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An investigation into the psychological help-seeking attitudes of persons with visual impairments. Heaslip, Sean Richard 2016

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       AN INVESTIGATION INTO THE PSYCHOLOGICAL HELP-SEEKING ATTITUDES OF PERSONS WITH VISUAL IMPAIRMENTS. by Sean Richard Heaslip B.A., Simon Fraser University, 2013  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS  FOR THE DEGREE OF  MASTER OF ARTS in FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2016   © Sean Richard Heaslip, 2016        ii  Abstract The present study explored the relationships between visual impairment status, attitude towards seeking psychological services, attitude towards visual impairment, and a variety of demographic and psychological variables.  A survey design was employed with persons with visual impairments (defined as having a visual acuity of 20/200 or less) residing in either Canada or the United States of America.  Participants in this study were 84 legally blind (a visual acuity ranging from 20/200 to 20/600) and 109 severely visually impaired (a visual acuity of 20/600 or less) adults between 21 and 64 years of age.  Measures administered in the survey included (a) the Attitude Towards Seeking Professional Psychological Help Scale - Short Form, (b) the Disclosure Expectation Scale, (c) the Distress Disclosure Index, (d) the Self-Stigma of Seeking Help Scale, (e) the  Stigma Scale for Receiving Psychological Help, (f) the Social Responsibility About Blindness Scale, as well as a demographic questionnaire.  Descriptive statistics (means, standard deviations) and inferential statistics (two-way ANOVAs, t-tests) were calculated, as well as inter-correlations among the above variables.  Results indicated that legally blind participants held more negative attitudes than did severely visually impaired participants towards disclosing distressing personal information, and toward visual impairment.  A statistically significant gender effect was found on attitudes towards seeking psychological services, with female respondents reporting more positive attitudes.  Results also indicated that positive attitudes towards visual impairment had significant positive correlations with attitudes towards seeking psychological services, the anticipated benefit of seeking services and comfort with disclosing distressing information, and significant negative correlations with the anticipated risk of seeking services, and both self-stigma and public stigma towards psychological services.  The findings from this study will help to inform future research into counselling persons with visual         iii  impairments, and are the first steps toward establishing a knowledge base regarding this population’s attitudes towards psychological services.  The current study offers valuable suggestions for exploring what would make best clinical practices with this population.  The present study contributes to the lack of counselling psychology research on disability, and lends credibility to the field’s focus on diversity, having been conducted by a researcher with a visual impairment.           iv  Preface This thesis is an original intellectual product of the author, Sean R. Heaslip.  The research project was conceptualized, designed, and researched by Master of Arts student, Sean Heaslip, with the support of research co-supervisors, Dr. Ishu Ishiyama, and Dr. Colleen Haney, and a thesis committee member, Dr. Cay Holbrook.  All participant recruitment and data collection were completed independently by Sean Heaslip  Data analysis was conducted individually by Sean Heaslip, and covered by The University of British Columbia’s Behavioural Research Ethics Board Certificate number H15-02667, entitled “Psychological help-seeking attitudes of persons with visual impairments.”  Original approval was provided on November 25, 2015.              v  Table of Contents Abstract ........................................................................................................................... ii Preface ............................................................................................................................ iv Table of Contents ........................................................................................................... v List of Tables ............................................................................................................... viii Acknowledgements ....................................................................................................... ix Dedication ....................................................................................................................... x CHAPTER 1: Introduction ........................................................................................... 1     1.1       Retirement Aged Persons with Visual Impairments ........................................ 2     1.2       Adolescent Aged Persons with Visual Impairments ........................................ 4     1.3       Working Aged Persons with Visual Impairments ........................................... 4     1.4       Counselling and Persons with Visual Impairments ......................................... 5 CHAPTER 2: Literature Review ................................................................................. 8     2.1       Psychological Help Seeking ............................................................................ 8          2.1.1       Demographic Variables ........................................................................... 9             2.1.2       Psychological Variables ......................................................................... 10           2.1.3       Self-Disclosure ....................................................................................... 13           2.1.4       Self-Concealment ................................................................................... 15             2.1.5       Anticipated Benefits............................................................................... 17           2.1.6       Anticipated Risks ................................................................................... 18               2.1.7       Stigma ................................................................................................ 19                      2.1.7.1       Stigma ...................................................................................... 19                      2.1.7 .2      Stigma ...................................................................................... 21          vi      2.2       Persons with Visual Impairments Seeking LVRS ......................................... 22     2.3       Current State of Disability Research .............................................................. 26 CHAPTER 3: Current Study ...................................................................................... 28     3.1       Research Questions and Hypotheses ............................................................. 28     3.2       Methods.......................................................................................................... 30          3.2.1       Participants ............................................................................................. 30             3.2.2       Procedure ............................................................................................... 31           3.2.3       Measures ................................................................................................ 31      3.3       Ethical Considerations ................................................................................... 34 CHAPTER 4: Results .................................................................................................. 36     4.1       Measure Means and Correlations................................................................... 36     4.2       Hypothesis Testing......................................................................................... 36 CHAPTER 5: Discussion ............................................................................................. 50     5.1       Hypothesis Discussion ................................................................................... 50     5.2       Limitations ..................................................................................................... 64     5.3       Implications.................................................................................................... 65          5.3.1       Research ................................................................................................. 65          5.3.2       Practice ................................................................................................... 68 References ..................................................................................................................... 70 Appendices ..................................................................................................................... 81 APPENDIX A: Sample Letter to Organizations ............................................................ 81 APPENDIX B: Sample Recruitment Advertisement .................................................... .83 APPENDIX C: Participant Instructions ........................................................................ .85         vii  APPENDIX D: Survey – Participant Version ............................................................. ..86 APPENDIX E: Prize Draw Instructions – Participant Version .................................. .104 APPENDIX F: Demographics .................................................................................... .105 APPENDIX G: Attitudes Towards Seeking Professional Psychological Help – SF ... 107 APPENDIX H: Social Responsibility About Blindness Scale .................................... 108 APPENDIX I: Disclosure Expectations Scale ............................................................. 110 APPENDIX J: Distress Disclosure Index .................................................................... 111 APPENDIX K: Self Stigma of Seeking Help .............................................................. 112 APPENDIX L: Stigma Scale for Receiving Psychological Help……………………113           viii  List of Tables Table 1 Descriptive Statistics and Inter-correlations for Measures Related to Psychological Help-Seeking………..……………………………………….36 Table 2 Means, SD’s and t-tests for ATSPPHS-SF by Visual Impairment Status ……...………….............................................................................................37 Table 3 Means, SD’s and t-tests for ATSPPHS-SF by Gender…………………...…38 Table 4 ANOVA Tests of Between-Subjects Effects on DES Risks Score ………...39 Table 5 ANOVA Tests of Between-Subjects Effects on DES Benefits Score……...40 Table 6 ANOVA Tests of Between-Subjects Effects on DDI……………………....41 Table 7 ANOVA Tests of Between-Subjects Effects on SSOSH Score…………....41 Table 8 ANOVA Tests of Between-Subjects Effects on SSRPH Score………….....42 Table 9 ANOVA Tests of Between-Subjects Effects on SRBS Score…….……......43 Table 10 Means, SD’s and t-test for ATSPPHS-SF by Level of Education…………………….………………………………………….….44 Table 11 Means, SD’s and t-tests for Approach and Avoidance Variables by Visual Impairment Status………..............................................................................45 Table 12 Means, SD’s and t-test for SRBS by Visual Impairment Status……………………………………………………………………….47 Table 13 Correlations for SRBS Scores with Avoidance and Approach Variables…………………………………………………………………....48           ix  Acknowledgements I would like to thank my research supervisor, Dr. Colleen Haney for her support throughout this process.  Thank you for encouraging me to do the research I wanted to see in the literature.  I would also like to extend my gratitude to my thesis committee members, Dr. Ishu Ishiyama and Dr. Cay Holbrook, for their expertise and thoughtful feedback.  This research was supported by the Rick Hansen “Man in Motion” Fellowship.          x  Dedication This thesis is dedicated to the visually impaired community that made this project possible.  Not only has my academic life benefited from my increased involvement in all things blindness and visual impairment, but so too has my personal life.  Thank you to the members of the Eclipse blind hockey team, the BC goalball team, and to Blind Beginnings, for helping to recruit participants for this research, and for welcoming me with open arms into a community I was not a part of for so long.  My life has been enriched through my increased acceptance of my visual impairment, and through my involvement in the visually impaired community. Thank you also to all the respondents with visual impairments who participated in this research.        1  CHAPTER 1 Introduction The Canadian National Institute for the Blind defines visual impairment in terms of legal blindness, which begins at a “best corrected visual acuity of 20/200, and/or a visual field of less than 20 degrees in the better eye”, and beyond (CNIB, 2013).  Visual impairment is often further demarcated (for example in Blind sports) depending on degree of remaining vision.  This study will seek to differentiate between persons who are legally blind and those who are severely visually impaired.  Severe visual impairment will be defined, for the purposes of this study, as having a best corrected visual acuity of less than 20/600.  This term is used for the purpose of distinguishing between impairment groups however; future studies may wish to explore alternatives to this term to distinguish between groups.  On the questionnaire administered in this research, the severe visual impairment group was described as being made up of persons with a visual acuity of “20 over 600 or less, ie: up to and including no vision”.  Severe visual impairment was chosen to represent that description.  These two categories combined comprise the category of persons with visual impairments that will be referred to throughout this paper (with the awareness that people with visual acuities between 20/40 and 20/200 are sometimes included in the persons with visual impairments category, specifically referred to as people with low vision).  It is estimated that the number of persons with visual impairments worldwide is more than 285 million, including 39 million with no vision (World Health Organization, 2014).  In Canada visual impairment is the fifth most common disability, affecting approximately 816,250 (3.2%) of Canadian adults (Statistics Canada, 2009).  This is more than the number of Canadians living with breast cancer, prostate cancer, Alzheimer’s and Parkinson’s combined (CNIB, 2013).  In spite of efforts to improve outcomes for persons with a visual impairment in         2  domains such as mental and physical health, education, employment, and social inclusion to name but a few, persons with visual impairments continue to experience lowered outcomes when compared to their sighted peers.  Persons with visual impairments are half as likely as their sighted peers to graduate from high school, and are three times as likely to suffer from depression (CNIB, 2013).   Persons with visual impairments also experience unemployment rates as high as 65% with half of those employed earning under 20,000 dollars per year (10,000 less than their sighted peers) (CNIB, 2013).  1.1  Retirement Age Persons with Visual Impairments Most of the research on outcomes for persons with visual impairments has looked at outcomes for older adults, which makes sense given the fact that globally 82% of persons with visual impairments are aged 50 or above (World Health Organization, 2014).  3.2 % of Canadians have some form of visual impairment, and consistent with the fact that prevalence of visual impairment increases with age, that number increases to 13.4% for Canadians over 75 years of age (Statistics Canada, 2009).  Older adults with visual impairment were found to be less engaged in daily activities and social roles, with a resulting increase in depressive symptomatology (Burmedi, Becker, Heyl, Wahl & Himmelsbach, 2002b; Desrosiers, Wanet-Defalque, Témisjian, Gresset, Dubois, Renaud & Overbury, 2009).  Older adults with visual impairments have been found to be more likely to experience reduced social functioning and support, pursuit of leisure activities, mobility, and an increase level of dependence for daily living tasks, as well as lowered scores on dimensions such as morale, life satisfaction and mood,         3  when compared to their sighted peers (Burmedi et al., 2002a; 2002b).   A complex relationship exists between visual impairment, reduced outcomes, and depression.  When considering dimensions such as ‘dependence on others for accomplishment of daily tasks’, depression is more influential in determining daily task accomplishment than visual impairment, however visual impairment has been associated with higher rates of depression in older adults (Burmedi et al., 2002a).  This indirect relationship highlights the often obscured influence of visual impairment on psychosocial well-being.  Depression rates in older adults with visual impairments range between 25% and 45%, while rates in their sighted peers typically fall below 20% (Burmedi et al., 2002a).  Visual functioning (and to a lesser degree, visual acuity) has also been found in many studies to be a strong predictor of depression in older adults with visual impairments (Burmedi et al., 2002a). In one study of 151 older adults with visual impairments (n = 151), the authors found that nearly one third (49) were experiencing clinical levels of depression (Brody, Gamst, Williams, Smith, Lau, Dolnak, & Brown, 2001).  Studies have also pointed to an increased risk for suicide related to poorer health outcomes experienced by older adults with visual impairments (De Leo, Hickey, Meneghel & Cantor, 1999; Waern , Rubenowitz , Runeson , Skoog , Wilhelmson & Allebeck, 2002; Lam , Christ , Zheng & Arheart , 2008).  It seems reasonable that research has focused on older adults, as they are the population most impacted by visual impairment, but this should not lead us to neglect research on those in         4  younger age ranges.  Keeffe (2005) notes that although the numbers of children with visual impairments are quite small, these children will spend their lives with visual impairment, and thus be affected for a greater part of their life span.  In light of this fact we owe it to those persons with visual impairments who will live with the impairment longer than older adults will to bolster the research for this age range in an effort to improve outcomes in a variety of domains.  1.2  Adolescent Age Persons with Visual Impairments Students with visual impairments have been found to experience greater social isolation and more limited social networks, lower self-confidence, lower social competence and lowered preparedness to enter the job market (Huurre & Aro, 1998; Wagner, 2004; Wolffe & Sacks, 1997).  In addition adolescents with low vision have been found to engage more in passive, socially isolated activities (such as watching tv, listening to music, and sleeping) when compared to their sighted peers (Sacks, Wolffe, & Tierney, 1998).  1.3  Adult Persons with Visual Impairments Amongst working age persons with visual impairments similar findings to those found in older populations are emerging.  A survey of 29 studies on the psychosocial outcomes of working age adults with visual impairments found reduced mental health outcomes, impaired social functioning, and quality of life when compared with their sighted same age peers (Nyman, Gosney, & Victor, 2009).  Nyman et al. (2009) found the link between depression and visual impairment in working age adults to be more robust than in studies linking depression to visual impairment in older adults.  