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. Author manuscript; available in PMC: 2023 Oct 1.
Published in final edited form as: J Couns Psychol. 2022 Mar 24;69(5):701–710. doi: 10.1037/cou0000614

The Effects of Group Counseling and Self-Affirmation on Stigma and Group Relationship Development: A Replication and Extension

Andrew J Seidman 1, Nathaniel G Wade 2, Jason Geller 3
PMCID: PMC10037926  NIHMSID: NIHMS1835037  PMID: 35324220

Abstract

The stigma of seeking counseling and negative attitudes about counseling are primary barriers to its use. In the only known study examining the utility of attending a group counseling session to ameliorate stigma (no control group), participation was associated with reductions in self-stigma (Wade et al., 2011). Self-affirmation interventions have shown promising results in reducing stigma and promoting positive expectations about counseling, but no research has examined its effects on a counseling session. In the present, two-part study, 172 college students who had previously completed an online screening survey, including measures of stigma, participated in a single session of group counseling at a mental health clinic. Upon arrival, participants completed a self-affirmation intervention before viewing psychoeducation (n = 66; 12 groups) or only viewed psychoeducation (n = 72; 14 groups); both groups then completed a session of group counseling. After, participants completed these same measures along with measures of group relationships. The remaining participants (n = 34; 7 groups) viewed psychoeducation and completed the same stigma measures before being informed of randomization to the waitlist-control condition. Our results replicate and extend findings from Wade et al. (2011): completing a single session of group counseling reduced self-stigma and promoted positive attitudes toward counseling. Further, completing self-affirmation reduced post-session perceptions of public stigma. Self-affirmation had no impact on group relationships. Overall, findings suggest the utility of offering a “try-out” session of group counseling as a stigma-reduction intervention; preceding with a brief self-affirmation intervention provides further benefits by reducing perceptions of public stigma.

Keywords: group counseling, stigma, self-affirmation, intervention, personal values

Young adults commonly experience psychological problems, but less than one in five seek counseling (National Institute of Mental Health, 2021). The stigmas (public, self) of seeking professional psychological help are a prominent reason (Clement, 2015; Corrigan, 2004; Vogel et al.., 2006; Vogel et al., 2007). Perceptions of public stigma comprise beliefs that others hold negative judgments toward counseling clients, including perceptions of help-seekers as incompetent and undesirable (Komiya et al., 2000). Self-stigma, or internalized stigma, develops when people agree with public stigma and turn those judgments towards oneself: in other words, negative self-judgments regarding a decision to seek help (e.g., “I am incompetent”; Vogel et al., 2006). Stigma is detrimental not only because it exacerbates negative self-judgments associated with having a mental health concern: it deters help-seeking behavior by worsening attitudes and lowering behavioral intentions to seek counseling (Clement, 2015; Vogel et al., 2007)

The consequences of stigma as a barrier to initiating help-seeking are well-known, and there is a complimentary body of research testing efforts to ameliorate its effects. However, despite the significant resources invested into stigma-reduction interventions, many of which include five or more sessions, meta-analyses and literature reviews have described the overall state of the literature as characterized by mixed effects (Mittal et al., 2012; Yanos et al., 2015). Although the success of stigma-reduction interventions relies on several mechanisms of change, a review of the literature clearly implicates one primary reason underlying inconsistent support for their benefits: a reliance on psychoeducation (e.g., information regarding prevalence rates, common reasons for seeking counseling). In an overview of their limitations, Keum et al. (2018, p. 662), describe psychoeducation-based interventions as “too impersonal, structured, and didactic to allow meaningful personally relevant exploration and examination of stigmatizing beliefs and attitudes.”

Consistent with experiential learning theory (Kolb, 1984), stigma-reduction interventions that promote an immersive and interactive experience among group members may offer a more effective pathway toward this goal. Interacting with other help-seekers within a session of group counseling provides an opportunity for “ideas [to be] formed and re-formed through experience… learning is described as a process whereby concepts are derived from and continuously modified by experience” (Kolb, 1984, p. 28). That is, small group-based and experiential interventions, when facilitated by a skilled leader, can help members directly challenge stereotypes of help-seeking in ways that are unlikely to be achieved through primarily didactic interventions (e.g., psychoeducation emphasizing the commonality of mental health concerns). A small amount of research has corroborated their promise. In the first known study to examine how stigma changed as a function of attending a single session of counseling, participating in a 90-minute group was associated with reductions in self-stigma (Wade et al., 2011). Similar effects have been found in role-playing scenarios analogous to counseling, in which students enrolled in a semester-long helping skills course reported lower levels of self-stigma and more positive attitudes toward seeking counseling upon completion (Keum et al., 2018). However, neither of these studies used random assignment, thus limiting causal conclusions.

A second, well-documented reason stigma-reduction interventions are not always beneficial is that they can unintendedly induce psychological reactance, defined as a repertoire of fear-based, defensive responses (e.g., denial, avoidance, derogation) to information perceived as threatening (Hovland, 1963). Indeed, studies have found that these interventions can evoke negative, unanticipated consequences, including increased levels of stigma and worsened attitudes toward seeking psychological help (e.g., Lienemann & Siegel, 2016). By engaging with counseling in any form (e.g., psychoeducation, actual help-seeking), clients must tend to the feelings of threat associated with its stigma.

