seeking care. However, childhood trauma was not significantly correlated with
indifference to stigma, r(34)=.27, p > .05.
Thus, the significant zero-order correlations between childhood trauma and
psychological symptoms met the initial criteria to examine psychological symptoms as a
mediator between childhood trauma history and barriers to care (Baron & Kenny, 1986).
Because both childhood trauma and psychological symptoms were all significantly
correlated with help-seeking propensity, emotional control, concrete barriers and distrust
of caregivers, and control and self-reliance, the second criteria to conduct meditational
analyses were met (Baron & Kenny, 1986). Hierarchical multiple regression analyses
were conducted to determine whether a mediation occurred. Specifically, the mediator
variable, total psychological symptoms, was entered first; the independent variable,
childhood trauma, was entered second, and the dependent variables included help-seeking
propensity, emotional control, concrete barriers and distrust of caregivers, and control
and self-reliance. All multiple regression analyses can be found in Table 3. All barriers
were used in the regression analyses with the exception of indifference to stigma because
it did not meet the necessary criteria in the preliminary analyses. The analysis revealed
that once psychological symptoms was entered into the model, it attenuated the
relationships between total childhood trauma and the dependent variables emotional
control, FΔ(1,33) = 4.08, p > .05, concrete barriers and distrust of caregivers, FΔ(1,33) =


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1.01, p > .05, and need for control and self reliance, FΔ(1,33) = 3.07, p > .05. However,
the relationship between childhood trauma and help-seeking propensity remained
significant when psychological symptoms was added to the equation, FΔ(1,33) = 10.29, p
< .01.
Discussion
Exploring the effects of childhood trauma history, psychological symptoms, and
their impact on barriers to mental health care in a college student population is of great
importance due to the high rates of prevalence and severity of psychological
symptomatology in this population. Research has shown that the more in need of mental
health care services an individual is, the less likely he/she is to have received them (Britt
et al., 2008; Ouimette et al., 2011).
To our knowledge, this study is the first study to examine whether or not there is a
relationship between childhood trauma and barriers to seeking mental health care. A
model was proposed that the experience of childhood trauma exerts its impact on barriers
to care through the experience of psychological symptoms. The results from this study
suggest that psychological symptoms did indeed attenuate this pathway or relationship
between childhood trauma and barriers to care.
Psychological symptoms were found to be a mediating variable in the relationship
between childhood trauma and the measured barriers to care. The four factors that met
the criteria for further analysis (concrete barriers and distrust of caregivers, control and
self-reliance, help-seeking propensity, and emotional control) were included in a
hierarchical regression. Partial correlations were reduced to be less significant when
psychological symptoms were introduced to the model, with the exception of help-


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seeking propensity. These results suggest that childhood trauma history exerts its effects
on barriers to care through the experience of psychological symptoms. Even though not
all variables demonstrated the model proposed, the large correlation coefficients still
suggest the importance of both childhood trauma, as well as psychological symptoms in
predicting emotional and behavioral barriers college students may experience when
thinking about seeking mental health care. A significant relationship between childhood
trauma and indifference to stigma was not found which we believe was a result of the
small sample size in this study. Further, when both childhood trauma and psychological
symptomatology were entered into the model, they accounted for 39% of the variance in
predicting treatment propensity, suggesting the importance of both factors in predicting
how likely a college student may or may not be willing to seek needed mental health care.
The results of this study bring forth several implications. Concrete barriers and
distrust of caregivers was found to be a significant outcome of psychological symptoms
and childhood trauma. Fifty percent of participants reported having little to no knowledge
of their on-campus counseling center. The students, even despite having these services
available to them, were unaware of them. Perhaps colleges can increase the students’ use
of their counseling services through texting or e-mails to increase awareness. A concern
about trust was also a barrier among those with a history of trauma. Perhaps testimonial
information from other students who have had experience with the counseling center
could help increase the likelihood that students would use the services that are available
to them. The results of this study also showed those individuals with a history of trauma
and subsequent psychological symptoms were more likely to feel they need to rely on
themselves rather then seek treatment. If students rely heavily on emotional strategies of