Pinquart and Pfeiffer (2011) also observed the most severe decline in psychological well-being in adults with visual impairments when compared with their sighted peers, suggesting the possibility that this may reflect difficulty in the labour market, or with other         5  age-related developmental tasks.  Another important consideration is the fact that persons with visual impairments may face discriminating or stigmatizing social attitudes that can have a detrimental impact on their psychological well-being (Hodge et al., 2010).  Given the positive impact counselling can have in many of the areas in which persons with visual impairments experience poorer outcomes than their sighted peers, an investigation was begun into the literature on persons with visual impairments willingness to access psychological services.  The literature however, is non-existent. What literature there is that relates to persons with visual impairments and psychological services in general will be outlined, in order to construct a rationale for the present research into this population’s attitudes towards seeking psychological services. 1.4 Counselling and Persons with Visual Impairments Although sparse there is research on the positive impact counselling can have in a variety of domains for people with visual impairments.  Many studies into the reduced psychosocial outcomes associated with visual impairment conclude with a recommendation that individual and group counselling could be helpful in addressing some of these concerns.  The fact that the typical low vision rehabilitation services (LVRS, discussed later in this paper), such as orientation and mobility, offered by charities like the CNIB, have been found to minimally improve lowered psychosocial outcomes is another argument for the benefit counselling services could contribute (Keeffe, 2005).  In a review of the grey literature Nyman, Gosney and Victor (2010) identified reduced wellbeing in persons with visual impairments, as well as a demand for support services that address emotional rather than just practical issues (ie: LVRS).  The review pointed to the fact that in the cases where counselling programs were offered significant improvements in client outcomes were reported (Nyman et al., 2010).  In one of the first         6  empirically validated studies of its kind, Ueda and Tsuda (2013) looked at the impact of skills training alone compared with skills training in combination with individual and group counselling and the resulting impact on psychological distress in a group of individuals with acquired vision loss.  In this study (n = 79), the authors found that those with low levels of psychological distress experienced decreased stress and increased acceptance of disability through skills training alone, while those with higher levels of psychological distress did not experience these benefits (Ueda & Tsuda, 2013).  Participants with high psychological distress who participated in skills training in combination with group counselling demonstrated improvements in their attitudes towards other persons with visual impairments, and those who also took advantage of individual counselling services in conjunction with group counselling experienced decreased tension, anxiety, depression, and fatigue, and an increase in disability acceptance (Ueda & Tsuda, 2013).  An important distinction here is that this population consisted of people with acquired vision loss, so the findings may not be generalizable to those whose vision loss has been present from birth.  In 2007 a UK pilot study designed to deliver emotional support and counselling services (ESC) to people (n = 35) accessing LVRS was delivered at two sites (Barr et al., 2012).  Prior to the beginning of the program, the participants recruited constituted a clinical sample in terms of their psychological distress.  Following the course of their participation in the ESC services, reduction of psychological distress to below clinical levels was evidenced in 91% of the participants (Barr et al., 2012).  Two questions present themselves in light of these few studies on persons with visual impairments utilization of counselling services: (a) to what extent is this population accessing these services?  And (b) what factors are involved in the decision to do so?  Although no         7  research exists on persons with visual impairments willingness to seek counselling services, research on other populations is plentiful.  First I will review the help-seeking literature, and then I will discuss the literature that does exist on help-seeking behaviours of persons with visual impairments in other domains in order to provide a context for the present study.           8  CHAPTER 2 Literature Review 2.1 Psychological Help Seeking Help-seeking, and in this case more specifically the willingness to seek psychological services (such as counselling), is a highly researched area.  Willingness to seek psychological services will be defined as the degree to which individuals are inclined to employ the services of a counsellor for academic, vocational, intrapersonal, social, health, or discrimination problems (Gim, Atkinson, & Whiteley, 1990; Choi & Miller, 2014).  Much of the research on help-seeking is in relation to individual’s attitude toward seeking help, a factor that has been found to predict actual help-seeking behavior (Cremer, 1999).   Fischer and Turner (1970) developed the Attitudes Towards Seeking Professional Psychological Help Scale (ATSPPHS), and Fischer and Farina (1995) later developed a short form version of the scale (ATSPPHS-SF). The latter of these measures will be employed in the present study to gauge participant’s willingness to seek psychological services.  The short form scale represents a psychometrically sound measure comprised of two sub-scales (recognition of personal need and confidence in the professional’s ability to help) (Fischer & Farina, 1995; Komiya, Good & Sherrod, 2000; Nam et al., 2013).  The primary motivation for the research into willingness to seek counselling services is known as ‘the service gap”, the fact that only about 30% of those who could benefit from psychological services at a given time will seek out and use them (Cramer , 1999; Vogel & Wester, 2003).  It has been found that people often view seeking counselling as a last resort (Hinson & Swanson, 1993).  As a result, an effort to understand the reasons that underlie people’s decision to seek these services has been undertaken in the hopes that it will allow professionals to reach out to those in need of these services (Komiya, et al., 2000).          9  2.1.1 Demographic Variables In the early stages of the research on willingness to seek psychological services demographic factors were identified as the primary influence.  These factors included gender variables like biological sex (Gourash, 1978; Fischer & Turner, 1970; Fischer & Farina, 1995; Vogel & Wester, 2003; Nam, Chu, Lee, Lee, Kim & Lee, 2010) and gender role adherence (Hammer, Vogel & Heimerdinger-Edwards, 2013), level of education (McKenzie, Gekoski & Knox, 2006; Jackson, 2013), cultural factors such as ethnicity and acculturation (Choi & Miller, 2014; Ginn, et al., 1990), and past use of counselling services (Deane & Todd, 1996; Vogel & Wester, 2003).  Variables such as these are now known to moderate the relationship between willingness to seek psychological services and a variety of psychological variables (see next section for a review of these variables).  This study will attempt to broaden the research base by including an as yet ignored variable in the equation: that of disability, and in specific, visual impairment.  As well, a question specific to visual impairment related to counsellor similarity will be included in this paper.  Results from previous research on the influence of counsellor similarity have been mixed.  Two meta-analyses found strong support in the literature for the idea that ethnic minorities will, all things being equal prefer an ethnically similar counsellor, and will rate that counsellor more highly than a European-American counsellor (Atkinson & Lowe, 1995; Coleman, Wampold, & Casali, 1995).  A later study however found that a preference for similar counsellor ethnicity held only when no other factors were considered, with the authors noting that in actuality the factor influencing the decision was a preference for cultural similarity, as reflected by attitudes and values (Atkinson, Wompold, Lowe, Matthews & Ahn, 1998).  Atkinson et al (1998) suggested that in the face of no other information, ethnic minorities chose counsellors of similar ethnic backgrounds as a way of attempting to choose a counsellor who         10  would be similar to them in attitudes and values.  With regard to gender, Bernstein, Hofmann and Wade (1987) reported finding client preferences for a same-gendered counsellor, however DeHeer, Wampold, and Freund (1992) were unable to replicate that finding.  Additionally Belaire and Young (2002) reported finding client preference for a counsellor of the same religious background.  To address this question of counsellor preference I will ask participants if they hold any preference for a visually impaired or sighted counsellor.  This will serve as a starting point for future studies that might consider any potential preferences found, in light of other counsellor characteristics such as a similarity in values and attitudes, as was found to be more important in the research on ethnic similarity. 2.1.2 Psychological Variables  In addition to demographic variables a variety of psychological variables have been introduced to explain more of the variance in the help-seeking decision making process (Cramer, 1999).  Help-seeking has been divided into approach variables (those factors which make a person more likely to seek psychological services) and avoidance variables (those factors which make it less likely that a person will seek these services (Kushner & Sher, 1989).  An examination of some of these variables in combination with the variable of visual impairment will provide a more nuanced picture of what variables may be at play in the decisions of persons with visual impairments to seek psychological services. Some previously researched variables that indicate a higher likelihood of seeking psychological services, termed approach variables, include social support, prior seeking of psychological services, level of psychological distress and the desire to reduce it, and perceived severity of psychological distress compared to typical others (Cepeda-Benito & Short, 1998; Kelly & Achter, 1995; Vogel & Wester, 2003).  A great deal of evidence has been presented         11  relating to these approach factors.  Persons who seek counselling are likely to harbor positive attitudes towards counselling and its efficacy (Cramer, 1999).  Research has also shown that individuals are more likely to seek counselling when their perceived level of distress surpasses their ability to cope, resulting in the motivation to seek psychological services (Cepeda-Benito & Short, 1998).  These findings have however, gained an added layer of complexity as recent research has shown that factors such as discomfort with emotional disclosure may dissuade help-seeking in spite of high distress levels, calling into question the traditional wisdom of help-seeking occurring when distress outweighs coping strategies (Komiya et al., 2000).  These findings support the assertion by Vogel and Wester (2003) that as little as 25% of the variance in help seeking behavior is explained by these approach factors alone, and resulted in the introduction of avoidance factors into the help-seeking literature.  Avoidance variables are factors associated with a decreased likelihood of seeking out psychological services, and have been shown to predict negative attitudes towards counselling as well as decreased willingness to seek counselling services (Vogel & Wester, 2003).  Recent research has investigated a number of these variables including social stigma, treatment fears, fear of emotion, self-concealment, and risks of disclosure to name a few (Komiya, et al., 2000; Vogel & Wester, 2003).  The question then becomes which approach and avoidance variables need be included along with the demographic variables of visual impairment in the current study.  A recent meta-analytic study of influential psychological variables was used to inform this decision making process. Nam, Choi, Lee, Lee, Kim and Lee (2013) conducted a meta-analysis consisting of 19 quantitative studies published between 1995 and 2011 on non-clinical University student samples (total n = 7,396) that examined the relationship between willingness to seek         12  psychological services and relevant psychological variables.  Willingness to seek psychological help was assessed in all of these studies using either of the equivalent forms of Fischer and Turner’s (1970) Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS (6 studies), or the ATSPPHS-Short Form (13 studies) the latter of which being one of the measures employed in the present research (Nam et al., 2013).  The authors limited their search to variables that had been previously examined by more than 3 studies, and to those studies that provided the employed measures’ reliability and validity, as well as statistics like mean, standard deviation, and t-statistics, ultimately identifying 9 psychological variables at play in participants willingness to seek psychological services (Nam et al., 2013).  These psychological variables (either positively or negatively correlated with willingness to seek psychological services), were found by the authors to be consistent with Kushner and Sher’s (1989) conception of help-seeking variables as being either approach or avoidance factors (Nam et al., 2013).  The 9 variables were: the anticipated benefit of seeking services, the anticipated risks of seeking services, depression, psychological distress, self-concealment, self-disclosure, social support, public-stigma, and self-stigma (Nam et al., 2013).  The author’s found all factors but psychological distress to have significant correlations (r = .06), with anticipated benefit, self-disclosure, and social support being positively correlated with willingness to seek services, and self-stigma, anticipated risk, public stigma, self-concealment and depression had negative correlations (Nam et al., 2013).  In analyzing effect size, the author’s found large effect sizes for self-stigma (r = -.63) and anticipated benefit (r = .52); medium effect sizes for self-disclosure (r = .34), anticipated risk (r = -.26), and public stigma (r = -.24); and somewhat small effect sizes for self-concealment (r = -.17), social support (r = .13), and depression (r = -.07) (Nam et al., 2013).  The authors went on to employ a calculation to detect sampling bias and found that aside from depression, all         13  predictors were robust variables (Nam et al., 2013).  Notably, the authors identified self-disclosure as being positively correlated, ostensibly an approach factor, indicating that those more comfortable with self-disclosure are more likely to seek services.  Due to the scope of this study and the need to keep the survey at a reasonable length for participants the social support variable was also dropped, in light of it being the next lowest correlate behind depression and psychological distress.  Given the strong evidence for the variables found to account for the majority of the variance in willingness to seek psychological services identified by the Nam et al., (2013) meta-analysis, a review of the extant research on each of the variables to be included in this study will be presented, followed by a review of the literature on persons with visual impairments seeking of help in non-psychological contexts. 2.1.3. Self-disclosure Research on self-disclosure and the related construct of self-concealment have proceeded separately however; aspects of each overlap (Kahn & Hessling, 2001). Research on each measure will be presented, followed by an overview of a measure employed in the present research that looks at aspects of these constructs as opposing ends of a spectrum. Self-disclosure refers to an individual’s willingness to reveal personal information about themselves, such as thoughts, feelings and beliefs (Leaper, Carson, Baker, Holiday & Myers, 1995), with an eye towards the disclosure of personally distressing information for the purposes of this study.  Self-disclosure is referred to as an avoidance variable by many authors (ex: Vogel & Wester, 2003) however, I will in this paper employ Nam et al’s., (2013) characterization of self-disclosure as an approach variable for clarity’s sake, given my use of Kahn and Hessling’s (2001) measure that views these as the poles of a unidimensional variable.  This should serve to         14  minimize confusion, as when self-disclosure is defined as an avoidance variable, the wording used is “discomfort with self-disclosure”, implying that this discomfort makes one less likely to seek services, (i.e. making it an avoidance variable.  However, at other points when speaking about self-disclosure authors refer to “comfort with self-disclosure”, meaning level of comfort.  This could be read as representing an approach variable, as the more comfortable a person is self-disclosing, the more likely they would be to seek counselling.  Given the inclusion of self-concealment, the greater presence of which lessens the likelihood of seeking services, I will refer to self-disclosure in the approach manner (“comfort with self-disclosure”), as Nam et al. do in their meta-analysis (Nam et al., 2013).  It has been found that those willing to self-disclose to others also feel more comfortable self-disclosing to health care professionals (Nam et al., 2013), and research has demonstrated a relationship between individual’s willingness to self-disclose and their attitudes towards seeking psychological help (Cepeda-Benito & Short, 1998; Kelly & Achter, 1995; Vogel & Wester, 2003).  It has been suggested that self-disclosure is a critical factor in the decision to seek psychological services because the act of engaging in the counselling process in itself is in essence one of self-disclosure to another (Hinson & Swanson, 1993).  Research has demonstrated the connection between the willingness to self-disclose and the likelihood of seeking psychological services.  In a study of 101 university students with no prior counselling experience, Hinson and Swanson (1993) found that an interaction between problem severity and willingness to self-disclose to a counsellor predicted the greatest amount of variance with respect to willingness to seek psychological help. Notably in this study no gender differences were observed (Hinson & Swanson, 1993).          15  In 2 studies of college students (n = 209 and n= 268) Vogel and Wester (2003) found that comfort with disclosing distressing information, and the perceived outcomes of such disclosure predicted a significant amount of the variance in participants help seeking attitudes and intentions.  In another study looking at university students (236 women, 118 men) from Vogel, Wester, Wei, and Boysen (2005) through the application of structural equation modeling, the authors found that comfort with self-disclosure (along with social support, anticipated utility, social stigma, social norms, and previous use of counselling) significantly predicted attitudes towards seeking psychological services.  These authors have also found self-disclosure to be an even stronger predictor of help-seeking than self-concealment (Vogel & Wester, 2003; Vogel et al., 2005).  These studies all contribute to the evidence that comfort with self-disclosure is an important factor in an individual’s willingness to seek psychological services. 2.1.4 Self-concealment On the other end of the spectrum lies fear of emotional disclosure, often characterized by high self-concealment, defined as one's tendency to actively conceal distressing or potentially embarrassing personal information from others (Kelly & Achter, 1995; Larson & Chastain, 1990).  Self-concealment is an avoidance factor (i.e., a factor that reduces the likelihood of a person seeking services) (Vogel & Wester, 2003).  