Although participating in an initial session of counseling appears to reduce stigma (Wade et al., 2011), stigma does not disappear at the therapy door. Stigma is likely especially salient upon beginning counseling, and even more so in group counseling, as clients contemplate disclosing personal problems in the presence of other members. Extant research, albeit limited to individual counseling, has elucidated the potential for the interfering effects of self-stigma during an intake and throughout the treatment process: clients with greater self-stigma report lower perceptions of the working alliance bond and engagement, and, ultimately, worse counseling outcomes (Kendra et al., 2014; Owen et al., 2013). Stigma-based fears are especially salient in group counseling, as potential clients regularly identify fears of self-disclosure, criticism, and an overall mistrust of other members (Shechtman & Kiezel, 2016), which present clear risk to the development of the four therapeutic relationships within group counseling: group cohesion, group engagement, working alliance-bond, and counselor empathy (see Johnson et al., 2005).

Self-Affirmation

According to self-affirmation theory, people are motivated to maintain positive self-perceptions, including judgments of oneself as stable, competent, and in control (Steele, 1988). Due to the prominent stigmas associated with seeking counseling, a behavior which is generally perceived as inconsistent with competence and self-control, psychoeducation commonly elicits a threat response: when viewing information about mental health, people commonly engage in avoidance-like behaviors, in which they minimize and derogate the content. At the same time, self-affirmation theory offers an intervention component to help restrain this threat response. During a self-affirmation intervention, participants rank-order the centrality and importance of personal values and their corresponding character strengths (e.g., curiosity, kindness, love) and then write about how their “top” value has provided them meaning in life (McQueen & Klein, 2006). Through this process, self-affirmation promotes a strengthening of self-perceptions, including a broader sense-of-self and increase in self-esteem, which may explain its utility to alleviate negative reactions to psychoeducation (McQueen & Klein, 2006; Steele, 1988).

Applied to counseling, self-affirmation offers a brief, feasible, and effective means toward reducing stigma and improving attitudes. For example, completing a self-affirmation intervention is associated with reductions in self-stigma (Lannin et al., 2013) and increases in positive beliefs and intentions to seek counseling (Lannin et al., 2017; Seidman et al., 2018). Furthermore, completing self-affirmation immediately before attending a counseling intake session is associated with reductions in self-stigma, and through the indirect effect of reductions in self-stigma, self-affirmed participants reported more favorable expectations about self-disclosure in the upcoming session (Seidman et al., 2019). However, despite growing evidence that self-affirmation offers potential clients a less threatening experience of seeking counseling - and thus, possibly a more favorable experience of counseling itself – there is no known research examining its effects after attending counseling, which precludes an understanding of its impact on an actual session experience and help-seeking constructs important for continued use of counseling.

Attending a single session of group counseling has been associated with reductions in self-stigma (Wade et al., 2011), but it is important to find ways to further attenuate its presence. First, not all research has found this effect: in the only other known study which measured changes in self-stigma throughout counseling, levels of self-stigma remained stable among a sample of clients seeking individual counseling, implicating it as a continued barrier to the therapeutic process (Kendra et al., 2014). Second, its reduction is not equivalent to its elimination; evidence for the former indicates the utility of an intervention in alleviating some degree of stigma, but its residual presence deserves further attention. Thus, it would be beneficial to examine ways to incorporate other brief interventions (i.e., self-affirmation) to examine synergistic effects toward its further attenuation.

During group counseling, interactions among members and with the counselor comprise the primary therapeutic relationships; when rated as positive, these relationships promote continued help-seeking behavior (e.g., Johnson et al., 2005; Yalom & Leszcz, 2005). However, upon entering a group, the fears associated with developing relational bonds are heightened, and potential clients regularly identify fears of criticism, self-disclosure, and an overall mistrust of other members (Shechtman & Kiezel, 2016). Fortunately, self-affirmation may offer an antidote to these concerns; beyond its documented effects on stigma and other attitudinal constructs related to help-seeking, there is reason to expect that self-affirmation might also facilitate a positive experience of an actual group counseling session, further reductions in stigma, and improvements in help-seeking attitudes and intentions. Research has found self-affirmation to promote positive, other-directed feelings including empathy and social connectedness, and reduce the downplaying of others’ misfortunes; these findings have been interpreted as a reflection of the utility of self-affirmation to increase openness to others (Crocker et al., 2008; Kim & McGill, 2018). More, its effects are not limited to feeling states: self-affirming has been found to facilitate communication and helping behaviors, including assisting a person in distress (Kim & McGill, 2018; Lindsay et al., 2014).