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self-reliance and perhaps as a result are unlikely to seek the help of a professional, further
research could examine whether these students would be willing to use more self-guided
treatments such as internet based therapies. Previous research has found that males are
more likely to employ strategies of self-reliance than females (Wilson & Deane, 2012).
The small sample size of this study precluded further analysis of gender differences.
Future studies could examine gender as a moderator between childhood trauma and self-
reliance
The small sample size was a great limitation of this study, making it hard to
generalize these findings as well as requiring a reduction in planned analyses. Rather
than examining the impact of specific types of childhood trauma (e.g., emotional abuse
and neglect, sexual and/or physical abuse) and different types of psychological disorders
(e.g., anxiety, depression, somatization) as they relate to students’ reluctance to seek
treatment, scales had to be reduced to total experience of trauma and total psychological
symptoms. Future studies using larger sample sizes can explore these different types of
relationships in greater detail. The experience of childhood emotional abuse and neglect
may be more insidious for its victims because it is not as overt as other forms of abuse,
which may result in less intervention for such individuals. Examining the impact of
various types of childhood trauma among college students may help researchers better
understand the impact of trauma on what prevents them from seeking needed mental
health care. Additionally, some studies suggest that anxiety disorders are
overrepresented among college students. Understanding the impact of childhood trauma
and the types of psychological symptoms students experience most and how they relate to


21

a reluctance to seek care would enable counseling centers to develop targeted
interventions and marketing material.
Lastly, this study was correlational in nature, and thus causation cannot be
inferred from the findings. Although there are relationships between these factors, it
remains unclear whether or not one factor directly caused another.
The literature continues to show how prevalent mental health problems are in
college student populations. Future research that expands our knowledge about the
impact of childhood trauma and specific types of psychological symptomatology
experienced in this population will go far in teaching counseling centers how to best
promote their materials and appropriately expand the services offered to students to make
them most engaging.


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26

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27

Table 1
Means and standard deviations of subscale scores
Subscale Mean (SD)
Barriers to Help Seeking Scale (BHSS)
Need for control and self-reliance (CSR) 13.14 (9.89)
Minimizing problem and resignation (MPR) 12.28 (6.10)
Concrete barriers and distrust of caregivers (BDC) 5.24 (4.25)
Privacy (P) 2.94 (2.19)
Emotional control (EC) 7.42 (4.64)
Inventory of Attitudes Toward Seeking Mental Health Services (IATSMHS)
Psychological openness (PO) 13.83 (6.93)
Help-seeking propensity (HSP) 20.67 (5.76)
Indifference to stigma (ITS) 10.25 (5.79)
Childhood Trauma Questionnaire (CTQ)
Emotional abuse (EA) 1.02 (.77)
Emotional neglect R (EN) 1.11 (.88)
Physical abuse (PA) .31 (.50)
Sexual abuse (SA) .42 (1.00)
Physical neglect R (PN) .38 (.52)
Patient Health Questionnaire and CAGE Questionnaire
Somatic (SOM) 7.67 (4.74)
Depression (DEP) 9.06 (6.50)
Anxiety (ANX) 7.39 (3.67)
Alcohol use (ETOH) 1.17 (1.21)


28

Table 2
Zero-order correlation matrix
T P HSP BDC ITS CSR EC
T -
P .44** -
HSP -.59** -.44** -
BDC .35* .47** -.40* -
ITS .27 .50** -.38* .59** -
CSR .40* .36* -.48* .65** .43** -
EC .50** .58** -.47** .43** .31 .50** -
Note: T, Total trauma (CTQ); P, Psychological symptoms (PHQ); HSP, Help-seeking
propensity (IATSMHS); BDC, Concrete barriers and distrust of caregivers (BHSS); ITS,
Indifference to stigma (IATSMHS); CSR, Need for control and self-reliance (BHSS);
EC, Emotional control (BHSS).
* p < .05.
** p < .01.