Those high in self-concealment have been found to have less positive attitudes towards seeking psychological help, expressing negative attitudes towards both counsellors and the counselling process (Cepeda-Benito & Short, 1998; Cremer, 1999; Kelly & Achter, 1995).  Cremer (1999) also found that high self-concealers tended to have impaired social support networks; consistent with previous findings that self-concealment interacts with social support to influence help-seeking behaviours (Cepeda-Benito & Short, 1998).  It has also been found that high self-concealers are three times less likely to         16  have sought psychological services when experiencing a problem, leading Cepeda-Benito and Short (1998) to conclude that self-concealment is detrimental in that it reduces the likelihood of recovery by discouraging individuals from seeking help. Related to the tendency to self-conceal and the reluctance to self-disclose are other psychological factors in the help-seeking research that will be addressed later in this paper. These include the perceived risks and benefits of seeking counselling.  The risks to someone who tends to self-conceal include the potential exposure to emotional distress brought about by the disclosure, as well as the embodiment of the stigmatized identity of “therapy client” (Cramer, 1999; Vogel & Wester, 2003).  The dangers brought about by disclosure, such as the potential to be judged following disclosure may be seen as outweighing the potential gains of disclosure by the client and result in concealment (Cramer, 1999).  The combination of a high perceived risk of counselling and a low perceived benefit are factors related to a tendency to self-conceal, and influence a person’s likelihood to seek out counselling services (Vogel & Wester, 2003).  As well, those high in self-concealment often perceive a greater stigma associated with seeking psychological services (Komiya et al., 2000), are more likely to have restricted social networks (Cremer, 1999), and are more likely to hold negative beliefs about seeking psychological help and possess lower intentions to do so  (Kelly & Achter, 1995).  To maximize the relevance of this discussion and research for the counselling field a measure will be employed that focuses specifically on distress disclosure and concealment, which can be seen as a subset of the constructs discussed above.  Kahn and Hessling’s Distress Disclosure Index (DDI) (2001) measures the typical behavior of concealing versus disclosing daily distress to others (e.g., depressed mood) rather than a general tendency to conceal or disclose.          17  2.1.5 Anticipated Benefits An individual’s expectations about the consequences of self-disclosure to a therapist, referred to as the anticipated benefits and risks of seeking psychological services also contribute to the formation of people’s help-seeking attitudes (Vogel, Wade & Hackler, 2008; Vogel, Wester & Larson, 2007), and are an important factor for many in the decision to seek those services (Kelly & Achter, 1995).  Vogel and Wester (2003) found that the anticipated benefits and risks associated with psychological services strongly predicted attitudes toward seeking them.  Vogel et al. (2005) found that anticipated benefits predicted help-seeking behavior, while anticipated risks was specifically predictive for those people who experienced a distressing event.  The notion of the anticipated benefits of seeking psychological services refers to the perceived value of the outcome to the individual for disclosing to a counsellor (Omarzu, 2000).  The anticipated benefits measure is an approach factor, one that makes it more likely that an individual will seek psychological services (Nam et al., 2013, Vogel & Wester, 2003).  As mentioned above anticipated benefits had the strongest positive correlation with willingness to seek psychological services in a meta-analysis of psychological factors that influence service seeking (Nam et al., 2013).  Anticipated benefits have also been associated with the eventual decision to seek help (Vogel et al., 2008).  Kelly and Achter (1995) found that 20% of participants reported the anticipated benefits of going to counselling were influential in their decision to seek services.  In essence, a person must believe counselling services will be beneficial in order for them to seek out those services during times of distress (Vogel & Wester, 2003).          18  2.1.6 Anticipated Risks The anticipated risks of seeking psychological services factor refers to an individual’s perception of the potential dangers of opening up to another person (Vogel & Wester, 2003).  Given that therapy is in itself self-disclosure, seeking therapy may be perceived as risky, opening up the potential client to feelings of being “misunderstood, ridiculed, judged, or even ignored” (Harris, Dersch, & Mital, 1999, p. 407).  Individuals face a dilemma in that although they may need help in dealing with a problem, the negative consequences they perceive as being associated with seeking that help may seem to them worse than the problem itself (Vogel et al., 2007a).  An example of this bind can be seen in the case of men, whose self-concept is built upon heteronormative gender roles, resulting in the perception of seeking help from a counsellor as weak and in conflict with the expectation that males be able to handle problems themselves (O’Neil, 2008).  The risk of violating gender role expectations is so strong that it held in studies of men across demographic factors such as race and sexual orientation, and is likely a contributing factor in the statistics mentioned above regarding men’s overall lower willingness to seek psychological services in comparison to women (O’Neil, 2008).  It is this type of anticipated risk that is balanced against perceived benefits when a person is considering seeking out psychological services.  A fear or discomfort around emotional expression is one example of the relationship between anticipated risk and benefit in action.  Vogel, Wade, and Hackler (2008) found that comfort with emotional expression was positively associated with anticipated benefits, and negatively associated with the anticipated risks of disclosure.  Komiya et al., (2000) found that a fear of talking about emotions directly led to fears about the counselling process.  If a person fears expressing emotional content, and anticipates that he or she will be required to do so in a         19  counselling session, they may view the risk of having to make this emotional expression as outweighing any benefit they may reap from the process, once again illustrating the approach avoidance conflict.  Here we see then that if the anticipated benefit does not outweigh the anticipated risks, people may choose not to seek counselling services. 2.1.7 Stigma Social stigma is another important psychological factor that influences individual’s willingness to seek, or fully engage with, psychological services (Corrigan, 2004).  Mental health concerns have been found to be stigmatized more than any other health issue (Corrigan, 2004).  Characteristic of the type of stigma that exists in relation to seeking psychological services is the belief that someone in need of these types of services is flawed in some way (Vogel et al., 2006).  Research has found that the stigma associated with seeking psychological help is negatively correlated with a willingness to seek these services (Komiya et al., 2000; Vogel et al., 2005;  Vogel et al., 2007b) In the literature stigma is divided into public stigma and self-stigma (Corrigan, 2004).   2.1.7.1 Public Stigma. Public stigma refers to the negative beliefs and attitudes held by society toward an individual or group that is perceived to be socially unacceptable (Corrigan, 2004; Vogel et al., 2006).  Common stereotypes held about those with mental illness include that they are dangerous, incompetent, and lacking in character (Corrigan & Watson, 2002).  An example of the impact of public stigma on the seeking of psychological services would be the belief that those labeled as having mental health issues are a danger to society, which could result in stereotyping, prejudice, and discrimination towards individuals with that label (Corrigan, 2004).  This fear of the negative social consequences of being labeled may account for the avoidance of such services, with those who need them choosing to cope on their own         20  rather than face being seen by others as dangerous (Corrigan, 2004).  Public stigma then acts as a barrier to seeking services through the exertion of social pressure that can result in diminished self-esteem and self-worth should a person take on the stigmatized identity of someone in need of such services (Corrigan, 2004; Vogel et al., 2006). Public stigma had a medium effect size (r = .24) in the Nam et al. (2013) meta-analysis of psychological factors.  In a study by Cooper, Corrigan and Watson (2003) of college students (n = 79) the authors found that individuals were less likely to seek psychological services if they viewed those with mental illnesses as responsible for their illness, had attitudes toward this fact characterized by anger, and endorsed beliefs that these people were undeserving of pity and services.  This type of endorsement of a publicly held stigma influencing an individual’s personal help-seeking attitudes is characteristic of the relationship between public stigma and self-stigma, as it has been found that public stigma is a separate but related construct to self-stigma (Vogel, Bitman, Hammer & Wade, 2013). In a study of college students (n = 360) Vogel, Wade and Hackler (2007) found that perceptions of public stigma directly predicted an individual’s self-stigma with seeking counselling, which predicted attitudes towards seeking help and willingness to seek counselling.  This study demonstrated the relationship between the perception of public stigma, and the internalization of that stigma, ultimately manifesting as self-stigma (Vogel et al., 2007b). In another longitudinal study of college students (n = 448), Vogel et al. (2013) used structural equation modeling to demonstrate that public stigma at time 1 predicted self-stigma at time 2, lending further strength to the evidence that public stigma directly influences the development of self-stigma.  This evidence for the indirect way that public stigma influences willingness to seek counselling services through its influence on the development of self-stigma speaks to the         21  necessity of its inclusion even though self-stigma has been shown to account for a greater amount of variance in willingness to seek psychological services (e.g., Nam et al., 2013).  2.1.7.2 Self Stigma. Self-stigma refers to what individuals may do to themselves if they internalize the public stigma (labelling themselves as socially unacceptable), and the reduction in self-worth and self-esteem that may occur as a result (Corrigan, 2004; Vogel et al., 2006; Vogel et al., 2007b).  Due to the fact that the public stigma marks those who seek counselling as socially unacceptable, the more an individual endorses the public stigma, the less likely they are to seek counselling, reflected by the large effect size (r = -.63) reported by Nam et al. (2013) showing the negative correlation between high self-stigma and lowered willingness to seek services.  This self-stigmatization has been referred to as a “second misfortune” for those already suffering the effects of the mental illness itself (Corrigan & Watson, 2002 p.35).  Corrigan and Watson (2002) described self-stigmatization as unfolding at four levels: stereotype awareness, stereotype agreement, belief that one embodies these stereotypes, and a reduction in self-esteem due to a loss of self-respect for one’s embodying of these stereotypes.  Therefore, the extent to which public stigma is internalized impacts the influence on self-esteem and self-worth (Corrigan & Watson, 2002). One example of the internalization of public stigma is the finding that those who perceive their family as disapproving of seeking psychological services will themselves internalize this belief, and choose not to seek these services even when they may be of benefit (Leaf, Bruce, & Tischler, 1986).  People then choose to avoid the threat to self-concept and self-esteem that would come from seeking services, ultimately avoiding seeking help (Corrigan, 2004; Link et al., 2001).  It has been found that people living with mental illness will often internalize public         22  stigma, and view themselves as responsible for their illness (Link, 1987), a finding consistent with the idea of viewing those with mental illnesses as personally responsible for their circumstances (outlined in the public stigma section).  Research has demonstrated that those who self-stigmatize have been found to have lower levels of self-esteem (Link et al., 2001), that self-stigma undermines hope (Rusch et al., 2009), and that it contributes to the development of a “why try” attitude, due to the individual having internalize their lower social status (Corrigan et al., 2009).  Studies have also shown that those who do seek services are less likely to return for future sessions as a result of self-stigma (Wade, Post, Cornish, Vogel & Tucker, 2011).  Thus we see ample evidence for the influence of social stigma on willingness to seek psychological services.  It will be interesting to look for a relationship between visual impairment and attitudes toward seeking counselling services.  It seems reasonable to assume that those with high levels of stigma in both categories would be less likely to seek psychological services. Having reviewed the literature on the seeking of psychological services, I will move to a review of what literature does exist with relation to the topic of help-seeking more generally for this population.  2.2 Persons with Visual Impairments Seeking LVRS Due to the fact that there are no studies on persons with visual impairments and their willingness to seek psychological services, I will present studies on barriers to persons with visual impairments help-seeking in a different context.  The main literature comes from the field of vocational rehabilitation counselling and is regarding persons with visual impairments willingness to access LVRS (defined earlier as Low Vision Rehabilitation Services).  LVRS aid in helping persons with visual impairments in adjusting to and living with visual impairment through the acquisition of skills such as cane usage, orientation and mobility (travel) skills,         23  Braille literacy, and meal preparation to name but a few (Southall & Wittich, 2012).  In spite of the necessity of the acquisition of these skills for effective functioning with a visual impairment, a low percentage of those who might benefit avail themselves of these LVRS.  In the province of Quebec for example it was found that only 20% of those eligible took advantage of LVRS (Gresset & Baumgarten, 2002).  On a national level the CNIB reported that only 28% of seniors eligible for services knew how to access them (CNIB, 2005).  Given the connection between success in the domains covered by LVRS and improved outcomes in the realms of employment, education and social integration, this low utilization of services poses a serious problem (Southall & Wittich, 2012). So the question becomes: why are people not accessing these seemingly essential services? Australian researchers conducted focus groups with 17 individuals in order to identify access barriers to rehabilitation services (Pollard, Simpson, Lamoureux, and Keeffe, 2003).  Three main topic areas emerged as potential barriers to service access.  The first was the general perception of LVRS and the individual’s self-identity. Many of these individuals who were visually impaired did not consider themselves “blind”, and were therefore reluctant to engage services that they perceived to be geared towards those with severe visual impairments (Pollard et al., 2003).  This would appear to be the lack of service use due to a desire to avoid a stigmatized label (the blind service user).  This identification of stigma as a barrier for visually impaired persons in accessing services contributes to my hypothesis about the lowered tendency of seeking psychological services by legally blind participants when compared to severely visually impaired participants.  The second theme was the necessity of overcoming distance and travel barriers in accessing LVRS, with a fear of becoming lost pointing to a catch 22 people find themselves in when needing to learn orientation and mobility skills, but finding themselves far         24  from LVRS (Pollard et al., 2003).  If people who are legally blind use LVRS less in order to avoid a stigmatized identity, then they are also less likely to be able to navigate successfully to access these services.  As a result, we would expect that those who are comfortable identifying as blind, would access the services available for that population more often, and thus be less impacted by this second hindering factor.  Finally the participants identified negative interactions and communication problems with eye care professionals and service providers as a barrier to accessing LVRS (Pollard et al., 2003).  Participants reported that ophthalmologists were not forthcoming with information about LVRS until it had been determined that nothing more could be done for the patient from a medical perspective (Pollard et al., 2003).  Furthermore participants reported that in some cases ophthalmologists never provided them information about LVRS (Pollard et al., 2003).  This finding represents a systemic influence on the adoption of the blind identity by persons who are legally blind, as an eye-care professional not providing information on LVRS may indicate to a client that they do not fit the criteria for what makes a person blind, and therefore their accessing of LVRS services would be inappropriate.  Another study designed to better understand barriers to accessing LVRS (part of the broader Montreal Barriers study), Southall and  Wittich (2012) employed a qualitative description research paradigm consisting of focus groups (n = 21)  and  identified three main areas in which barriers arise.  These areas were barriers inherent in the person, the clinic, and society at large (Southall & Wittich, 2012).  Focus will be given here to themes one and three, though communication issues at the clinic could also be positively influenced through the utilization of counselling services, as counselling could serve to improve client’s interpersonal functioning and communication skills.  In terms of barriers inherent in the person, participants identified severity of vision loss as a key determinant of seeking LVRS (Southall & Wittich,         25  2012).  This main theme was moderated by two sub themes.  Firstly, use of compensatory behaviours (such as relying on a friend or family member) in order to continue to participate in valued daily activities acted as a barrier to seeking services (Southall & Wittich, 2012).   Secondly, emotional factors (such as denial of one’s impairment) acted as a barrier to seeking LVRS.  In terms of theme three (barriers in society at large), participants reported feeling devalued in their communities, with negative interactions with typically sighted people in their daily activities serving as a barrier to accessing LVRS services (Southall & Wittich, 2012).  Specifically participants found interactions between themselves and their sighted peers as stressful and misinformed, and feared adopting a stigmatized identity as a “blind” person (Southall & Wittich, 2012).  Participants commented also that many of these stressful interactions took place while using public transportation, the use of which has been previously identified as a barrier in itself (Pollard et  al.,, 2003; Southall & Wittich, 2012).  