Self-affirmation, when completed before group counseling, may work by promoting openness to others, which could underlie positive effects on the development of counseling relationships. For example, during an initial meeting, increased self-disclosure is associated with higher ratings of the working alliance (Nakash et al., 2015). In group, “here-and-now” disclosures are a primary predictor of cohesion ratings (Slavin, 1993). Finding ways to facilitate client openness is especially important among college students, as few will have experience in disclosing here-and-now reactions (Johnson, 2009). Thus, self-affirming prior to group counseling may offer benefits by promoting openness to developing therapeutic relationships with other members and the group leader (e.g., through increased self-disclosure, attentiveness to other members), leading to heightened perceptions of group cohesion, group engagement, working alliance-bond, and counselor empathy. More, these effects may extend to related help-seeking constructs, including reduced stigma (public, self), improved attitudes, and higher intentions to seek counseling.

Overview of the Present Study

Prior research from Wade et al. (2011) has demonstrated the utility of a single group counseling session in reducing self-stigma, but their omission of a control group confounds group effects with time. Therefore, a primary goal of the current study is to replicate and extend upon these findings by examining the effects of a group session compared with a group waitlist condition, as well as testing its effects on other help-seeking variables (i.e., public stigma, attitudes, intentions). We hypothesized that, after completing a group session, participants would report lower levels of help-seeking stigmas (public, self) and improved attitudes and intentions toward counseling. Another primary goal is to examine the potential additive benefits of self-affirming immediately prior to a group counseling session. We hypothesized that participants who completed a self-affirmation intervention prior to a group session would report lower stigma (public, self), improved attitudes, and increased intentions toward counseling (compared to those in the group-only condition). Finally, we hypothesized that self-affirmed participants would report more favorable perceptions of the working alliance-bond, group cohesion, engagement, and counselor empathy. As an exploratory aim, we tested predictors of post-group help-seeking intentions.

Method

Participants

The present sample includes college students at a large Midwestern university (N = 172; Mage = 19.19, SD = 2.41, Range = 18 – 43) randomized to 33 groups. There were 72 participants in the group-only condition (14 groups), 66 participants in the self-affirmation plus group condition (12 groups), and 34 participants in the group-waitlist condition (7 groups). The average group consisted of 5.2 participants (SD = 1.5, Range = 3 – 8). Participants self-identified as female (68.6%), male (29.7%), or did not report their gender (1.7%). The racial and ethnic make-up of the present sample was predominantly White (87.6%), followed by Hispanic or Latinx (4.7%), Asian or Pacific Islander (3.5%), other (2.3%), Black (1.7%), or did not self-identity (1.7%). Participants were primarily heterosexual (87.2%) or identified as bisexual (5.8%), gay or lesbian (2.9%), or other-identified (1.7%). Consistent with a nationally representative sample of college students (Lipson et al., 2019), 31% of the sample had previous counseling experience. The majority (90%) had never attended group counseling. There were no differences in demographic variables across groups.

Procedures

Time 1.

Upon receiving Institutional Review Board approval for the project, we used SONA, a campus research database, to recruit undergraduate students enrolled in introductory courses in psychology and communications studies in exchange for course credit. The study was listed as “A Group Counseling Experience.” After providing informed consent using Qualtrics, participants were asked to sign up for a two-hour timeslot for the second part of the study in the following two weeks, which took place at a university-based mental health clinic and research lab. Participants were informed of the potential to be randomized to participate in a 75-minute session of group counseling upon arrival. Groups were closed when eight members registered; if a group had less than three people, participants were asked to reschedule. Participants completed a series of measures assessing help-seeking, including public and self-stigma, attitudes, and intentions.

Time 2.

We pre-randomized groups to one of three conditions by using a random number generator ranging from 1–5 (Random.org): 1) group-only, 2) self-affirmation plus group counseling, and 3) waitlist. To increase sample size within our intervention conditions, we purposively over-assigned participants to the group conditions by assigning two numbers to each group counseling condition, and one for the waitlist (40%, 40%, 20%).

Upon arrival and regardless of condition (i.e., group vs. waitlist), a research assistant escorted participants to a counseling room with chairs arranged in a circle, including one reserved for the group counselor. In the self-affirmation condition, participants completed a series of pen-and-paper tasks rank-ordering the personal importance of values and character strengths derived from the Values in Action Inventory (Peterson & Seligman, 2004). Upon choosing their most important value, participants were asked to write for seven minutes about how it brings purpose to their life and engenders feelings of pride; they were asked not to proceed to the next task until the seven minutes were up to ensure equivalent “dosing.” Upon completion, participants read a psychoeducational brochure to prepare them for the process group, which was also read by participants in the group-only and waitlist conditions. The brochure described the group as space for members to “learn how they interact with others, and how these patterns of interaction help and/or hurt their relationships”; it emphasized that members would primarily interact with each other (as opposed to with the counselor) and the importance of providing and receiving feedback. For those randomized to complete a counseling session, the group counselor entered the room and began after members had read the brochure. Participants in the waitlist condition completed a series of help-seeking measures (stigma, attitudes, intentions) before being informed of their waitlist randomization and then debriefed.

Group sessions and counselors.