29

Table 3
Multiple regressions analyses predicting barriers to seeking mental health care
R RΔ2
fΔ df Partial Correlation
Control & Self-Reliance
Step 1
Psych Symptoms .36 .13 5.11* 1, 34
Step 2
Childhood Trauma .45 .07 3.07 1, 33 .29
Barriers and Distrust of Caregivers
Step 1
Psych Symptoms .47 .22 9.72** 1, 34
Step 2
Childhood Trauma .50 .03 1.10 1, 33 .18
Emotional Control
Step 1 .58 .34 17.30** 1, 34
Psych Symptoms
Step 2 .64 .07 4.08 1, 33 .33
Childhood Trauma
Help-Seeking Propensity
Step 1 .44 .20 8.35** 1, 34
Psych Symptoms
Step 2 .62 .19 10.29** 1, 33 -.49
Childhood Trauma
* p < .05.
** p < .01.


30

Appendix
Demographic Information
1. Age (at last birthday): ___________________________
2. Gender: 1  Male 2  Female
3. Race/Ethnicity: (check all that apply)
1  American Indian or Alaska Native
2  Asian American
3  Black or African American
4  Hispanic or Latino American
5  Native Hawaiian or Other Pacific Islander
6  White
7  Other, please specify: _____________________

4. Religion:

1  Christian
2  Muslim
3  Jewish
4  Hindu
5  Other, please specify:
_____________________

5. What
year
are
you
currently
in
college?______________

6. What
is
your
current
major?

_____________________________________________

7. Do you identify yourself as:
1  Straight or heterosexual
2  Lesbian, gay, or homosexual
3  Bisexual
4  Transgender
5  Something else
6  Don’t know

8. Rating on a scale from 0-4, how familiar are you with the psychological services
available to you at Purchase College?
0  Not at all
1  A little bit
2  Moderately
3  Quite a bit
4  Very much


31

Barriers To Help Seeking Scale: Below are some reasons why people do NOT seek
help for a psychological problem (e.g. feeling down or depressed, feeling anxious, having
anxiety attacks, and/or personal difficulties such as relationship problems or stress at
work). Please read each of the following reasons and decide how important each would
be in keeping YOU from seeking help. Your answers will be kept confidential.
Not at all A little bit Moderately Quite a bit Very much
1. I would think less of myself for needing help. 0 1 2 3 4
2. I don’t like other people telling me what to do. 0 1 2 3 4
3. Nobody knows more about my problems than I do. 0 1 2 3 4
4. I’d feel better about myself knowing I didn’t need help
from others.
0 1 2 3 4
5. I don’t like feeling controlled my other people. 0 1 2 3 4
6. It would seem weak to ask for help. 0 1 2 3 4
7. I like to make my own decisions and not be too
influenced by others.
0 1 2 3 4
8. I like to be in charge of everything in my life. 0 1 2 3 4
9. Asking for help is like surrendering authority over my
life.
0 1 2 3 4
10. I do not want to appear weaker than my peers. 0 1 2 3 4
11. The problem wouldn’t seem worth getting help for. 0 1 2 3 4
12. The problem wouldn’t be a big deal; it would go away in
time.
0 1 2 3 4
13. I wouldn’t want to overreact to a problem that wasn’t
serious.
0 1 2 3 4
14. Problems like this are part of life; they’re just something
you have to deal with.
0 1 2 3 4
15. I’d prefer to just suck it up rather than dwell on my
problems.
0 1 2 3 4
16. I would prefer to wait until I’m sure the health problem
is a serious one.
0 1 2 3 4