Based on the findings of the Pollard et al. (2003) and the Southall and Wittich (2012) studies, it is clear there are similarities between the avoidance and approach variables identified in the willingness to seek psychological help literature and the literature on barriers to accessing LVRS.  One common factor is the fear of the adoption of a stigmatized identity, in the former as the “mental health services user”, and in the latter as the stigmatized blind identity.  Southall and Wittich (2012) speak to the complexity of the barriers to accessing LVRS as more complicated than simply motivated by symptoms of disease, but rather by an interaction of personal, clinical and societal factors.  This acknowledgement echoes the explanation of the service gap in the willingness to seek psychological services literature that has been demonstrated to be influenced by more than simply a need for psychological services.  Self-concealment is another psychological factor in attitudes towards seeking help that seems as though it could be at play in         26  this population. Persons with visual impairments embody a stigmatized identity that could conceivably lead to negative social assessment by others.  As such there may be a desire to downplay the extent to which the disability impacts the person, or in other words there may be a tendency to conceal the impact.  It seems reasonable to conclude that persons with visual impairments may be high in the self-concealment trait, which has been shown to be negatively associated with seeking counselling.  Furthermore, persons with visual impairments may perceive a higher risk of disclosure, given a variety of negative assessments they experience in day to day life from unsupportive others, and thus may be judging the perceived risk as high and not worth the potential benefits counselling may offer.  It appears that persons with visual impairments embody many of the characteristics found in those who are less likely to seek psychological services, and given this fact, an investigation into the willingness of persons with visual impairments to seek psychological services is more than justified, it is long overdue.  2.3 Current State of Disability Research Taking a multicultural perspective, disability as a category signifies group differences in similar ways to other categories such as ethnicity and socioeconomic status do (Artman & Daniels, 2010 as cited in Foley-Nicpon & Lee, 2012).  For the purposes of this study, culture as it relates to blindness will be defined as referring to the shared lived experience of what it is to be a person with a visual impairment.  It seems reasonable to assume that like other established multicultural differences in the seeking of psychological services, visual impairment will play an important role.  An investigation is warranted into the ways in which visual impairment influences attitudes towards psychological services, as well as the ways it may interact with the established approach and avoidance variables in the help-seeking model.  The lack of research into disability as a general category is of course, situated within a broader context.         27  This lack of research on disability issues is alarming given the espoused orientation of the counselling field and literature as being highly sensitive to issues of multiculturalism and diversity.  Indeed disability has received little focus when compared with other issues under the banner of diversity such as acculturation, social class, and multicultural counseling competency (Foley-Nicpon & Lee, 2012).  The fact that multiculturalism and diversity was the most researched topic in the Journal of Counselling Psychology over the past 20 years, and yet only 18 articles on disability were published during that time speaks to this disproportionate lack of focus on disability issues (Foley-Nicpon & Lee, 2012).  Foley-Nicpon and Lee (2012) found that in a survey of the articles published in the top 5 counselling psychology journals over the past 20 years, only 55 dealt with issues of disability generally, let alone with visual impairment specifically.  Furthermore there are currently no evidence-based practices for working with the population of persons with disabilities, and ethical guidelines have only recently begun to be developed (Artman & Daniels, 2010; Cornish et al., 2008 as cited in Foley-Nicpon & Lee, 2012).  There is clearly a dearth of research in the area of disability in the counselling psychology literature.  This study will contribute to the knowledge base in terms of disability research in the counselling field by investigating the help seeking experiences of persons with visual impairments.            28  CHAPTER 3 Current Study There is no previous research into the impact that disability status, specifically visual impairment, has on an individual’s willingness to seek counselling services.  This fact in combination with the findings that persons with visual impairments suffer a variety of negative outcomes that counselling may positively impact (psychological, social, health), and the fact that counselling has been found to improve the use of LVRS serves as a mandate for the present research.  The current study addresses these shortcomings by exploring the relationship between visual impairment status, willingness to seek counselling services, and a variety of demographic and psychological variables that have been associated with the seeking of psychological services in previous research.  The primary aim of this study is to examine this sample’s attitudes towards seeking counselling services, and to identify variables that may be influence the formation of these attitudes.    3.1  Research Questions and Hypotheses    Based on previous research, a number of hypotheses can be made.  Research Question 1: Is visual impairment status (legal blindness or severe visual impairment) related to attitudes towards seeking psychological services? Hypothesis 1: Scores on the ATSPPHS-SF will differ based on visual impairment status (legal blindness or severe visual impairment), with legally blind participants scoring lower than severely visual impaired participants. Research Question 2: Is willingness to seek psychological services influenced by the sample demographics?         29  Hypothesis 2: Scores on the ATSPPHS will differ based on demographic variables such as gender, ethnicity, education, and past use of counselling services. Research Question 3: Is visual impairment status related to outcomes on the measures of the psychological variables associated with willingness to seek psychological services?  Hypothesis 3: Scores on the psychological factor measures associated with willingness to seek psychological services will differ depending on visual impairment status (legal blindness or severe visual impairment), with legally blind respondents scoring in ways indicative of being less willing to seek psychological services.  Specifically legally blind participants will (a) score higher on avoidance variables (DES Anticipated Risk Subscale, SSOSH – Self Stigma, SSRPH - Public Stigma), and  (b) score lower on approach variables (DES Anticipated Benefits Subscale, DDI – Self Disclosure), indicating a lesser likelihood of seeking psychological help. Research Question 4: Is attitude toward visual impairment related to visual impairment status and willingness to seek psychological services? Hypothesis 4: Attitudes toward visual impairment, as measured by scores on the SRBS will differ based on visual impairment status (legal blindness versus severe visual impairment),with legally blind participants holding more negative attitudes towards visual impairment than severely visually impaired participants. Hypothesis 5: Scores on the psychological factor measures associated with willingness to seek psychological services will differ depending on participant’s attitudes toward visual impairment (as indicated by scores on the SRBS), with participants harbouring more negative attitudes towards visual impairment scoring in ways indicative of a lesser likelihood of seeking         30  psychological services.  Specifically participants with more negative attitudes towards visual impairment will (a) score higher on avoidance variables (DES Anticipated Risk Subscale, SSOSH – Self Stigma, SSRPH - Public Stigma), and  (b) score lower on approach variables (DES Anticipated Benefits Subscale, DDI – Self Disclosure), indicating a lesser likelihood of seeking psychological help. Research Question 5: Will participants report a preference for certain counsellor characteristics? Hypothesis 6: Participants will report a preference for receiving psychological services from a visually impaired counsellor or therapist. 3.2  Methods 3.2.1 Participants The participants in this study were 84 (43.5%) legally blind and 109 (56.5%) severely visually impaired adults (n = 193) between the ages of 21 and 64 (M = 41.88, SD = 13.36) and resided in either Canada (56%) or the United States (44%).  The sample was comprised of 58.5% women (47 legally blind, 66 severely visually impaired), 40.4% men (36 legally blind, 42 severely visually impaired), and 2 (1%) “other” (1 legally blind, 1 severely visually impaired).  The sample was predominantly Caucasian, with 64.8% White/Caucasian, 23.3 Multiple Ethnicities, 4.1% Other Ethnicity, 2.1% East Asian, 2.1% South Asian, 1.6% Black/African American, 1.0% Hispanic, and 1.0% Middle Eastern.  Participant’s employment status was Unemployed 12.4%, Disability Benefits/Other Benefits 36.8%, Employed - Part Time 16.6%, Employed - Full Time 23.3%, and Student 10.9%.  Participant’s relationship status was Single 36.8%, Dating 14.0%, Married or Common-law 37.8%, Separated 1.6%, Divorced 8.3%, and         31  Widowed 1.6%.  Participant’s highest level of education achieved were High School 9.8%, Some College/University 30.1%, Two Year Degree 9.3%, College/University Degree 35.2%, Master’s Degree 14.0%, and PhD or Post-Doctoral Degree 1.6%.  78.8% of participants had sought counselling services previously, while 83.9% of participants had sought out low vision rehabilitation services (LVRS) in the past.  Regarding counsellor preference, 74.1% of participants reported having had no preference, while 20.7% preferred a visually impaired counsellor, and 5.2% preferred a sighted counsellor.  All collected participant demographic information is available in Appendix G.  3.2.2 Procedure Participants were provided with a link to the survey which took the form of an online questionnaire created using the online survey tool fluid survey.  Survey participants were offered the chance to enter a draw for one of three 25$ gift cards following their completion of the survey.  Pilot testing was done on the survey format to ensure that it was accessible to persons who use screen readers and screen magnification software.  Participants completed a page on informed consent where by clicking agree they agreed to participate in the survey.  3.2.3 Measures Attitudes Toward Seeking Professional Psychological Help Scale: A Shortened Form (ATSPPHS-SF).  (See Appendix H).  The ATSPPHS-SF is a 10-item version of Fischer and Turner’s 29-item scale for assessing attitudes on seeking psychological help (Fischer & Farina, 1995).  Each item is scored on a 4-point Likert-type scale, ranging from 0 (“strongly disagree) to 3 (“strongly agree”).  A total score is the sum of the scores of each individual item.  A high score on this scale is related to a favourable attitude towards seeking professional help for         32  psychological issues.  The ATSPPH-SF has an adequate internal consistency for the author’s original sample (a = .73) (Fischer & Farina, 1995). Social Responsibility about Blindness Scale (SRBS).  This 20 item instrument, (See Appendix I) is designed to measure attitudes towards blindness as a condition, as well as toward the capabilities of blind individuals to perform important social tasks like childcare and employment (Bell & Silverman, 2011).  The measure can be administered to blind and visually impaired as well as sighted populations.  This is a recent scale, and has demonstrated reasonable internal consistency, as well as correlation with a measure of hope, indicating a relationship between a positive view of one’s disability and feelings of hope (Bell & Silverman, 2011).  Further testing is needed, and is underway. Disclosure Expectations Scale (DES).  (See Appendix J).  This 8 item scale is designed to measure the anticipated benefits and risks associated with seeking psychological services (Vogel & Wester, 2003).  The author’s conducted a principal-component factor analysis with a varimax rotation that revealed two factors accounting for 61% of the variance (Anticipated Risk, eigenvalue = 2.1, 28%; Anticipated Utility, eigenvalue = 2.9, 33%).  The factors consist of 4 items each asking either how risky it would be or how beneficial it would be to self-disclose personal information about a problem to a counsellor (Vogel & Wester, 2003).  The author’s reported that each item had a factor loading of .4 or greater, and a Cronbach’s alpha of .74 for the Anticipated Risk subscale and .83 for the Anticipated Utility subscale, respectively (Vogel & Wester, 2003).  Support for the construct validity of the subscales was demonstrated by its negative correlations with self-disclosure as measured by Kahn and Hessling‘s (2001) Distress Disclosure Index and Larson & Chastain’s (1990) Self-Concealment Scale (Vogel & Wester, 2003).  Anticipated risk was negatively correlated with self-disclosure  (r = -.17, p < .02) and         33  positively correlated with self-concealment (r = .26, p < .001), while Anticipated benefit was positively correlated with self-disclosure (r = .24, p < .001), and negatively correlated with self-concealment (r = -.12, p < .05) (Vogel & Wester, 2003).  Concurrent validity was demonstrated by a correlation between the Anticipated Risk subscale (r = .19, p < .01) with a measure of psychological distress (Hopkins Symptom Checklist-21 [HSCL-21]; Green, Walkey, McCormick, & Taylor, 1988), as well as both the Anticipated Risk (r = -.14, p < .05) and Anticipated Utility (r = .18, p < .01) subscales correlating with the Social Provisions Scale (SPS; Cutrona & Russell, 1987) (Vogel & Wester, 2003). Distress Disclosure Index (DDI).  (See Appendix K).  This 12 item Likert type scale with responses ranging from 1 (“strongly disagree”) to 5 (“strongly agree”) is used to measure people’s tendency to conceal versus disclose personally distressing information (Kahn & Hessling, 2001).  6 of the items are reverse scored in order to allow higher scores to indicate a higher tendency to disclose personally distressing information (Vogel & Wester, 2003).  Confirmatory factor analysis revealed a single construct comprised of two poles (self-disclosure and self-concealment (Kahn & Hessling, 2001).  The convergent validity of the DDI was demonstrated by the authors through its positive correlation with Miller, Berg, and Archer’s (1983) Self-Disclosure Index (r = .43), and its negative correlation with Larson and Chastain’s (1990) Self-Concealment Scale (r = .35) (Kahn & Hess-ling, 2001).  The DDI has also demonstrated stable test–retest reliability across 2 and 3 month periods (r = .80, r = .81 respectively) (Kahn & Hessling, 2001).  Self Stigma of Seeking Help Scale (SSOSH).  (See Appendix L).  The SSOSH is a 10-item scale designed “to assess concerns about the loss in self-esteem a person would feel if they decided to seek help from a psychologist or other mental health professional” (Vogel, Wade &         34  Haake, 2006).  The scale has a unidimensional factor structure and has demonstrated adequate reliability across US samples (Vogel, Armstrong, Tsai, Wade, Hammer, Efstathiou & Topkaya, 2013).  The SSOSH has demonstrated test-retest reliability of .72 in college populations, and internal consistency ranging from .79 to .92 (Vogel et al., 2006; Vogel et al., 2013).  Stigma Scale for Receiving Psychological Help (SSRPH).  (See Appendix M).  This is a 5 item scale “designed to assess individuals' perceptions of how stigmatizing it is to receive psychological treatment” (Komiya et al., 2000).  Each question is rated from 0 (“strongly disagree”) to 3 (“strongly agree”), with higher scores indicating a greater perception of stigma associated with receiving psychological services (Komiya et al., 2000).  The SSRPH is a unidimensional scale with an adequate level of internal consistency (coefficient alpha = .72), with construct validity coming from its negative correlation with the ATSPPHS–SF (-.40, p < .0001) (Komiya et al., 2000). Demographic Questionnaires.  (See Appendix D).  Demographic information was collected using a custom questionnaire which included age, gender, ethnicity, location, employment status, education, relationship status, vision diagnosis, visual acuity, age of diagnosis, past use of counselling services, past use of LVRS, and counsellor preference. 3.3 Ethical Considerations One major ethical consideration was the mode of delivery of the survey to the participants.  The survey was distributed electronically by way of an online survey tool that was the most compatible with screen readers and screen magnifiers, to avoid requiring participants having to travel to participate in the study.  Travel can often be an issue for persons with visual impairments, and the intention was for this factor to not be a barrier in the present research.  Another ethical consideration in conducting this research was my personal attachment to the         35  topic and the population.  I am visually impaired, and passionate about shoring up the lack of research on visual impairment in the counselling psychology literature.  I was vigilant in my efforts to remain objective in my analysis of the results. This was achieved in large part through consultation with my committee members.           36  CHAPTER 4 Results 4.1: Measure Means and Correlations: To assess whether the measures employed in this study are interrelated in ways consistent with previous research, a correlation matrix is presented for all measures related to psychological help seeking in Table 1.  Scores on the ATSPPH-SF are correlated in the directions expected based on previous research (negatively with avoidance variables and positively with approach variables).  Measure means and standard deviations are also presented for the entire sample (n = 193). Table 1. Descriptive Statistics and Inter-correlations for Measures Related to Psychological Help-Seeking  1 2 3 4 5 6 M SD 1. ATSPPHS-SF — -.329** .648** .368** -.564** -.312** 20.4560 6.28402 2. DES Risks   — -.273** -.396** .499** .344** 10.7150 4.38233 3. DES Benefits    — .302** -.478** -.335** 14.7254 4.05717 4. DDI    — -.487** -.344** 39.2021 10.82414 5. SSOSH     — .539** 21.3057  7.18033 6. SSRPH      — 5.7358 2.86459 Note: n = 193. ** p < 0.01. * p < .05. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form. DES Risks: Disclosure Expectation Scale - Anticipated Risks Subscale. DES Benefits: Disclosure Expectation Scale - Anticipated Benefits Subscale. DDI: Distress Disclosure Index. SSOSH: Self Stigma of Seeking Help Scale. SSRPH: Stigma Scale for Receiving Psychological Help.   4.2: Hypothesis Testing   Hypothesis one: The first hypothesis stated that attitudes towards seeking psychological services as indicated by scores on the ATSPPHS-SF would differ based on participant’s visual         37  impairment status (legally blind or severely visually impaired), with legally blind participants reporting lower scores than severely visually impaired participants.  The mean scores on the ATSPPHS-SF for the legally blind group (M = 20.5, SD = 6.39) and the severely visually impaired group (M = 20.42, SD = 6.23) were compared using an independent samples t-test (Table 2).  All hypotheses employing t-tests to determine group differences between visual impairment status groups were conducted using a Bonferroni adjusted alpha level of .00714 (.05/7).  The t-test was statistically non-significant at the adjusted Bonferroni p value of .00714, and as a result hypothesis 1 was disconfirmed.  Table 2.  