Sessions were 75-minutes and led by doctoral students in Counseling Psychology enrolled in an advanced group practicum (n = 4; three female and one male). Group counselors identified as Asian American (n = 1), Latin American (n = 1), or European American (n = 2). All counselors adhered to an interpersonal process orientation (Yalom & Leszcz, 2005) and received weekly supervision from a licensed psychologist who is also a certified group psychotherapist. Group sessions followed a semi-structured format: counselors began each session discussing privacy and confidentiality before teaching briefly about the role of the “here-and-now”; then, members were asked to disclose current levels of anxiety on a scale of 1–10. Discussion ensued; common self-disclosure by group members pertained to difficulties in college (e.g., grades, homesickness), loneliness and struggles with making friends, issues in romantic and friend relationships, and grief. Consistent with the interpersonal process model, counselor interventions focused on promoting member-member interactions and processing of member disclosures. When there were 10 minutes left, counselors began a check-out process in which members were asked to reflect on their experience of the session. Then, the counselor left the room, at which point the research assistant returned with post-session surveys, which included ratings of group relationships and the same measures of stigma, attitudes, and intentions. Upon completion, all participants were debriefed and provided with information about local counseling resources.

Measures

Public stigma.

The Stigma Scale for Receiving Psychological Help (SSRPH; Komiya, Good, & Sherrod, 2000) is a five-item scale which measures perceptions of public stigma towards individuals who seek counseling. A sample item is: “People tend to like less those who are receiving professional psychological help.” Items are rated on a 4-point Likert scale (0 = Strongly Disagree, 3 = Strongly Agree). Higher scores indicate more perceived public stigma. Research has provided evidence for its reliability (Cronbach’s α = 0.72; Komiya et al., 2000). Internal consistency in this sample was adequate at both timepoints (α’s = 0.77 – 0.79).

Self-stigma.

The Self-Stigma of Seeking Help scale (SSOSH; Vogel et al., 2006) is a ten-item scale which measures internalized stigma for seeking professional psychological help. A sample item is: “Seeking psychological help would make me feel less intelligent.” Items are rated on a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree). Higher mean scores indicate a stronger degree of self-stigma. It has strong psychometric qualities, including internal consistency (α = 0.91) and 2-month test-retest reliability (r = .72; Vogel et al., 2006). Internal consistency for the current sample was α = 0.85 at both timepoints.

Help-seeking attitudes.

The Mental Help Seeking Attitudes Scale (MHSAS; Hammer et al., 2018) is a nine-item measure of attitudes towards counseling. The question stem is: “If I had a mental health concern, seeking help from a mental health professional would be...”. Items are rated using a semantic differential scale on a 7-point Likert scale from −3 to 3, with 0 representing “undecided.” Sample items are “useless-useful” and “healing-hurting”. Participants mark the circle that represents their opinion (e.g., if they thought seeking help would be extremely useless, they would mark the “3” circle closest to “useless.”). Per author instructions, we recoded responses into a ‘1’ to ‘7’ scale. All five positive-negative directionally-valenced items (i.e., healing-hurting) are reverse-scored, so that a “1” becomes a “7.” Higher scores suggest more positive attitudes. The MHSAS has demonstrated reliability across samples (α = 0.93 – 0.94) and incremental validity to predict variance in help-seeking intentions beyond that accounted for by other popular help-seeking measures (Hammer et al., 2018). Internal consistency for the current sample was strong at both timepoints (α = 0.88 – 0.89).

Help-seeking intentions.

The Mental Help Seeking Intentions Scale (MHSIS; Hammer & Vogel, 2013) is a three-item scale which measures intentions to seek professional psychological help. The question stem reads “If I had a mental health concern…” and examines the degree to which a person would try, intend, and plan to seek counseling. Items are rated on a 7-point Likert scale (i.e., intend, 1 = Extremely unlikely, 7 = Extremely likely; try, 1 = Definitely false, 7 = Definitely true; plan, 1 = Strongly disagree, 7 = Strongly agree). Higher scores indicate more intentions to seek help. The MHSIS has documented reliability (α = 0.94; Hammer & Vogel, 2013). Internal consistency was strong at both timepoints (α = 0.93 – 0.94).

Cohesion.

The seven-item Group Environment Scale (GES; Wilson et al., 2008) was used to measure ratings of group cohesion. The original scale is eight items; we removed the item “The group is a good place to make friends”, as counselors informed members of session boundaries. A sample item is “Group members feel a sense of belongingness to the group.” Items are rated using a 4-point Likert scale (0 = Strongly disagree, 3 = Strongly agree). Higher mean scores suggest increased perceptions of cohesion. The GES has demonstrated reliability (α = 0.87; Wilson et al., 2008). Internal consistency for the current sample was α = 0.81.

Engagement.

The five-item Group Climate Questionnaire – Engagement subscale (GCQ-E; MacKenzie, 1981) was used to measure perceptions of engagement during the group counseling session. A sample item is “The members felt what was happening was important and there was a sense of participation.” Participants rated their agreement using a 7-point Likert scale (0 = Not at all, 6 = Extremely). Higher mean scores indicate more favorable perceptions of engagement. Research has provided evidence of strong internal reliability (Cronbach’s α = 0.94; Johnson et al., 2005). Internal consistency for the current sample was α = 0.73.

Working alliance - bond.