32

Not at all A little bit Moderately Quite a bit Very much
17. People typically expect something in return when they
provide help.
0 1 2 3 4
18. I would have real difficulty finding transportation to a place
where I can get help.
0 1 2 3 4
19. I wouldn’t know what sort of help was available. 0 1 2 3 4
20. Financial difficulties would be an obstacle to getting help. 0 1 2 3 4
21. I don’t trust doctors and other health professionals. 0 1 2 3 4
22. A lack of health insurance would prevent me from asking
for help.
0 1 2 3 4
23. Privacy is important to me, and I don’t want other people to
know about my problems.
0 1 2 3 4
24. This problem is embarrassing. 0 1 2 3 4
25. I don’t want some stranger touching me in ways I’m not
comfortable with.
0 1 2 3 4
26. I don’t like taking off my clothes in front of other people. 0 1 2 3 4
27. I wouldn’t want someone of the same sex touching my
body.
0 1 2 3 4
28. I don’t like to get emotional about things. 0 1 2 3 4
29. I don’t like to talk about feelings. 0 1 2 3 4
30. I’d rather not show people what I’m feeling. 0 1 2 3 4
31. I wouldn’t want to look stupid for not knowing how to
figure this problem out.
0 1 2 3 4


33

1. Have you ever discussed psychological problems with your family physician?
0  No 1  Yes
2. Have you ever discussed psychological problems with a mental health professional (e.g.
psychologist, psychiatrist,
social worker)?
0  No 1  Yes
3. To your knowledge, has a family member and/or close friend ever seen a mental health
professional (e.g. psychologist,
psychiatrist, social worker) for a psychological concern?
0  No 1  Yes
4. Please circle the number that best reflects your opinion of the following question.
If you have sought mental health treatment in the past, rating on a scale of 0-4, how
helpful did you find these services?
Not at all…………………………………………….0
A little bit……………………………………...........1
Moderately………………………………………….2
Quite a bit…………………………………………...3
Very much…………………………………………...4


34

Inventory of Attitudes Toward Seeking Mental Health Services: Please indicate your
agreement with the following statements. The term Professional refers to individuals who
have been trained to deal with mental health problems (e.g., psychologists, psychiatrists,
and social workers). The term psychological problems refers to the reasons one might
visit a professional. Similar terms include mental health concerns, emotional problems,
mental troubles, and personal difficulties. Your answers will be kept confidential.
Disagree
Somewhat
disagree
Undecided
Somewhat
agree
Agree
1. There are certain problems which should not be
discussed outside of one’s immediate family.
0 1 2 3 4
2. I would have a very good idea of what to do and who to
talk to if I decided to seek professional help for
psychological problems.
0 1 2 3 4
3. I would not want my significant other (spouse, partner,
etc.) to know if I were suffering from psychological
problems.
0 1 2 3 4
4. Keeping one’s mind on a job is a good solution for
avoiding personal worries and concerns.
0 1 2 3 4
5. If good friends asked my advice about a psychological
problem, I might recommend that they see a professional.
0 1 2 3 4
6. Having been mentally ill carries with it a burden of
shame.
0 1 2 3 4
7. It is probably best not to know everything about oneself. 0 1 2 3 4
8. If I were experiencing a serious psychological problem at
this point in my life, I would be confident that I could
find relief in psychotherapy.
0 1 2 3 4
9. People should work out their own problems; getting
professional help should be a last resort.
0 1 2 3 4
10. If I were to experience psychological problems, I could
get professional help if I wanted to.
0 1 2 3 4
11. Important people in my life would think less of me if
they were to find out that I was experiencing
0 1 2 3 4
12. Psychological problems, like many things, tend to work
out by themselves.
0 1 2 3 4
13. It would be relatively easy for me to find the time to see
a professional for psychological problems.
0 1 2 3 4
14. There are experiences in my life that I would not discuss
with anyone.
0 1 2 3 4
15. I would want to get professional help if I were worried or 0 1 2 3 4