Means, SD’s and t-tests for ATSPPHS-SF by Visual Impairment Status Measure Visual Impairment Status   Legally Blind (n = 84) Severely Visually Impaired  (n = 109)   Mean SD Mean SD t(191) p ATSPPHS-SF 20.5 6.39 20.42 6.23 .085 .932        Note: n = 193. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form.   Hypothesis Two: The second hypothesis stated that attitudes towards seeking psychological services as indicated by scores on the ATSPPHS-SF would differ based on the demographic variables of gender, education, ethnicity, past use of counselling services, and past use of low vision rehabilitation services (LVRS).  Due to the fact that the current sample’s ethnicity was predominantly Caucasian (64.8%) ethnicity was not a suitable variable for analysis in relation to scores on the ATSPPHS-SF (Appendix G).  Due to the fact that the majority of participants had accessed counselling services (78.8%) and LVRS (83.9%) in the past these two         38  variables were not included in the testing of this hypothesis (Appendix G).  As a result the testing of this hypothesis consists of the differences in mean scores on the ATSPPHS-SF for the gender and education variables only.  Gender: For the purposes of this analysis the gender variable was collapsed into a dichotomous variable comprised of either male or female participants, excluding two participants who selected ‘other’ on the gender variable (n = 191).  The mean scores on the ATSPPHS-SF for the male participants (M = 19.2, SD = 6.06) and the female participants (M = 21.2, SD = 6.27) were compared using an independent samples t-test (Table 3). There was a statistically significant effect for gender t(189) = -2.218, p < .05, with women receiving higher scores than men, indicating that women held more positive attitudes towards seeking psychological services than did men in this sample.  As a result hypothesis 2 as it relates to gender was confirmed.  Table 3.  Means, SD’s and t-tests for ATSPPHS-SF by Gender Measure Gender   Male (n = 78) Female (n = 113)   Mean SD Mean SD t(189) p ATSPPHS-SF 19.17 6.06 21.19 6.27 -2.218 .028        Note: n = 191. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form.    Due to the statistically significant effect detected for gender on mean scores on the ATSPPHS-SF, two-way factorial ANOVAs were conducted on all measures.  This analysis was undertaken in an attempt to detect an effect for gender on the remaining measures.  This analysis also allowed for the detection of any interaction effect between gender and visual impairment status.  In light of the lack of difference detected between the two visual impairment status groups on the ATSPPHS-SF, a two-way factorial ANOVA was not conducted on this measure.          39  No gender effects were detected for the remaining psychological variables employed in the present research.  As a result, visual impairment status was confirmed as the main contributing factor to differences in mean scores on the remaining psychological variables.  With respect to scores on the DES Anticipated Risks subscale, there was a statistically non-significant effect for gender F(1, 187) = 2.28, p = .113 (Table 4).  There was a statistically non-significant interaction between gender and visual impairment status F(1, 187) = 1.70, p = .194 (Table 4). Table 4.   Tests of Between-Subjects Effects  Dependent Variable: DES Anticipated Risks Subscale   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 13.548 1 13.548 .714 .399 Gender 43.228 1 43.228 2.277 .133 Impairment Status * Gender 32.289 1 32.289 1.701 .194 Error 3549.352 187 18.980   Total 25772.000 191    Corrected Total 3640.398 190    a. R Squared = .025 (Adjusted R Squared = .009)    With respect to scores on the DES Anticipated Benefits subscale, there was a statistically non-significant effect for gender F(1, 187) = 2.16, p = .143 (Table 5).  There was a statistically non-significant interaction between gender and visual impairment status F(1, 187) = .311, p = .578 (Table 5).           40  Table 5.  Tests of Between-Subjects Effects  Dependent Variable: DES Anticipated Benefits Subscale   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 2.556 1 2.556 .155 .695 Gender 35.723 1 35.723 2.162 .143 Impairment Status * Gender 5.142 1 5.142 .311 .578 Error 3090.512 187 16.527   Total 44393.000 191    Corrected Total 3140.387 190    a. R Squared = .016 (Adjusted R Squared = .000)  With respect to scores on the DDI, there was a non-significant effect for gender F(1, 187) = 1.87, p = .173 (Table 6).  The interaction effect between gender and visual impairment status was statistically non-significant at: F(1, 187) = 1.36, p = .245 (Table 6).           41  Table 6.  Tests of Between-Subjects Effects  Dependent Variable: DDI Total Score   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 693.436 1 693.436 6.123 .014 Gender 211.932 1 211.932 1.871 .173 Impairment Status * Gender 154.314 1 154.314 1.363 .245 Error 21177.558 187 113.249   Total 315718.000 191    Corrected Total 22470.586 190    a. R Squared = .058 (Adjusted R Squared = .042)  With respect to scores on the SSOSH, there was a non-significant effect for gender F(1, 187) = 1.80, p = .182 (Table 7).  There was a non-significant interaction between gender and visual impairment status F(1, 187) = .71, p = .401 (Table 7). Table 7. Tests of Between-Subjects Effects  Dependent Variable: SSOSH Total Score   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 67.211 1 67.211 1.307 .254 Gender 92.326 1 92.326 1.796 .182 Impairment Status * Gender 36.405 1 36.405 .708 .401 Error 9614.243 187 51.413   Total 96688.000 191    Corrected Total 9790.220 190    a. R Squared = .018 (Adjusted R Squared = .002)         42   With respect to scores on the SSRPH, there was a non-significant effect for gender F(1, 187) = 1.01, p = .315 (Table 8).  There was a non-significant interaction between gender and visual impairment status F(1, 187) = .017, p = .896 (Table 8). Table 8.  Tests of Between-Subjects Effects  Dependent Variable: SSRPH Total Score   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 38.293 1 38.293 4.894 .028 Gender 7.938 1 7.938 1.014 .315 Impairment Status * Gender .134 1 .134 .017 .896 Error 1463.245 187 7.825   Total 7675.000 191    Corrected Total 1511.518 190    a. R Squared = .032 (Adjusted R Squared = .016)  With respect to scores on the SRBS, there was a non-significant effect for gender F(1, 187) = .81, p = .369 (Table 9).  There was a non-significant interaction between gender and visual impairment status F(1, 187) = .005, p = .942 (Table 9).           43  Table 9.  Tests of Between-Subjects Effects  Dependent Variable: SRBS Total Score   Source Type III Sum of Squares df Mean Square F Sig. Impairment Status 3473.448 1 3473.448 19.808 .000 Gender 142.419 1 142.419 .812 .369 Impairment Status * Gender .932 1 .932 .005 .942 Error 32791.835 187 175.357   Total 1084306.000 191    Corrected Total 36613.246 190    a. R Squared = .104 (Adjusted R Squared = .090)  The result of the two-way ANOVAS confirms that gender effects held only for mean scores on the ATSPPH-SF. Education: The education variable was collapsed into a dichotomous variable consisting of those participants who had not completed a university or college degree (high school, some college or university, or a two year degree) (n = 95), and a university or college degree or higher (university or college degree, Master’s degree, PhD or post-doctoral degree) (n = 98). The mean scores on the ATSPPHS-SF for the less than a Bachelor’s degree group (M = 20.3, SD = 6.15) and the Bachelor’s degree or higher group (M = 20.6, SD = 6.44) were compared using an independent samples t-test (Table 10).  The t-test was statistically non-significant and as a result hypothesis 2 as it relates to level of education was disconfirmed.            44  Table 10.  Means, SD’s and t-test for ATSPPHS-SF by Level of Education Measure Education   Less than a Bachelor's Degree (n = 95) Bachelor's Degree or Higher  (n = 98)   Mean SD Mean SD t(191) p ATSPPHS-SF 20.32 6.15 20.59 6.44 -.304 .761        Note: n = 193. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form.   Hypothesis three: The third hypothesis stated that legally blind participants would a) score higher on avoidance variables (DES Anticipated Risk Subscale, SSOSH – Self Stigma, SSRPH - Public Stigma), and b) score lower on approach variables (DES Anticipated Benefits Subscale, DDI – Self Disclosure), indicating a lesser likelihood of seeking psychological help.         45  Table 11.  Means, SD’s and t-tests for Approach and Avoidance Variables by Visual Impairment Status Measure Visual Impairment Status    Legally Blind (n = 84) Severely Visually Impaired  (n = 109)   Mean SD Mean SD t(191) p DES Anticipated Risks Subscale 10.9 4.53 10.6 4.28 .494 .622 DES Anticipated Benefits Subscale  14.5 4.08 14.9 4.05 -.605 .546 DDI 36.8 10.1 41.0 11.0 -2.727 .007** SSOSH 22.0 7.58 20.8 6.84 1.201 .231 SSRPH 6.39 2.16 5.31 2.54 2.369 .019* Note: n = 193. ** p < 0.01. * p < .05. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form. DES Risks: Disclosure Expectation Scale - Anticipated Risks Subscale. DES Benefits: Disclosure Expectation Scale - Anticipated Benefits Subscale. DDI: Distress Disclosure Index. SSOSH: Self Stigma of Seeking Help Scale. SSRPH: Stigma Scale for Receiving Psychological  Help. SRBS: Social Responsibility About Blindness Scale.   Avoidance Variables:  1. The mean scores on the DES Anticipated Risks Subscale for the legally blind group (M = 20.3, SD = 6.15) and the severely visually impaired group (M = 20.6, SD = 6.44) were compared using an independent samples t-test (Table 11).  The t-test was statistically non-significant at the adjusted Bonferroni p value of .00714, and as a result hypothesis 3 as it relates to scores on the DES Anticipated Risk Subscale was disconfirmed.          46   2. The mean scores on the SSOSH for the legally blind group (M = 22.0, SD = 7.58) and the severely visually impaired group (M = 20.8, SD = 6.84) groups were compared using an independent samples t-test (Table 11).  The t-test was statistically non-significant at the adjusted Bonferroni p value of .00714, and as a result hypothesis 3 as it relates to scores on the SSOSH was disconfirmed.  3. The mean scores on the SSRPH for the legally blind group (M = 6.39, SD = 2.16) and the severely visually impaired group (M = 5.31, SD = 2.54) were compared using an independent samples t-test (Table 11).  The t-test was statistically non-significant at the adjusted Bonferroni p value of .00714, and as a result hypothesis 3 as it relates to scores on the SSRPH was disconfirmed. Approach Variables: 1. The mean scores on the DES Anticipated Benefits Subscale for the legally blind group (M = 14.5, SD = 4.08) and the severely visually impaired group (M = 14.9, SD = 4.05) were compared using an independent samples t-test (Table 11).  The t-test was statistically non-significant at the adjusted Bonferroni p value of .00714, and as a result hypothesis 3 as it relates to scores on the DES Anticipated Benefits Subscale was disconfirmed. 2. The mean scores on the DDI for the legally blind group (M = 36.8, SD = 10.1) and the severely visually impaired group (M = 41.0, SD = 11.0) were compared using an independent samples t-test (Table 11).  There was a statistically significant effect for visual impairment status at the adjusted Bonferroni p value of .00714, t(191) = -2.727, p < .00714 with legally blind participants receiving lower scores than severely visually impaired participants.   As a result hypothesis 3 as it relates to scores on the DDI was confirmed.          47  Hypothesis four: The fourth hypothesis stated that attitudes towards visual impairment as indicated by scores on the SRBS would differ based on participant’s visual impairment status, with those who are legally blind having more negative attitudes towards their visual impairment than those who are severely visually impaired. Table 12.  Means, SD’s and t-test for SRBS by Visual Impairment Status Measure   Visual Impairment Status    Total Legally Blind (n = 84) Severely Visually Impaired  (n = 109)   Mean SD Mean SD Mean SD t(191) p SRBS 74.05 13.91 69.4 14.0 77.7 12.7 -4.361 .000***          Note: n = 193. *** p < 0.001. SRBS: Social Responsibility About Blindness Scale    The mean scores on the SRBS for the legally blind group (M = 69.4, SD = 14.0) and the severely visually impaired group (M = 77.7, SD = 12.7) were compared using an independent samples t-test (Table 12).  There was a statistically significant effect for visual impairment status at the adjusted Bonferroni p value of .00714, t(191) = -4.361, p < .00714 (Bonferroni adjusted p value), with legally blind participants receiving lower scores than severely visually impaired participants.  As a result hypothesis 4 was confirmed.   Hypothesis five: The fifth hypothesis stated that participants with more negative attitudes towards visual impairment as indicated by scores on the SRBS would a) score higher on avoidance variables (DES Anticipated Risk Subscale, SSOSH – Self Stigma, SSRPH - Public Stigma), and b) score lower on approach variables (DES Anticipated Benefits Subscale, DDI – Self Disclosure), indicating a lesser likelihood of seeking psychological help.         48   Correlational analysis was employed for the testing of hypothesis 5 due to the fact that this is a comparison of scale variables.  Correlations between the SRBS and all other measures employed in this study can be found in Table 13.  Table 13. Correlations for SRBS Scores with Avoidance and Approach Variables Measure ATSPPHS-SF  DES Anticipated Risks Subscale DES Anticipated Benefits Subscale  DDI   SSOSH   SSRPH   SRBS Pearson Correlation .189** -.151* .152* .200** -.209** -.198** Note: n = 193. ** p < 0.01. * p < .05. ATSPPHS-SF: Attitudes Towards Seeking Professional Psychological Help Scale – Short Form. DES Risks: Disclosure Expectation Scale - Anticipated Risks Subscale. DES Benefits: Disclosure Expectation Scale - Anticipated Benefits Subscale. DDI: Distress Disclosure Index. SSOSH: Self Stigma of Seeking Help Scale. SSRPH: Stigma Scale for Receiving Psychological  Help. SRBS: Social Responsibility About Blindness Scale.  Avoidance Variables: Correlational analysis revealed statistically significant negative relationships between scores on the SRBS and the avoidance variables.  The SRBS was correlated negatively with the DES Anticipated Risks Subscale r(191) -.151, p < .05, indicating that participants with more positive attitudes towards their visual impairment anticipated less risk in terms of seeking psychological services.  The SRBS also correlated negatively with the SSOSH r(191) -.209, p < .01, and the SSRPH r(191) -.198, p < .01., indicating that participants with more positive attitudes towards their visual impairment associated less self-stigma and public stigma respectively, with the seeking of psychological services. Approach Variables: Correlational analysis revealed statistically significant positive relationships between scores on the SRBS and the approach variables.  The SRBS was correlated positively with the ATSPPHS-SF r(191) .189, p < .01, indicating that participants with more         49  positive attitudes towards their visual impairment also held more positive attitudes towards the prospect of seeking psychological services.  The SRBS also correlated positively with the DES Anticipated Benefits Subscale r(191) .152, p < .05, and the DDI r(191) .200, p < .01., indicating that participants with more positive attitudes towards their visual impairment also anticipated greater benefits to seeking psychological services, and a greater comfort with disclosing distressing personal information, respectively.  Scores on the SRBS representing attitude toward visual impairment are correlated negatively with avoidance variables and positively with approach variables.  In this sample those participants who held more negative views about visual impairment scored in ways consistent with a lowered likelihood of seeking psychological services. As a result hypothesis 5 was confirmed.  Hypothesis six: The sixth hypothesis stated that participants would report a preference for receiving psychological services from a visually impaired counsellor or therapist.  One hundred and forty three (74%) of participants reported no preference, while 40 (21%) reported a preference for a visually impaired counsellor, and 10 (5%) reported a preference for a sighted counsellor (Appendix G).  No preference for a either a visually impaired or sighted counsellor or therapist was present in this sample of visually impaired participants. As a result hypothesis 6 was disconfirmed.             50  CHAPTER 5 Discussion  The purpose of this study was to investigate the attitudes of persons with visual impairments towards seeking psychological services, relevant variables associated with seeking psychological help, and visual impairment.  In my discussion of the findings of this study I will comment on the results of the statistical analysis with regard to each hypothesis, discuss these results in relation to the literature, comment on limitations of the present research, and suggest implications for future research and practice. 5.1 Hypothesis Discussion  Hypothesis one: The first hypothesis stated that attitudes towards seeking psychological services would differ between participants who were legally blind and those who were severely visually impaired.  Results revealed no statistically significant difference in mean scores between the two visual impairment status groups with regard to their attitudes towards seeking psychological services as measured by the ATSPPHS-SF.  The sample reported a mean score that was higher than that of the sample in the author’s paper outlining the development of the ATSPPHS-SF (Fischer & Farina, 1995).  This comparison to previous research indicates that the participants in the current study held more positive attitudes towards seeking psychological services as measured by scores on the ATSPPHS-SF than the sample in Fischer and Farina’s (1995) study.  One possible reason for this could be the higher than average number of participants in this study who reported having accessed counselling services in the past.  Given the fact that previous studies have found an association between past use of counselling services and positive attitudes towards seeking services (Deane & Todd, 1996; Vogel & Wester, 2003), we might expect the present sample to harbor more positive attitudes towards seeking services.          51  Another consideration in the interpretation of this finding is the fact that the majority of participants in the present study had also accessed low vision rehabilitation services previously.  This figure stands in contrast with previous studies that found only 28% of Canadian seniors who could benefit from LVRS knew how to access them (Southall & Wittich, 2012), while only20% of eligible elderly clients residing in Quebec who could benefit from LVRS had accessed them (Gresset & Baumgarten, 2002).  It is possible that the percentage of participants who reported having accessed LVRS in the present sample was influenced by age, as the studies mentioned previously that found low rates of LVRS utilization were conducted amongst elderly populations.  One possibility is that the working age adults in the current sample face a more pressing need for technology and skills related to workplace or educational demands, and as a result could have been more likely to have accessed LVRS.  Elderly individuals by contrast, who do not find themselves in these contexts, may feel a less urgent need to access low vision services.  It is also possible that the present study is comprised of a sample of people who happened to be more willing to access services in general, as reflected by the high rates of accessing LVRS and counselling services in the past, and the positive attitudes towards seeking psychological services.  Replication of these findings for this population in future studies will be important to determine whether this finding holds across samples.  