The four-item Bond subscale from the Working Alliance Inventory–Short Form (WAI-S; Tracey & Kokotovic, 1989) was used to measure perceptions of bond with the group counselor. In the present study, “therapist” was changed to “group leader.” A sample item is “I feel that the group leader appreciated me.” Items are rated using a 7-point Likert scale (1 = Strongly Disagree, 7 = Strongly Agree). The use of the bond subscale after a one-time group session has demonstrated reliability (α = 0.86; Wade et al., 2011). Internal consistency for the current sample was α = 0.86.

Empathy.

The 16-item Empathic Understanding subscale from the Barrett-Lennard Relationship Inventory (BLRI; Barrett-Lennard, 1962) was used to measure client perceptions of the group counselor’s empathy. A sample item is “My therapist always knows exactly what I mean.” For this study, items were reworded to reflect perceptions of a single session (e.g., “The group leader seemed to always know exactly what I meant”). Items are rated on a 6-point Likert scale (−3 = No, I feel that it is probably untrue, or more untrue than true, 3 = Yes, I strongly feel that it is true); there is no zero (i.e., neutral) point. Eight items are reverse-scored, and higher mean scores suggest more perceived empathy. Additionally, because it is likely the counselor did not interact with all clients equally, participants were given a response option of “not applicable”. In a review of 24 reliability studies, internal consistency for the Empathic Understanding subscale was α = 0.84 (Gurman, 1977). Internal consistency for the current sample was α = 0.80.

Data Analytic Plan

Data were analyzed using R Version 4.1.2 and multilevel models were fit using the lme4 statistical package (Bates et al., 2015). An alpha level of .05 for all was maintained for all statistical tests performed herein and the p values for multilevel models were adjusted using a false discovery rate correction (Jafari & Ansari-Pour, 2019). In all models, we included a random intercept for the group to account for its effect on outcome variance as indexed by the intraclass correlation coefficient (N = 33 groups).1 The ICC range was 0.00 – 0.30. We kept the group term in the equation, even when ICC < .1 to reduce the likelihood of Type 1 and Type 2 errors (Baldwin et al., 2005).2 Consistent with recommendations from McNeish & Stapleton (2016), we also included group counselor as a fixed effect; we did not model random effects due to the small sample size (n = 4). We removed the therapist effect from our final models as it was not significant for any of the outcomes (p’sadj: .37-.81).

Aim 1:

To test for post-group differences in help-seeking variables (public stigma, self-stigma, attitudes, intentions), we fit a series of multilevel models. The independent variables were the fixed effect of the grand-mean centered variable at Time 1 and group condition (group vs. waitlist), with the latter as the reference group.

Aim 2:

To test the effects of self-affirmation (vs. group-only) on help-seeking variables, we fit another series of multilevel models. Independent variables included the fixed effect of the grand-mean centered variable at Time 1 and group condition (self-affirmation vs. group-only), with the latter as the reference group.

Aim 3:

To test the effects of self-affirmation (vs. group-only) on group relationships (cohesion, engagement, bond, empathy), we fit another series of multilevel models. Independent variables included group condition (self-affirmation vs. group-only), with the latter as the reference group. Group size was included as a covariate.

Exploratory analysis:

We were interested in examining which variables predicted intentions to seek further counseling after completing group. To do so, we fit a multilevel model testing group condition (self-affirmation vs. group-only), Time 2 stigma (public, self), attitudes, cohesion, engagement, working alliance-bond, and empathy.

Results

Descriptive Analyses

The means, standard deviations, and correlations among study variables, grouped by condition, are available in Tables 1 and 2. We conducted a Multivariate Analysis of Variance (MANOVA) to examine Time 1 differences on help-seeking variables between participants in the three group conditions, F(8, 326) = 2.12, Wilk’s λ = 0.90, p = .03. Post-hoc analysis using Bonferroni’s Correction revealed a difference in public stigma at Time 1, with participants randomized to self-affirmation reporting lower levels compared to the waitlist condition, Mdiff = −0.38, SE = .11, p = .02, 95% CI [−.72, −.04]. No other differences were observed. We also used a Chi-square analysis to examine if the proportion of participants with a help-seeking history was equal across groups; results indicated no differences, χ2 = 1.03, p = .59.

Table 1.

Bivariate Correlations, Means, and Standard Deviations for Self-Affirmation and Group-Only.