35

15. I would want to get professional help if I were worried or
upset for a long period of time.
0 1 2 3 4
16. I would be uncomfortable seeking professional help for
psychological problems because people in my social or
business circles might find out about it.
0 1 2 3 4
Disagree
Somewhat
disagree
Undecided
Somewhat
agree
Agree
17. Having been diagnosed with a mental disorder is a blot
on a person’s life.
0 1 2 3 4
18. There is something admirable in the attitude of people
who are willing to cope with their conflicts and fears
without resorting to professional help.
0 1 2 3 4
19. If I believed I was having a mental breakdown, my first
inclination would be to get professional attention.
0 1 2 3 4
20. I would feel uneasy going to a professional because of
what some people would think.
0 1 2 3 4
21. People with strong characters can get over psychological
problems by themselves and would have little need for
professional help.
0 1 2 3 4
22. I would willingly confide intimate matters to an
appropriate person if I thought it might help me or a
member of my family.
0 1 2 3 4
23. Had I received treatment for psychological problems, I
would not feel that it ought to be “covered up.”
0 1 2 3 4
24. I would be embarrassed if my neighbor saw me going
into the office of a professional who deals with
0 1 2 3 4


36

Childhood Trauma Questionnaire: The following questions ask about some of your
experiences growing up as a child and a teenager. Although these questions are of a
personal nature, please try to answer as honestly as you can. For each question, circle the
response that best describes how you feel. Your answers will be kept confidential.
When I was growing up…
Never
True
Rarely
True
Sometimes
True
Often
True
Very Often
True
1. I didn’t have enough to eat. 0 1 2 3 4
2. I knew there was someone to take care of me and protect me. 0 1 2 3 4
3. People in my family called me things like “stupid,” “lazy,” or “ugly.” 0 1 2 3 4
4. My parents were too drunk or high to take care of the family. 0 1 2 3 4
5. There was someone in my family who helped me feel that I was important or
special.
0 1 2 3 4
6. I had to wear dirty clothes. 0 1 2 3 4
7. I felt loved. 0 1 2 3 4
8. I thought my parents wished I had never been born. 0 1 2 3 4
9. I got hit so hard by someone in my family that I had to see a doctor or go to
the hospital.
0 1 2 3 4
10. There was nothing I wanted to change about my family. 0 1 2 3 4
11. People in my family hit me so hard that it left me with bruises or marks. 0 1 2 3 4
12. I was punished with a belt, a board, a cord, or some other hard object. 0 1 2 3 4
13. People in my family looked out for each other. 0 1 2 3 4
14. People in my family said hurtful or insulting things to me. 0 1 2 3 4
15. I believe that I was physically abused. 0 1 2 3 4
16. I had the perfect childhood. 0 1 2 3 4
17. I got hit or beaten so badly that it was noticed by someone like a teacher,
neighbor, or doctor.
0 1 2 3 4
18. I felt that someone in my family hated me. 0 1 2 3 4
19. People in my family felt close to each other. 0 1 2 3 4
20. Someone tried to touch me in a sexual way, or tried to make me touch them. 0 1 2 3 4
21. Someone threatened to hurt me or tell lies about me unless I did something
sexual with them.
0 1 2 3 4
22. I had the best family in the world. 0 1 2 3 4
23. Someone tried to make me do sexual things or watch sexual things. 0 1 2 3 4
24. Someone molested me. 0 1 2 3 4
25. I believe that I was emotionally abused. 0 1 2 3 4


37

26. There was someone to take me to the doctor if I needed it. 0 1 2 3 4
27. I believe that I was sexually abused. 0 1 2 3 4
28. My family was a source of strength and support. 0 1 2 3 4


