I am a mental illness and help-seeking stigma researcher and yet, somehow, I have severe internalized stigma of mental illness as measured by the 9-item short form of the Internalized Stigma of Mental Illness Scale (ISMI-9). I began studying mental illness and help-seeking stigma because I witnessed it. I continued studying it, more passionately, because I experienced it. But nothing could have prepared me to learn that I had internalized the stigma of mental illness to that degree. It led me to contemplate the process by which I had done so, and I concluded that it was not by believing some disembodied stereotypes about people with mental illness, it was a result of instance after instance of negative treatment due to my severe mental illness. In this first-person narrative, I describe several significant examples of such in my life, tying them back to the process of developing severe internalized stigma of mental illness. I offer this first-person narrative not out of some grandiose notion that I am special, but rather for the specific reason that I doubt I am the only one. In this work, I hope to give ear to an underrepresented voice in stigma research-the voice of those who are suffering.

While mental health stigma is a burgeoning field of research, little work has been done on whether mental health stigma in different subcultures is the same or different as the general population. There is qualitative evidence that beliefs about the etiology and effective treatments for mental illness differ in religious communities as compared to the general population, but efforts to quantify this difference have been sparse and reflect poor methodology. The purpose of the present study is to create and validate a measure of mental health stigma in religious communities. Items will be generated using extant literature and revised after expert review and piloting. In Study 1, the items were tested with 703 undergraduate students at a large Midwestern university. Exploratory Factor Analysis was then used to determine a factor structure with good fitting items. In Study 2, items were retested with a second sample of undergraduate students at the same university, to conduct a Confirmatory Factor Analysis, to cross-validate the scale, and to measure convergent and discriminate validity using several scales measuring related constructs. The outcome is a psychometrically strong, valid self-report instrument to measure mental health stigma in religious communities. 1 CHAPTER 1. OVERVIEW A Surgeon General report named mental illness stigma "the most formidable obstacle to future progress in the arena of mental illness and health" (Abdullah & Brown, 2011; U.S. Department of Health and Human Services, 1999). Considering that one epidemiological study, the National Comorbidity Survey-Revised (NCS-R), estimated that 26.2% of adult Americans have a diagnosable mental illness in a given year, this stigma has significant impact on the health of Americans (Kessler, Chiu, Demler, & Walters, 2005). In a given year at most one-third of those with a diagnosable mental disorder will seek treatment from a mental health professional (Bathje & Pryor, 2011). While approximately 80% of all people with a mental disorder eventually seek treatment, the median delay between first onset of the disorder and first treatment contact is nearly ten years (Wang, Berglund, Olfson, & Kessler, 2004). Many factors contribute to this finding, but mental health stigma is one of the most powerful factors (Bathje &

Although research on the stigma associated with mental health care has grown substantially in the last decade, most of this work focuses on outpatient treatment; recent research on the stigma associated with inpatient treatment is strikingly absent. In this study, we examined the stigma of seeking professional psychological help from outpatient and inpatient treatment settings. College students (N = 350) at a large, Midwestern university completed three commonly used mental health stigma scales which we modified to reflect either outpatient stigma or inpatient stigma. Overall, participants’ ratings on inpatient and outpatient stigma were significantly different (partial η2 = .39). Compared to outpatient treatment, participants reported significantly greater public stigma and self-stigma associated with inpatient treatment (partial η2 = .14 and .16, respectively) as well as poorer attitudes about inpatient treatment (partial η2 = .36). Path analysis with bias-corrected bootstrapping indicated that the relationships between inpatient and outpatient public stigma with their respective attitudes toward seeking treatment were partially mediated by their respective self-stigmas. This differs slightly from previous findings demonstrating support for full mediation. Research and clinical implications are discussed.

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The student author, whose presentation of scholarship herein was approved by the program of study committee, is solely responsible for the content of this dissertation. The Graduate College will ensure this dissertation is globally accessible and will not permit alterations after a degree is conferred.