Measure 1 2 3 4 5 6 7 8 9 10 11 12
1. Public stigma, T1 - .49*** −.32** −.19 .63*** .53*** −.16 −.30* −.12 −.00 −.17 −.07
2. Self-stigma, T1 .47*** - −.60*** −.60*** .48*** .76*** −.34** −.47*** −.09 .09 −.22 −.17
3. Attitudes, T1 −.55*** −.60*** - .67*** −.34** −.47*** .50*** .46*** .15 .10 .42*** .34**
4. Intentions, T1 −.30* −.50*** .54*** - −.22 −.58*** .37** .73*** .02 .06 .24* .19
5. Public stigma, T2 .73*** .38** −.56*** −.33** - .46*** −.34** −.31** −.22 −.05 −.24* −.16
6. Self-stigma, T2 .40** .76*** −.50*** −.36** .41*** - −.45*** −.66*** −.25* −.05 −.33** −.34**
7. Attitudes, T2 −.40*** −.46*** .46*** .21 −.35** −.63*** - .48*** .32** .20 .55*** .43***
8. Intentions, T2 −.32** −.46*** .46*** .70*** −.48*** −.43*** .41*** - .25* .25* .41*** .33**
9. Cohesion −.21 −.15 .32** .05 −.22 −.32* .44*** .22 - .63*** .42*** .34**
10. Engagement −.14 −.13 .12 −.05 −.14 −.18 .30* .17 .59*** - .31** .28*
11. Working alliance-bond −.31* −.24 .27* .14 −.25* −.44*** .46*** .35** .41*** .41*** - .58***
12. Empathy −.12 −.16 .24 .20 −.11 −.29** .34** .33** .34** .14 .68*** -
Self-affirmation + group
 M 0.94 2.44 5.82 4.59 0.95 2.15 6.11 5.12 2.45 4.22 5.78 1.56
 SD 0.65 0.71 0.92 1.59 0.60 0.67 0.82 1.44 0.38 0.97 0.96 0.69
Group-only
 M 1.13 2.62 5.89 4.77 1.26 2.23 6.10 5.12 2.48 4.14 5.92 1.60
 SD 0.71 0.71 0.90 1.63 0.65 0.70 0.92 1.57 0.38 0.76 0.82 0.68
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Note. Self-affirmation plus group (below the diagonal) (N = 66); Group-only (above the diagonal) (N = 72).

*

p < .05,

**

p < .01,

***

p < .001.

Table 2.

Bivariate Correlations, Means, and Standard Deviations for Group Waitlist condition.

Measure 1 2 3 4 5 6 7 8
1. Public stigma, T1 -
2. Self-stigma, T1 .32 -
3. Attitudes, T1 .23 −.30 -
4. Intentions, T1 −.37* −.56*** .13 -
5. Public stigma, T2 .58*** .40* −.03 −.30 -
6. Self-stigma, T2 .34 .67*** −.25 −.67*** .34 -
7. Attitudes, T2 .14 −.20 .52** .16 −.06 −.43* -
8. Intentions, T2 −.12 −.39* .10 .68*** .05 −.63*** .19 -
Group Waitlist
 M 1.32 2.54 6.06 4.66 1.27 2.49 5.69 4.73
 SD 0.58 0.65 0.70 1.75 0.52 0.59 0.95 1.48
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Note. N = 34. p < .05,

**

p < .01,

***

p < .001.

Aim 1: Group Versus No-Group

Public stigma.

Time 1 public stigma predicted Time 2 public stigma, γ00 = 0.63, padj = .002, 95% CI = [.52, .73]. However, completing a session of group counseling did not change perceptions of public stigma, γ00 = −.00, padj = .99, 95% CI = [−0.20, 0.19].

Self-stigma.

Time 1 self-stigma predicted Time 2 self-stigma, γ00 = 0.70, padj = .002, 95% CI = [0.61, 0.80]. Completing a group counseling session led to lower levels of self-stigma, γ00 = −0.26, padj = .007, 95% CI = [−0.43, 0.09].

Attitudes toward Seeking Help.

Time 1 attitudes predicted Time 2 attitudes, γ00 = 0.49, padj = .002, 95% CI = [0.35, 0.63]. Completing a group session promoted more positive attitudes toward counseling, γ00 = 0.50, padj = .002, 95% CI = [0.20, 0.81].

Help-seeking intentions.

Time 1 predicted Time 2 intentions, γ00 = 0.64, padj = .002, 95% CI = [0.54, 0.74]. Completing a group session had no effect on intentions to seek psychological help, γ00 = 0.29, padj = .31, 95% CI = [−0.14, 0.72].

Aim 2: Self-Affirmation vs. Group-Only on Help-Seeking Outcomes

Public stigma.

Time 1 public stigma predicted Time 2 public stigma, γ00 = 0.63, padj = .002, 95% CI = [0.51, 0.74] Self-affirmed participants reported lower perceptions of public stigma after the group session compared with those who attended group without self-affirmation, γ00 = −0.20, padj = 0.031, 95% CI = [−0.36, −0.04].

Self-stigma.

Time 1 self-stigma predicted Time 2 self-stigma, γ00 = 0.73, padj = .002, 95% CI = [0.62, 0.84]. There was no difference in self-stigma between those who self-affirmed prior to the group session and those who did not, γ00 = 0.04, padj = .78, 95% CI = [−0.12, 0.19].

Attitudes toward Seeking Help.

Time 1 attitudes predicted Time 2 attitudes, γ00 = 0.46, padj= .002, 95% CI = [0.31, 0.60]. There was no difference in attitudes between those who completed self-affirmation and those who did not, γ00 = 0.06, padj = .78, 95% CI [−0.23, 0.36].

Help-seeking intentions.

Time 1 predicted Time 2 intentions, γ00 = 0.67, padj = .002, 95% CI = [0.56, 0.78]. Completing a self-affirmation had no effect on intentions to seek help, γ00 = 0.13, padj =.72, 95% CI = [−0.26, 0.52].