Although no significant difference was found between visual impairment status groups, the present study is the first to survey persons with visual impairments on their attitudes towards seeking psychological services, and as such helps to establish a baseline measurement for future research to build on.  This work also contributes a previously overlooked demographic variable for consideration to the literature on attitudes towards seeking psychological help.         52  Hypothesis two: The second hypothesis stated that attitudes towards seeking psychological services would differ depending on gender and level of education.  It is important to note that although the two participants who chose “other” for gender were dropped to accommodate the current analysis, the presence of these responses should not be overlooked or dismissed.  Future studies could utilize a qualitative approach to analyze the responses of non-binary gender expressions, to ensure that this minority within the visually impaired community does not go unrepresented. Result’s revealed a statistically significant difference in mean scores between male and female participants in their attitudes towards seeking psychological services as measured by the ATSPPH-SF, indicating that female participants held more positive attitudes towards seeking services than did male participants.  This finding is consistent with previous research in the field (Fischer & Farina, 1995; Fischer & Turner, 1970; Vogel & Wester, 2003).  The authors of the ATSPPHS-SF found in their sample of 389 undergraduate students that the female participants held more positive views than did the male participants (Fischer & Farina, 1995).  In the current study male participants held less positive attitudes towards seeking psychological services than did female participants however, both groups held more positive attitudes than either group in the author’s original research, as indicated by their ATSPPH-SF scores (Fischer & Farina, 1995).  The elevated scores in comparison to previous research  for both gender groups found in the current study is logical given the discussion of hypothesis 1 which noted that attitudes towards seeking psychological services on the whole were more positive than in past studies on non-visually impaired populations.  The statistically significant difference in scores between gender groups prompted a series of two-way factorial ANOVAs to be conducted, to determine whether differences in scores         53  reported on in the remaining hypotheses might be better accounted for by differences between male and female participants, or may in fact be influenced by an interaction between gender and visual impairment status.  Results of the two-way factorial ANOVA’s indicated no statistically significant effects for gender on any of the remaining psychological variables, nor participant’s attitudes towards visual impairment.  Furthermore there was no statistically significant interaction between gender and visual impairment status on any of these measures.  These results strengthen the findings of hypotheses 2, 3 and 4, as they demonstrate that either gender or visual impairment respectively are the main variable at play in the differences in scores on the ATSPPH-SF, DDI and SRBS.  Results revealed no statistically significant differences in scores between participants in the two education groups in terms of their attitudes towards seeking psychological services as measured by the ATSPPH-SF.  This lack of statistically significant difference between education levels is an important finding in itself, as the literature is inconsistent regarding the influence of level of education on attitudes towards seeking psychological services.  McKenzie, Gekoski, and Knox (2006) reported a relationship between higher levels of education and attitudes towards seeking psychological services, with those holding a bachelor’s degree or higher possessing more positive attitudes towards seeking services, although notably this result held only for male participants.  In contrast, Jackson (2013) found that among African American participants, level of education was related to attitudes towards seeking psychological help.  However, the relationship was such that those with high school educations held more positive views of seeking psychological help than did those participants who held bachelor’s degrees.  The findings of the current study contribute to the literature on the influence of this demographic variable.  An important consideration in the interpretation of this result is the fact that only 10% of the current         54  sample possessed a high school education alone. It may be that an effect for education is obfuscated by the elevated rates of post-secondary education in the sample. As a result of the small number of high school education only participants, high school was group in with two year degrees and those who had attended some college.  The effects of these levels of education may not be similar in terms of their impact on attitudes; however this difference would not be detectable in the present data.  Future studies looking to examine the impact of education on the attitudes of persons with visual impairments will need to ensure that they have enough participants with high school educations alone to make comparisons with persons with higher levels of education, as previous research has done (i.e., Jackson, 2013).  Hypothesis three: The third hypothesis stated that scores on variables associated with seeking psychological services would differ depending on visual impairment status.  In the current study no statistically significant differences were found between the participants who were legally blind and those who were severely visually impaired on the measures related to the anticipated risks and benefits of seeking psychological services, nor the perception of self or public stigma related to seeking services.  Scores on these four measures in the current study fell within one standard deviation of the scores reported in the validation studies originally conducted by the measure’s authors, indicating that they did not represent a drastic departure from expected results.  The remainder of the discussion of hypothesis 3 will focus on the variable that did report a significant difference in mean scores between visual impairment status groups, that being comfort with disclosing distressing information (an approach variable).  Results revealed a statistically significant difference in level of comfort disclosing distressing information as measured by scores on the DDI, between the legally blind group and the severely visually impaired group.  This difference indicates that legally blind participants         55  were less comfortable disclosing distressing information than were severely visually impaired participants in the current study.  Scores for the two visual impairment status groups fell on either side of that of the sample reported by the authors in their validation study of the measure (Vogel & Wester, 2003). The difference between the two visual impairment groups found in the present study offers important insight, particularly when this lack of difference is considered in conjunction with the lack of differences between groups on the measures of anticipated risks and benefits associated with seeking services, as the three of these variables have been found to be related in previous research (Vogel & Wester, 2003).  Legally blind participants in this study perceived there to be similar levels of risk and possibilities for benefit to the severely visually impaired participants.  This finding stimulates researchers to ask why legally blind participants would seemingly perceive seeking psychological services as equally risky and beneficial respectively to their severely visually impaired peers, and yet still indicate a greater tendency to conceal distressing information.  Relevant here may be the confirmation of the hypothesis that legally blind participants would have more negative attitudes towards visual impairment than would severely visually impaired participants.  It could be the case that legally blind participant’s negative attitude towards visual impairment constitutes distressing personal information, representing a level of discomfort with a fundamental aspect of their identities.  If this were the case, legally blind participants may not wish to disclose this distress, as this disclosure could put them in direct contact with the contradictory facts that they are both visually impaired, and harbor negative attitudes towards visual impairment.  In my discussion of these findings I will suggest the notion of “comfort with disclosing distressing personal information related to disability” as a possible contributing factor.  If a         56  legally blind participant were distressed by their status as a visually impaired person (as indicated by the legally blind groups negative attitude toward visual impairment), perhaps they would prefer not to disclose on the topic of disability, but would still perceive potential benefits and few risks in disclosing other distressing personal information to a counsellor or therapist.  This decision might indicate the necessity for a disability related distress specific measure to tease apart differences in content specific disclosure tendencies  The possible differing natures of the disabilities of the legally blind and severely visually impaired groups respectively may also shed light on these findings and help to explain the relationship between visual impairment status, comfort with disclosure and attitude towards disability.  There is a possible differential disability experience between the two visual impairment status groups that relates to the idea of visible versus invisible disabilities.  A disability is referred to as ‘invisible’ if it is not readily apparent to an onlooker (Harder, 2009).  With respect to visual impairment, a legally blind individual with a higher level of functional vision may not require a long mobility cane, a talking wristwatch, or a service dog, all of which would typically constitute visible markers of visual impairment.  If we placed a legally blind person who does not use any of these implements, and a severely visually impaired person with a guide dog next to one another, many observers may assume that only the guide dog user was visually impaired, thus rendering the legally blind person’s disability ‘invisible’.  It may be noted that it is likely not the case that all participants in the legally blind group would be classifiable as having an invisible disability, as some may use canes or guide dogs.  It does, however, seem more likely that with a greater amount of functional vision we might expect a greater number of participants whose disability could be classified as “invisible”.          57  Being a person who is visually impaired constitutes the embodiment of a stigmatized identity, with much research pointing to the negative ways in which people with visual impairments are perceived (Hodge et al., 2010).  When someone possesses an invisible disability, the issue of disclosure becomes relevant because the individual can pick and choose where, when, and how they will disclose this disability to others, and as a result they might determine how and when they adopt this stigmatized identity.  This choice is likely to be contextual, and based on a number of factors, such as a cost-benefit analysis of the ramifications of revealing the disability (Chaudoir & Quinn, 2010).  The ongoing management of this decision making process may lead one to be more sensitive to the possibility of being perceived as a member of a stigmatized group.  Given the negative attitudes often associated with visual impairment, a legally blind person who is able to conceal their disability may choose not to disclose that disability in certain circumstances in order to avoid the negative appraisal this disclosure could elicit.  This decision would make sense in light of the negative attitudes towards visual impairment reported by the legally blind participants in the present study.  The flip side of this ability to conceal a visual impairment is the fact that often the disability goes unrecognized, and can be misunderstood, or viewed as excuse making.  In some situations the presence of a visible disability could make it easier to acquire help when needed (for example the presence of a guide dog cuing a store employee to inquire with a customer about the need for assistance) (Harder, 2009).  The presence of a marker of disability gives structure and context for a request for help, whereas the legally blind person whose visual impairment is not readily visible will have to make the choice to step into the stigmatized identity in order to justify a request for assistance. (Harder, 2009).         58  These different possible disclosure experiences of  legally blind and severely visually impaired persons respectively could help to explain a differential experience with the stigma associated with visual impairment, and the disparity in attitudes towards visual impairment found in the present research.  The severely visually impaired person whose disability is visible may be more readily able to, and required to, incorporate their visual impairment status into their self-concept due to its omnipresence as a component of their public persona.  This interpretation would appear to be supported by the more favorable attitudes towards visual impairment held by the severely visually impaired participants in this study.  One aspect of the development of a positive sense of self for a person with a disability is the incorporation of the disability into a positive view of the self as a whole (Bell & Silverman, 2011).  The legally blind person with the invisible disability however, aware of the stigma associated with visual impairment may choose to disclose their disability only when absolutely necessary, and in most other cases strive to present themselves as more similar to the less stigmatized and thus more highly socially valued sighted majority.  Goffman (1963) wrote that members of a stigmatized group are often hyper-aware of, and sensitive to, the negative stigmas associated with their group, and may internalize those negative opinions of the group, resulting in the decision to conceal their group membership when possible.  This would in theory allow for negative views towards disability to persist in legally blind persons, in spite of their embodiment of the identity of ‘person with a visual impairment. Future studies could investigate whether visually impaired participants view disclosure related to distress about disability as any more or less distressing, compared to disclosures around other issues.  Additionally it would be helpful to know whether there are differences in the perceived risks and benefits associated with disclosures related to distress around issues of         59  disability.  The answers to these questions may also re-open the discussion on counsellor similarity, as if there are differences related to types of disclosure, a visually impaired client might report differing comfort levels discussing distress related to visual impairment with a sighted or visually impaired counsellor respectively.  See the discussion of hypothesis 6 for an elaboration on the inclusion of counsellor preference in future research. Hypothesis four: The fourth hypothesis stated that attitudes towards visual impairment would differ depending on visual impairment status.  Results revealed statistically significant differences in attitudes towards visual impairment with legally blind participants reporting more negative attitudes towards visual impairment than did severely visually impaired participants, as measured by scores on the SRBS.  Scores for the two visual impairment groups fell below that of the sample reported by the authors in their validation study of the measure (Bell & Silverman, 2011).  A study by Rowland and Bell (2012) compared scores on the SRBS between sighted participants and blind participants.  The mean score of the legally blind participant group in the current study fell between those of the sighted and blind groups in Rowland and Bell (2012), while the mean score of the severely visually impaired participant group in the current study fell above that of the blind group in Rowland and Bell (2012). In comparing means on the SRBS in the current study to those in the Rowland and Bell (2012) study, I noted that the legally blind participant’s scores in the current study fell between those of the sighted and blind groups in the author’s study.  Because the author’s categories were “sighted” and “blind”, it is likely that there blindness sample was assumed to be homogenous, having met the cutoff of a visual acuity of less than 20/200 (i.e., legally blind).  The fact that the legally blind and severely visually impaired group’s scores in the present study were different, and that the legally blind group’s scores fell between the sighted and blind groups in the author’s         60  research support the findings of the present research that detected between group differences on multiple variables, and points to the non-homogeneity of blindness as a category.  The present study then adds nuance to the category of blind persons by identifying the existence of sub-categories within blindness that have yet to be reported on in previous attitude towards visual impairment research. The finding in the present study that the legally blind group’s scores fell between the sighted and blind group’s scores in previous research  also mirrors the reality of legal blindness, in that it lies somewhere between the identities of sightedness and total blindness.  In fact, people who are legally blind are sometimes referred to as ‘partially-sighted.’  In the face of this in-between-ness, and given the stigma associated with visual impairment, it makes sense that there would be a movement by legally blind persons towards the attitudes of the higher status sighted majority.  In the discussion of hypothesis 3 it was suggested that the lower levels of comfort disclosing distressing information reported by the legally blind group in the present sample could be related to their more negative attitudes towards visual impairment.  Invisible disabilities are complex in that they lack a social protocol with which to engage.  Whereas a cane or guide dog may indicate that a blind person may require assistance, a legally blind individual may be required to explain his or herself prior to receiving help (Harder, 2009).  A person’s level of comfort around disclosure related to disability could lead to that person seeking help less often than their severely visually impaired counterparts.  Thus; legally blind persons may come to associate this discomfort with disclosure with being visually impaired, and as a result may never come to identify positively with visual impairment.  The more negative attitudes held by legally blind participants in this study could relate to the fact that they are in-between identities, and thus do not benefit from full identity adoption in the same way that         61  severely visually impaired individuals do.  One study looking at stigma related to mobility cane usage found that early in the adoption process, new cane users perceived there to be high levels of stigma associated with cane use, yet with cane mastery participants came to view their canes as positive symbols of independence (Wainapel, 1989).  Here we see the potential for someone who might appear more stigmatized, or in other words “more blind,” to actually have a healthier sense of self and a more positive attitude towards visual impairment, given their new appreciation for what mastery of implements like the white cane can mean for quality of life.  As noted above, many legally blind individuals do not require mobility canes or other external visible signifiers of visual impairment, and thus may never have the opportunity to make this transition from regarding such implements as signifiers of stigma to positive symbols of independence.  