38

Patient Health Questionnaire & CAGE Questionnaire: This questionnaire is an important
part of providing you with the best health care possible. Your answers will help in
understanding problems that you may have. Please answer every question to the best of your
ability unless you are requested to skip over a question. Your answers will be kept confidential.
1. During the last 4 weeks, how much have you been
bothered by any of the following problems?
Not
bothered
Bothered a
little
Bothered a
lot
a. Stomach pain 0 1 2
b. Back pain 0 1 2
c. Pain in your arms, legs, or joints (knees, hips, etc.) 0 1 2
d. Menstrual cramps or other problems with your periods 0 1 2
e. Pain or problems during sexual intercourse 0 1 2
f. Headaches 0 1 2
g. Chest pain 0 1 2
h. Dizziness 0 1 2
i. Fainting spells 0 1 2
j. Feeling your heart pound or race 0 1 2
k. Shortness of breath 0 1 2
l. Constipation, loose bowels, or diarrhea 0 1 2
m. Nausea, gas, or indigestion 0 1 2
2. Over the last 2 weeks, how often have you been
bothered by any of the following problems?
Not at
all
Several
days
More
than
half the
days
Nearly
every
day
a. Little interest or pleasure in doing things 0 1 2 3
b. Feeling down, depressed, or hopeless 0 1 2 3
c. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
d. Feeling tired or having little energy 0 1 2 3
e. Poor appetite or overeating 0 1 2 3
f. Feeling bad about yourself – or that you are a failure or
have let yourself or your family down
0 1 2 3
g. Trouble concentrating on things, such as reading the
newspaper or watching television
0 1 2 3
h. Moving or speaking so slowly that other people could
have noticed? Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual
0 1 2 3


39

3. Questions about anxiety No Yes
a. In the last 4 weeks, have you had an anxiety attack – suddenly feeling fear or panic?
If you checked “NO”, go to question #5.
0 1
b. Has this ever happened before? 0 1
c. Do some of these attacks come suddenly out of the blue – that is, in situations
where you don’t expect to be nervous or uncomfortable?
0 1
d. Do these attacks bother you a lot or are you worried about having another attack? 0 1
4. Think about your last bad anxiety attack. No Yes
a. Were you short of breath? 0 1
b. Did your heart race, pound, or skip? 0 1
c. Did you have chest pain or pressure? 0 1
d. Did you sweat? 0 1
e. Did you feel as if you were choking? 0 1
f. Did you have hot flashes or chills? 0 1
g. Did you have nausea or an upset stomach, or the feeling that you were going
to have diarrhea?
0 1
h. Did you feel dizzy, unsteady, or faint? 0 1
i. Did you have tingling or numbness in parts of your body? 0 1
j. Did you tremble or shake? 0 1
k. Were you afraid you were dying? 0 1
5. Over the last 4 weeks, how often have you been bothered by any of the
following problems?
Not
at
all
Several
days
More
than
half
the
days
a. Feeling nervous, anxious, on edge, or worrying a lot about different things
If you checked “Not at all”, go to question #6. 0 1 2
b. Feeling restless so that it is hard to sit still. 0 1 2
c. Getting tired very easily 0 1 2
d. Muscle tension, aches, or soreness 0 1 2
e. Trouble falling asleep or staying asleep 0 1 2
f. Trouble concentrating on things, such as reading a book or watching TV 0 1 2
g. Becoming easily annoyed or irritable 0 1 2


40

6. Questions about eating No Yes
a. Do you often feel that you can’t control what or how much you eat? 0 1
b. Do you often eat, within any 2-hour period, what most people would regard as
an unusually large amount of food?
If you checked “No” to either #a, or #b, go to question #9.
0 1
c. Has this been as often, on average, as twice a week for the last 3 months? 0 1
7. In the last 3 months have you often done any o the following in order to avoid
gaining weight?
No Yes
a. Made yourself vomit? 0 1
b. Took more than twice the recommended dose of laxatives? 0 1
c. Fasted – not eaten anything at all for at least 24 hours? 0 1
d. Exercised for more than an hour specifically to avoid gaining weight after binge
eating?
0 1
No Yes
8. If you checked “YES” to any of these ways of avoiding gaining weight, were any
as often, on average, as twice a week?
0 1
9. CAGE Questionnaire No Yes
a. Have you ever felt you should cut down on your drinking? 0 1
b. Have people annoyed you by criticizing your drinking? 0 1
c. Have you ever felt bad or guilty about your drinking? 0 1
d. Have you ever had a drink first thing in the morning to steady your nerves or get rid
of a hangover?
0 1


41

Not
difficult
at all
Somewhat
difficult
Very
difficult
Extremely
difficult10. If you checked off any problems on this
questionnaire, how difficult have these problems
made it for you to do your work, take care of
things at home, or get along with other people? 0 1 2 3

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