Aim 3: Self-Affirmation vs. Group-Only on Group Relationships

Self-affirmation had no effect on perceptions of group cohesion (γ00 = −0.03, padj = .78, 95% CI [−0.17, 0.12]), engagement (γ00 = 0.14, padj = .72, 95% CI [−0.31, 0.59]), the working alliance-bond (γ00 = −0.09, padj = .78, 95% CI = [−0.47, 0.29]), nor counselor empathy (γ00 = 0.04, padj = .78, 95% CI [−0.28, 0.19]). Furthermore, group size was not related with any outcomes.

Exploratory Analysis: Predictors of Post-Session Intentions to Seek Counseling

Time 2 intentions were predicted by intentions at Time 1, γ00 = 0.54, padj = .002, 95% CI = [0.43, 0.66]. Among the remaining variables, public stigma explained further unique variance in post-group levels of intentions to seek counseling, γ00 = −0.32, padj = .043, 95% CI = [−0.60, −0.03]. There was a trend effect for group engagement, γ00 = 0.28, padj = .051, 95% CI = [0.04 – 0.52].

Discussion

The present study had two primary aims. First, we sought to replicate and extend upon previous findings from Wade et al. (2011) that participating in a single session of group counseling is associated with reductions in self-stigma. In the present study, which included a waitlist-control condition, completing a group session was found to have a causal role in reducing self-stigma and improving attitudes toward counseling. Second, we aimed to provide the first test of the utility of a self-affirmation intervention prior to a single session of group counseling. Self-affirmed participants reported lower perceptions of public stigma after the group than those who attended group “as usual”; no other differences were found on help-seeking variables nor on perceptions of group relationships.

In the present study, completing a single session of group counseling caused reductions in self-stigma and improvements in positive attitudes toward counseling. Our results replicate and extend upon previous findings from Wade et al. (2011) by including a control condition and documenting a change in attitudes. It is likely that attendance provided members with an experiential learning opportunity to directly challenge perceptions of the self-stigma associated with help-seeking, as they perceived that they can still maintain a positive sense-of-self despite seeking counseling (Kolb, 1984). Furthermore, the change in attitudes can be explained by a similar process: by seeking counseling, members also were able to more accurately discern its potential benefits. Thus, the present study finds further support for the utility of a “try-out” session of group counseling as a stigma-reduction intervention.

Our findings provide modest support for the benefit of preceding a counseling session with a brief, self-affirmation intervention as a “waiting room” intervention. Self-affirmed participants reported lower perceptions of public stigma compared with those who completed group “as usual,” but did not experience parallel decreases in self-stigma nor improvements in attitudes or intentions. Our findings regarding the ameliorative effects of self-affirmation on perceptions of public stigma may be explained by its effects on prosociality (Crocker et al., 2008; Lindsay et al., 2014). By reflecting on the importance of personal values and developing positive, other-directed feelings and thoughts, group members may have experienced more compassion directed toward others for seeking counseling, thereby alleviating perceptions of negative beliefs other members may endorse. The lack of change among other help-seeking outcomes may be attributed to their orientation; that is, self-stigma, attitudes, and intentions capture personal beliefs, while public stigma reflects perceptions of other’s judgments. Thus, self-affirmation may be most beneficial in alleviating concerns of how clients may be viewed by other group members, but less impactful on judgments regarding oneself and help-seeking.

Our study provides the first known test for the benefits of completing a self-affirmation intervention on client perceptions of counseling relationships within a session. In the present study, we did not find evidence for its utility to improve ratings of the working alliance-bond, group cohesion, engagement, or perceptions of counselor empathy. There is only one other study which tested the benefits of self-affirming prior to a counseling session and suggested its utility to reduce self-stigma and increase positive expectations about counseling, but it did not examine its effects on the session itself (Seidman et al., 2019). There are two likely explanations for the findings from the present study: one conceptual and one statistical. Group interactions are complex, dynamic, and occur across levels of relationships (i.e., member-member; member-counselor; group-as-a-whole; Johnson et al., 2005). Even if self-affirmed group members were temporarily bolstered in their sense-of-self and thus more ‘equipped’ (vs. non-affirmed members) to engage in the counseling process, its effects may wash out in the context of within-session dynamics, which are dependent on the actions and interactions of all the group members and its leader. Another explanation involves statistical power. Using a sensitivity analysis, which allowed us to determine the smallest effect size we could observe with 80% power, the present study can start detecting effects at d = .45; only medium-large effects could be detected. Therefore, it is possible that self-affirmation does promote the development of group relationships, but its effect was unable to be detected within smaller sample sizes. Even a small effect might be worthwhile given how easy and accessible self-affirmation interventions are. Given this, it may be worthwhile to conduct further research with a larger sample.

Implications for Counseling

The present study suggests the feasibility of offering “try-out” group counseling sessions to reduce stigma and promote positive attitudes toward seeking psychological help. That no participants discontinued their participation during the counseling session nor reported adverse events suggests it is a low-commitment and low-risk intervention among college students. The test of this intervention in the current study dovetails with an increased effort by universities to offer drop-in mental health services (e.g., “Let’s Talk”) and a simultaneous emphasis on promoting the use of group counseling (Center for Collegiate Mental Health, 2021). These interventions, by offering members a positive “first-contact” experience, seem to show promise in getting clients in the door and to continue with counseling. One important consideration involves how to reach individuals with traditionally higher levels of stigma who are unlikely to participate in a “try-out” session. Effective strategies include the use of community partnerships to identify trusted organizations and individuals who can promote these services; doing so can help identify relevant needs and the appropriate format of counseling (e.g., tailored psychoeducational group vs. interpersonal process); it will also be important to be flexible with the format of service delivery (e.g., telehealth for those without a nearby provider) (see Flanagan & Hancock, 2010). Furthermore, if counselors were to offer one-time sessions in a group format, it will be important that potential members be screened for difficulties which might be contraindicated for a process-oriented group, including participants with suicidal concerns or notable personality pathology (Yalom & Leszcz, 2005). Previous research which examines strategies to prepare clients for counseling has provided a wealth of conceptual and practical considerations (for a review, see Walitzer et al., 1999).

The present findings provide modest support for the benefits of completing a self-affirmation intervention prior to counseling. Still, it is a feasible intervention that can provide counselors with an early understanding of a client’s values and character strengths. By integrating its use into counseling, for example, as a waiting room intervention prior to an intake or as part of an assessment battery, counselors can readily assess a client’s personal values. This is important as values are related but distinct from personality constructs (for a meta-analysis, see Parks-Leduc et al., 2015). Further, many people seek counseling (explicitly or implicitly) for what can be described as a value-based problem, including distress caused by limited clarity, or a misalignment between personal values and behavior (e.g., Rokeach & Regan, 1980). Therefore, self-affirmation offers potential benefits to both counselors and clients with little extra burden.

In our exploratory analyses of predictors of post-group help-seeking intentions, only perceptions of public stigma emerged as significant (and group engagement at the trend-level) - and did so in expected directions. Therefore, the present findings indicate the need to attend to client’s fears of stigmatization from others while beginning counseling when it may be most salient. While research has found self-stigma to mediate the relationship between public stigma and help-seeking intentions (e.g., Vogel et al., 2007), public stigma still presents a formidable barrier to counseling use. That self-affirmation had an ameliorative effect on perceptions of public stigma (compared with group “as usual”) further indicates its use when beginning counseling.

The trend-level relationship between perceptions of group engagement and future help-seeking intentions corroborates the importance for group counselors, immediately upon forming a group, to focus on promoting a welcoming and engaging climate. Naturally, the four primary group relationships are conceptually and empirically linked (e.g., Johnson, 2005; McClendon & Burlingame, 2011); in the current study, they were also significantly correlated (r ‘s = 0.20 – 42). Thus, attending to engagement should enhance cohesion, while also providing counselors an opportunity to develop working alliance-bonds via empathic helping skills.

Limitations and Future Directions

Although 67% of participants who attended the second part of the study (which included the group counseling session) indicated they were experiencing mental health problems and wanted to try out group, the present study included a convenience sample of college students. Additionally, the sample was predominantly White, female, and heterosexual. Group composition is inextricably linked to its unique experience, and the degree to which people hold help-seeking stigmas, attitudes, and intentions - as well as perceptions and experiences of counseling - can differ across a diverse array of identities, including race/ethnicity, gender, and sexual orientation (e.g., Corrigan, 2004; Kivlighan et al., 2021). Thus, further work is needed to test the utility of a “try-out” group counseling session with more diverse samples. Future research could also test the effect of themed group sessions, including those more targeted toward problems common among specific populations or problem areas.

Conclusion

Counseling is an effective treatment for mental health concerns, but its associated stigmas and negative attitudes comprise a substantial barrier to its use. Stigma-reduction interventions have demonstrated mixed efficacy, and one reason may be their emphasis on psychoeducation, which can elicit defensive reactions. Self-affirmation interventions have shown promise in ameliorating this response, reducing stigma, and promoting positive attitudes and intentions toward counseling. Our results suggest the utility of a one-time group counseling session as a feasible and effective stigma-reduction intervention. Furthermore, self-affirming prior to group decreased perceptions of public stigma compared with attending group “as usual” but did not impact judgments of group relationships. Offering “try-out” groups preceded with a self-affirmation intervention provides counselors a way to offer potential clients a positive, first-contact experience which may sustain future help-seeking behavior.

Public Significance Statement:

Attending a single “try-out” session of group counseling is an effective stigma-reduction intervention. Further, preceding with a self-affirmation intervention decreased perceptions of public stigma beyond the effects of attending group “as usual.”

Acknowledgments

This study was conducted for a dissertation project. Andrew Seidman was supported by NIMH grant T32 MH #08159 during manuscript preparation.

Data from this study were presented as a poster at the annual American Psychological Association meeting in August 2020.

Data and study analysis code are available on OSF at https://osf.io/zkyb8/. This study was not pre-registered.

Footnotes

There are no conflicts of interest to disclose.

1

Random slope models for time and condition did not converge.

2

When ICC was < 0.1, all models were re-run without the nested group term. There were no changes in findings.

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