The fact that they are often able to get by without adopting implements associated with visual impairment could help to explain how this more negative view of disability is reinforced and maintained in legally blind individuals.   This suggestion in combination with the fact that the concealment of invisible stigmas has been found to be related to lowered levels of self-esteem (Chaudoir & Quinn, 2010) provides a context for the findings about the difference in attitudes between visual impairment status groups.  Hypothesis five: The fifth hypothesis stated that more positive attitudes towards visual impairment would be positively associated with approach variables and negatively associated with avoidance variables.  The directionality of these associations indicates that those with more positive attitudes towards their visual impairment tended to have scores indicative of a greater likelihood of seeking psychological services.  All approach and avoidance variables were significantly correlated in the ways predicted by hypothesis 5.  Correlational analysis revealed statistically significant positive relationships between attitudes towards visual impairment and         62  attitudes towards seeking psychological services, the anticipated benefits of seeking psychological services, and comfort with the disclosure of distressing personal information.  Correlational analysis also revealed statistically significant negative correlations between attitude towards visual impairment and the anticipated risks of seeking psychological services, as well as the perceived self-stigma, and the perceived public stigma associated with seeking psychological services.  In light of this pattern of correlation, and given the similar inter-correlations amongst the approach variables to the measure of attitudes towards seeking psychological services employed in this study, it seems reasonable to suggest that attitude towards visual impairment be classified as an approach variable, as higher scores on this measure were positively associated with higher scores on the measure of attitudes towards seeking psychological services.  It is important to note that given the correlational nature of this research, no causal inferences can be gleaned from the present findings.  Future research might investigate attitude towards visual impairment using moderated multiple regression analysis to explore a possible moderating effect for attitude towards visual impairment on the other approach and avoidance variables.  Hierarchical multiple regression analysis might be used to investigate how much of the variance in scores on the ATSPPHS-SF is accounted for by scores on the SRBS, compared to that accounted for by scores on the other approach and avoidance variables. Hypothesis six: The sixth hypothesis stated that participants with visual impairments would report a preference for a visually impaired counsellor or therapist.  In the current study it was found that the majority of participants reported no preference when provided with the response options of receiving psychological services from a visually impaired counsellor or therapist, a sighted counsellor or therapist, or no preference.  This finding is consistent with         63  previous research on counsellor similarity that found no preference amongst clients for similarly-gendered or ethnically similar counsellors (Atkinson et al., 1998; DeHeer, Wampold, & Freund, 1992).  Atkinson et al. (1998) suggested that a preference among ethnic minorities for an ethnically similar counsellor that had been identified in previous studies was actually a proxy for a culturally similar counsellor (one who shared similar attitudes and values).  The lack of preference found in the current study could indicate that visually impaired clients may not view themselves as culturally different than their sighted peers.  It could also be the case that given the low incidence of counsellors with disabilities, and the high percentage of this sample that has accessed counselling services, participants may have already experienced a positive therapeutic relationship with a non-visually impaired counsellor.  A positive experience with a non-visually impaired counsellor may have made this distinction less important than it might be for visually impaired participants who had never accessed counselling services.   As mentioned during the discussion of hypothesis 3 as it related to the lower comfort level of legally blind participants with disclosing personally distressing information, future studies may wish to look at whether there are differences in willingness to disclose all types of distressing personal information, versus distressing personal information related to disability specifically.  If there were a difference in attitudes towards these types of disclosures, the question of counsellor similarity may be a relevant in future studies, in spite of the lack of preference reported in the current study.  Support for this notion can be drawn from research by Pope-Davis, Toporek, Ortega-Villalobos, Ligiéro, Brittan-Powell, Liu, and Liang (2002) who found that clients who defined themselves or their concerns in terms of cultural constructs had a greater preference for a racially or gender-similar counsellor.  In considering visual impairment         64  from a multicultural perspective, a client wishing to discuss issues around visual impairment may report a preference for a visually impaired counsellor.  5.2 Limitations  In the current study the hypotheses tested were correlational.  A series of t-tests were performed to detect differences between the two visual impairment status groups.  Further, the effects of gender and visual impairment status variables were entered into 2x2 factorial ANOVAs.  More sophisticated statistical analysis may be required to examine the amount of variance in scores on the ATSSPH-SF that each psychological variable accounted for. Another limitation of this study is related to the ability of the participants to easily access the survey.  Although UBC offers graduate students access to a survey tool that is more accessible than other survey platforms as it relates to assistive technology for the visually impaired, (such as screen readers and magnifiers) the survey platform employed ran into numerous issues for participants.  As a matter of ethics and equity of access it is my recommendation that UBC find a survey platform that has been made fully accessible to those with impairments.  This is an issue not only for studies such as this one, but also a matter of ensuring the inclusion of this population in non-disability specific research.  Another limitation related to technology is the fact that this survey was offered online only, and thus participants were required to be skilled enough with assistive technology to navigate their way through the survey.  An additional limitation of the current study is that all measures employed in this survey relied on self-report information, and thus the results may have been influenced by an inclination to answer in a socially desirable manner.           65  5.3  Implications 5.3.1 Research This study represents a significant step towards inclusivity in the counselling psychology literature, and for the research topic of attitudes towards the seeking of psychological services specifically.  The present study broadens the scope of previously considered variables by including visual impairment status and attitude toward visual impairment.  It represents to the author’s knowledge the first survey of the attitudes of persons with visual impairment towards the seeking of psychological services, and has identified that legally blind and severely visually impaired participants in this sample differed in their attitudes towards disclosing distressing personal information, and toward visual impairment.  In instances where no between group differences were detected, valuable data were obtained on the attitudes of persons with visual impairments, and will serve as a foundation for future research both on this topic, and with this population.  This work replicated the findings of previous research that reported an effect for gender on attitudes toward seeking counselling services (Fischer & Farina, 1995; Fischer & Turner, 1970; Vogel & Wester, 2003; Choi & Miller, 2014).  The follow up analyses detecting no effects for gender or for an interaction between gender and visual impairment status on the remaining variables point to the fact that visual impairment status exerted a significant and unique effect on comfort disclosing distressing information and attitude toward visual impairment.  This work also contributes to research on attitude towards visual impairment, and points to the existence of sub-groups within the previously researched “blind” category.  The difference between legally blind and severely visually impaired participants in their attitudes towards visual impairment provides insight into the different relationships the two groups may         66  have with disability status, and expands on previous work that considered only one blindness category (Bell & Silverman, 2011; Rowland & Bell, 2012). To expand on the findings presented in this paper, future studies could look to apply hierarchical multiple regression analysis in order to determine the amount of variance accounted for by each of the psychological variables with regard to their influence on participant’s attitudes toward seeking psychological services.  This would aid in supporting previous work that has reported on the effect of these psychological variables (Kahn & Hessling, 2001; Komiya et al., 2000; Vogel & Wester, 2003).  The inclusion of attitude towards visual impairment in that analysis would also allow for the examination of whether that variable should be classified as an approach variable (as suggested by the pattern of associations reported in hypothesis 5).  If this relationship were not confirmed, an investigation into attitude towards visual impairment as a possible moderating variable on the relationship between the approach and avoidance variables and attitudes toward seeking psychological services could also yield important results.  Additionally, in light of the significant effect found for distress disclosure between groups, future studies may wish to target distress disclosure to ascertain a more detailed picture of what underlies this difference.  The creation of a measure of “comfort with disclosing distressing information related to disability” could help to elucidate why it is that legally blind participants held similar views to the severely visually impaired participants in terms of seeking counselling services, while at the same time reporting a lesser comfort with disclosing distressing information.  It would be valuable to discover whether different tendencies to self-disclose emerge depending on the topic to be disclosed on (i.e., disability, anxiety, depression).  The inclusion of the anticipated benefits and risks of disclosing each type of distressing information would be important here as well, given its prior association with distress disclosure in past work         67  (Vogel & Wester, 2003).  As suggested earlier in this thesis, a consideration of the role of attitude towards visual impairment could also be useful in the investigation of disclosure with this population.  As well, research into counsellor preference as a function of disclosure type could contribute to the previously mixed counsellor preference research on gender and ethnic similarity (Atkinson et al., 1998; DeHeer et al., 1992; Pope-Davis et al., 2002).  There are a number of considerations for future research that are important from a methodological perspective.  In light of the barrier of technology competence, future studies could offer other survey completion options for persons with visual impairments, such as having someone deliver the survey to the person via telephone.  The present research could also serve as a foundation for qualitative research with this population.  Of particular interest would be an investigation into the experience of disclosing distressing information for persons who are legally blind.  Qualitative work would also be well-suited to investigate the small number of respondents who chose “other” in the gender response category, as the number of these responses was too small to be included in the quantitative analysis techniques employed in this research design.  Focus groups could also be useful in identifying thematic differences and possible explanatory factors underlying the differential attitudes towards visual impairment reported by visual impairment status groups in the present study.  Finally, perhaps the most significant of the implications of the present study for the counselling psychology literature is the fact that this work not only represents a contribution on the topic, but also a contribution by a researcher who identifies as having a disability.  Foley-Nicpon and Lee (2012) reported that the number of APA members who identify as having a disability is less than 1%.  An increase in the amount of research on the topic of disability, done by stakeholders from this population will aid in lending credibility to the focus and direction of         68  disability research in the field.  This research answers the first half of the call from scholars for specialty areas in psychology such as counselling psychology to incorporate disability into both research and training (Foley-Nippon & Lee, 2012).  The findings of this research highlight the need for the latter part of that call to be addressed. 5.3.2 Practice  In considering working with clients with visual impairments from a multicultural perspective, the issue of cultural competency is pertinent (Foley-Nippon & Lee, 2012).  In light of the high rates of persons with visual impairments having accessed counselling services in the past, and their positive attitudes towards seeking psychological services found in the current study, the field of counselling needs to develop ethical guidelines and protocols for practicing with this population.  Given the findings of this research and their relevance to working aged adults, and the fact that levels of visual impairment will rise in Canada as its population ages, it will be a matter of great importance to prepare working therapists to work with visually impaired clients.  This study found a relationship between attitude towards visual impairment and attitudes towards seeking psychological services.  If a client with a visual impairment is less likely to disclose distressing information, attitude towards disability may be a pertinent conversation to engage in with the client.  Studies that have run group interventions geared towards disability acceptance and making a positive shift in attitude toward visual impairment have found scores on the SRBS, the measure employed in this study, as having risen significantly (Bell & Silverman, 2011).  The results of this type of intervention could then increase the likelihood of a client seeking individual psychological services, given the relationship between attitude toward visual impairment and seeking psychological services.  Other studies have found that when persons with visual impairments are offered LVRS in combination with individual counselling they         69  experience improvements in a number of psychosocial domains, as well as an improved attitude towards visual impairment (Ueda & Tsuda, 2013). These findings paired with findings in past research indicating that persons with visual impairments will remain more engaged with LVRS when LVRS are offered in combination with counselling services, provides counsellors with a direct target when working with  this population (Southall & Wittich, 2012).  In a low vision rehabilitation setting, a focus on client’s attitudes towards their disability may bare fruitful results in terms of the uptake of skills such as Braille literacy or cane usage, but may also then increase a client’s likelihood of seeking psychological services, which we know, in turn influences a client to stay more engaged with their LVRS training.   These implications for practice then span beyond the field of counselling and into the field of vocational rehabilitation, and indeed point toward the importance of an interdisciplinary partnership when working towards the best possible outcomes for visually impaired clients.  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Professional Psychology: Research and Practice, 44(1), 37-45. Nicholls, T. (2005). RNIB Bristol counselling project report. London: Royal National Institute for the Blind. National Coalition for Vision Health. (2013). FAQ . Retrieved from http://www.visionhealth.ca/faq.htm Nyman, S. R., Gosney, M. A., & Victor, C. R. (2009). Psychosocial impact of visual impairment in working age adults. British Journal of Ophthalmology, 11(94) 1427-1431. Nyman, S. R., Gosney, M. A., & Victor, C. R. (2010). Emotional well-being in people with sight loss: Lessons from the grey literature. British Journal of Visual Impairment, 28(3), 175-203. doi:10.1177/0264619610374171 Omarzu, J. (2000). A disclosure decision model: Determining how and when individuals will self-disclose. Personality and Social Psychology Review, 4(2), 174-185. O'Neil, J. M. (2008). Summarizing 25 years of research on men's gender role conflict using the gender role conflict scale new research paradigms and clinical implications. The Counseling Psychologist, 36(3), 358-445.         77   Pinquart, M., & Pfeiffer, J. P. (2011). Psychological well-being in visually impaired and unimpaired individuals: A meta-analysis. British Journal of Visual Impairment, 29(1), 27-45. doi:10.1177/0264619610389572 Pollard, T. L., Simpson, J. A., Lamoureux, E. L., & Keeffe, J. E. (2003). Barriers to accessing low vision services. Ophthalmic and Physiological Optics, 23(4), 321-327. doi:10.1046/j.1475-1313.2003.00123.x Pope-Davis, D. B., Toporek, R. L., Ortega-Villalobos, L., Ligiéro, D. P., Brittan-Powell, C. S., Liu, W. M., & Liang, C. H. (2002). Client perspectives of multicultural counseling competence: A qualitative examination. The Counseling Psychologist, 30(3), 355-393. doi:10.1177/0011000002303001 Robinson, B. L., & Lieberman, L. J. (2004). Effects of visual impairment, gender, and age on self-determination. Journal of Visual Impairment & Blindness, 98(6), 351-366. Rowland, M. P., & Bell, E. C. (2012). Measuring the Attitudes of Sighted College Students toward Blindness. Journal of Blindness Innovation and Research, 2(2). Rusch, N., Corrigan, P. W., Wassel, A., Michaels, P., Olschewski, M., Wilkniss, S., & Batia, K. (2009). Ingroup perception and responses to stigma among persons with mental illness. Acta Psychiatrica Scandinavica, 120(4), 320-328. doi:10.1111/j.1600-0447.2009.01403.x Sacks, S. Z., Wolffe, K. E., & Tierney, D. (1998). Lifestyles of students with visual impairments: Preliminary studies of social networks. Exceptional Children, 64(4), 463-478. Sirey, J. A., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Raue, P., Friedman, S. J., & Meyers, B. S. (2001). Perceived stigma as a predictor of treatment discontinuation in         78  young and older outpatients with depression. The American Journal of Psychiatry, 158(3), 479-481. doi:10.1176/appi.ajp.158.3.479 Southall, K., & Wittich, W. (2012). Barriers to low vision rehabilitation: A qualitative approach. Journal of Visual Impairment & Blindness, 106(5), 261-274.  Statistics Canada. (2009, February 26, 2009). Facts on Seeing Limitations. Publications. Retrieved May 21, 2014 Ueda, Y., & Tsuda, A. (2013). Differential outcomes of skill training, group counseling, and individual cognitive therapy for persons with acquired visual impairment. Japanese Psychological Research, 55(3), 229-240. doi:10.1111/jpr.12010 Vogel, D. L., Bitman, R. L., Hammer, J. H., & Wade, N. G. (2013). Is stigma internalized? The longitudinal impact of public stigma on self-stigma. Journal of Counseling Psychology, 60(2), 311-316. doi:10.1037/a0031889 Vogel, D. L., Shechtman, Z., & Wade, N. G. (2010). The role of public and self-stigma in predicting attitudes toward group counseling. The Counseling Psychologist, 38(7), 904-922. doi:10.1177/0011000010368297 Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology, 53(3), 325-337. Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007b). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40-50. Vogel, D. L., Wade, N. G., & Hackler, A. H. (2008). Emotional expression and the decision to seek therapy: The mediating roles of the anticipated benefits and risks. Journal of Social and Clinical Psychology, 27(3), 254-278.         79   Vogel, D. L., & Wester, S. R. (2003). To seek help or not to seek help: The risks of self-disclosure. Journal of Counseling Psychology, 50(3), 351-361. doi:10.1037/0022-0167.50.3.351 Vogel, D. L., Wester, S. R., & Larson, L. M. (2007a). Avoidance of counseling: Psychological factors that inhibit seeking help. Journal of Counseling and Development, 85(4), 410-422. Vogel, D. L., Wester, S. R., Wei, M., & Boysen, G. A. (2005). The Role of Outcome Expectations and Attitudes on Decisions to Seek Professional Help. Journal of Counseling Psychology, 52(4), 459-470. Wade, N. G., Post, B. C., Cornish, M. A., Vogel, D. L., & Tucker, J. R. (2011). Predictors of the change in self-stigma following a single session of group counseling. Journal of Counseling Psychology, 58(2), 170-182. doi:10.1037/a0022630 Wainapel, S. F. (1989). Attitudes of visually impaired persons toward cane use. Journal of Visual Impairment & Blindness, 83(9), 446-448.  Waern M., Rubenowitz, E., Runeson, B., Skoog, I., Wilhelmson, K., & Allebeck, P. (2002). Burden of illness and suicide in elderly people: Case-control study. British Medical Journal, 324(7350), 1355-1358. Wagner, E. (2004) Development and Implementation of a Curriculum to Develop Social Competence for Students with Visual Impairments in Germany. Journal of Visual Impairment & Blindness, 98(11), 703-710. Willig, C. (2013). Introducing qualitative research in psychology. Liverpool, UK: Open University Press McGraw-Hill Education.         80   Wolffe, K., & Sacks, S. Z. (1997). The lifestyles of blind, low vision, and sighted youths: A quantitative comparison. Journal of Visual Impairment & Blindness, 91(3), 245-257.  World Health Organization (2014). Vision Impairment and Blindness: Fact Sheet N*282. Retrieved From: http://www.who.int/mediacentre/factsheets/fs282/en/          81  Appendices APPENDIX A Sample Letter to Organizations  Visually Impaired Research Participants Needed     October 30, 2015    Dear (Recipient Organization),   My name is Sean Heaslip. I am a graduate student at the University of British Columbia, working towards my Master of Arts Degree under the co-supervision of Dr. Ishu Ishiyama, and Dr. Colleen Haney, in the Department of Educational and Counselling Psychology, and Special Education. I also happen to be visually impaired, having been diagnosed with Stargardt’s Macular Degeneration at age 8.   The purpose of this letter is to briefly explain my thesis project, and ask for your permission and assistance distributing the invitation for your members and subscribers to your email correspondence to participate in our study.   The purpose of the study is to investigate about the attitudes of visually impaired people towards the seeking of psychological services (for example counselling services). This is an opportunity for people with visual impairments to share their thoughts as a member of the visually impaired community, and contribute to the research on psychological help-seeking by serving as representative voice of this often overlooked group.   This voluntary survey consists of an online questionnaire which will require approximately 45 min. to complete. It is completely anonymous and confidential.  Participants will be offered entry into a draw for one of three $25 gift cards, via a separate webpage.     Information will be collected securely via FluidSurvey, (the Canadian version of SurveyMonkey) (https://www.surveymonkey.com/mp/policy/security//), and stored on secure servers only accessible by researchers (Dr. Ishiyama, Dr. Haney and S. Heaslip).   Faculty of Education  Department of Educational and Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC   Canada   V6T 1Z4  Phone  604 822 0242 Fax  604 822 3302          82  If your organization agrees to distribute our study to your members, please reply to this email indicating your agreement.  You will then be sent a description and link to the study to share with members.  If you have any further questions you may contact Sean Heaslip at , or xxx-xxx-xxxx. You may also contact Dr. Ishiyama at , or xxx-xxx-xxxx 5329, and Dr. Colleen Haney at , or xxx-xxx-xxxx.     Your organization’s participation in this study is highly valued and appreciated, as hearing the opinions of your members is extremely important to us. Thank you for considering our request.   Sincerely,   Sean Heaslip T:  E:    Dr. Ishu Ishiyama                              T:  E:     Dr. Colleen Haney                              T:  E:                        Counselling Psychology • Human  Development • Learning and Culture Measurement, Evaluation and Research Methodology • School Psychology • Special Education            83    APPENDIX B Sample Recruitment Advertisement  Visually Impaired Research Participants Needed                You are invited to take part in a study exploring the attitudes of visually impaired people towards seeking psychological services.    What Is Involved?  You will be asked to complete an anonymous online survey which will require approximately 45 minutes.   In this survey, you as a person with a visual impairment are asked questions about your attitudes towards seeking psychological services (e.g., professional counselling services) and about visual impairment.    Why participate?  It is very rare to find research which investigates the attitudes and perspectives of the visually impaired on seeking psychological services. This is one of the very few studies on this subject, and we are hoping that you will consider volunteering to participate in this survey.   We hope to produce important information that contributes to improving the research on people’s attitudes towards seeking psychological services by including the perspectives of the visually impaired, making your contribution essential and greatly appreciated. Sean Heaslip is a graduate student in counselling psychology at UBC conducting research for his MA thesis and is also visually impaired. He is committed to ensuring equal representation for the visually impaired community in research.  You will also be offered entry into a draw for one of three $25 gift cards.      Who is eligible to participate?   People who are blind or visually impaired (a visual acuity of 20/200 or less, (typically described as either “legally blind” or “blind” respectively). People between the ages of 21 and 64. People from Canada or the United States.   Faculty of Education  Department of Educational and Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC   Canada   V6T 1Z4  Phone  604 822 0242 Fax  604 822 3302          84   The study is located at: https://survey.ubc.ca/surveys/37-3d32884db03e77386ce8688b73b/willing-and-vi/  Freedom to withdraw from study at any time  If you wish to participate, click or copy and paste the link into your browser, and follow instructions.   Clicking on the study link or contacting us in no way commits you to participate.   If you do decide to participate you can quit at any time.   If you would like more information, please contact graduate student researcher, Sean Heaslip at: , or xxx-xxx-xxxx.  You may also contact Sean’s supervisors, Dr. Ishiyama at , or xxx-xxx-xxxx, and Dr. Colleen Haney at , or xxx-xxx-xxxx.    The Title of this project is “An investigation into the psychological help-seeking attitudes of persons with visual impairments ”The principal investigator is Dr. Ishiyama in the Department of Educational and Counselling Psychology, and Special Education at the University of British Columbia | Ethical concerns about the study may be directed to UBC's Behavioural Research Ethics Board at xxx-xxx-xxxx.            85  APPENDIX C Participant Instructions Visual Impairment and Seeking Psychological Services Instructions Study Information: The following study is being conducted as part of Sean Heaslip’s M.A. thesis, under the co-supervision of principal investigator Dr. Ishu Ishiyama, and Dr. Colleen Haney, at the University of British Columbia’s Department of Educational and Counselling Psychology, and Special Education. Study Purpose:We are asking you to complete this anonymous survey to help explore the attitudes of visually impaired people towards seeking psychological services and visual impairment. The purpose of the study is to obtain information about the attitudes of visually impaired people towards the seeking of psychological services. This is your opportunity to share your thoughts as a member of the visually impaired community, and contribute to the research on psychological help-seeking by serving as representative voice of this often overlooked group. Study Requirements:Completing an approximately 45 minute survey· Having a visual acuity of 20/200 or greater (more commonly phrased as being either legally blind or blind).· Being between the ages of 21 and 64.· Living in either Canada or the United States. Confidentiality:The survey is completely confidential. There will be no records identifying participants, and you will remain anonymous. If you choose to enter the prize draw (for 1 of 3 $25 gift cards), you will be redirected to a new page, and your email address will not be connected to your survey responses. Information will be collected securely via FluidSurvey, the Canadian version of SurveyMonkey (https://www.surveymonkey.com/mp/policy/security//), and stored on secure servers only accessible by the researchers (Dr. Ishiyama, Dr. Haney, and S. Heaslip). The findings from this study may be used in future research presentations and publications, though no identifying information will be shared. Potential Risk:        If you experience an emotional reaction as a result of completing this survey, and feel as though you would like some counselling resources in your area, please contact the student researcher with your location and he was pass resources along to you. You may quit at any time.  Please answer the questions as completely as possible.  However, after you submit the completed survey, it will not be possible to withdraw your contribution. Questions or Concerns:If you have any questions or concerns about the study, please contact graduate student researcher Sean Heaslip by email at , or by phone at xxx-xxx-xxxx, the principal investigator Dr. Ishu Ishiyama by email at, or by phone at xxx-xxx-xxxx,or Dr. Colleen Haney by email at , or by phone at xxx-xxx-xxxx. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at xxx-xxx-xxxx 8 or if long distance e-mail , or call toll free xxx-xxx-xxxx.           86  APPENDIX D: Survey – Participant Version Directions: For the following statements, please select the item that most closely fits your response. 1. If I believed I was having a mental breakdown, my first inclination would be to get professional attention.  Disagree  Partly Disagree  Partly Agree  Agree 2. The idea of talking about problems with a psychologist strikes me as a poor way to get rid of emotional conflicts.  Disagree  Partly Disagree  Partly Agree  Agree 3. If I were experiencing a serious emotional crisis at this point in my life, I would be confident that I could find relief in psychotherapy.  Disagree  Partly Disagree  Partly Agree  Agree 4. There is something admirable in the attitude of a person who is willing to cope with his or her conflicts and fears without resorting to professional help.  Disagree  Partly Disagree  Partly Agree  Agree         87  5. I would want to get psychological help if I were worried or upset for a long period of time.  Disagree  Partly Disagree  Partly Agree  Agree 6. I might want to have psychological counseling in the future.  Disagree  Partly Disagree  Partly Agree  Agree 7. A person with an emotional problem is not likely to solve it alone; he or she is likely to solve it with professional help.  Disagree  Partly Disagree  Partly Agree  Agree 8. Considering the time and expense involved in psychotherapy, it would have doubtful value for a person like me.  Disagree  Partly Disagree  Partly Agree  Agree 9. A person should work out his or her own problems; getting psychological counseling would be a last resort.  Disagree  Partly Disagree  Partly Agree  Agree         88  10. Personal and emotional troubles, like many things, tend to work out by themselves.                                                                           Disagree  Partly Disagree  Partly Agree  Agree Please answer each of the following statements with how strongly you agree or disagree. 1. I am uncomfortable using the word "blind" when referring to someone's sight loss.  Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 2. Blind people are best suited for jobs in which they can be stationary like sitting and answering the phone.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 3. Blindness is just a normal characteristic like being tall or short.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree         89  4. Being totally blind is worse than being visually impaired.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 5. The word "blind" is negative and should be avoided whenever possible.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 6. Families should assume responsibility for taking care of their blind relatives.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 7. I am concerned when I see blind people walking around alone in public.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree         90  8. I believe that someone who is blind could be a good elementary school teacher.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 9. I believe that having vision is related to greater happiness.  Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 10. If I were blind I would give almost anything to get my sight back.  Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 11. I believe that totally blind pedestrians can be just as safe as the general public when crossing streets.  Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 12. Blindness is such an overwhelming condition that it affects every aspect of one's life.  Strongly Disagree         91   Disagree  Don't know or unsure  Agree  Strongly Agree 13. Blindness does not affect one's ability to be a good parent.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 14. I think it is very courageous of blind people to try to be independent.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 15. I would hire a blind accountant to manage my taxes.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 16. I would hire a blind person to baby-sit my children.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree         92  17. It must be very frustrating living life without being able to see.  Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 18. The less vision someone has, the more challenging his or her life will be.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 19. It is irresponsible of blind people to have children.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree 20. people who have eyesight should help those with less vision whenever possible.   Strongly Disagree  Disagree  Don't know or unsure  Agree  Strongly Agree         93  For the following questions, you are asked to respond using the following scale: (1) Not at all, (2) Slightly, (3) Somewhat, (4) Moderately, or (5) Very.Question 21 1. How difficult would it be for you to disclose personal information to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 2. How vulnerable would you feel if you disclosed something very personal you had never told anyone before to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 3. If you were dealing with an emotional problem, how beneficial for yourself would it be to self-disclose personal information about the problem to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 4. How risky would it feel to disclose your hidden feelings to a counselor?  Not at all  Slightly  Somewhat  Moderately         94   Very 5. How worried about what the other person is thinking would you be if you disclosed negative emotions to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 6. How helpful would it be to self-disclose a personal problem to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 7. Would you feel better if you disclosed feelings of sadness or anxiety to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very 8. How likely would you get a useful response if you disclosed an emotional problem you were struggling with to a counselor?  Not at all  Slightly  Somewhat  Moderately  Very         95  Please answer each of the following statements with how strongly you agree or disagree. 1. When I feel upset, I usually confide in my friends.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 2. I prefer not to talk about my problems.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 3. When something unpleasant happens to me, I often look for someone to talk to.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 4. I typically don’t discuss things that upset me.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 5. When I feel depressed or sad, I tend to keep those feelings to myself.  Strongly Disagree         96   Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 6. I try to find people to talk with about my problems.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 7. When I am in a bad mood, I talk about it with my friends.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 8. If I have a bad day, the last thing I want to do is talk about it.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 9. I rarely look for people to talk with when I am having a problem.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree         97  10. When I’m distressed I don’t tell anyone.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 11. I usually seek out someone to talk to when I am in a bad mood.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree 12. I am willing to tell others my distressing thoughts.  Strongly Disagree  Disagree  Neither Agree nor Disagree  Agree  Strongly Agree INSTRUCTIONS: People at times find that they face problems that they consider seeking help for. This can bring up reactions about what seeking help would mean. Please use the 5-point scale to rate the degree to which each item describes how you might react in this situation.  1 = Strongly Disagree 2 = Disagree 3 = Agree & Disagree Equally 4 = Agree 5 = Strongly Agree 1. I would feel inadequate if I went to a therapist for psychological help.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree         98  2. My self-confidence would NOT be threatened if I sought professional help.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 3. Seeking psychological help would make me feel less intelligent.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 4. My self-esteem would increase if I talked to a therapist.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 5. My view of myself would not change just because I made the choice to see a therapist.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 6. It would make me feel inferior to ask a therapist for help.  Strongly Disagree  Disagree         99   Agree and Disagree Equally  Agree  Strongly Agree 7. I would feel okay about myself if I made the choice to seek professional help.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 8. If I went to a therapist, I would be less satisfied with myself.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 9. My self-confidence would remain the same if I sought professional help for a problem I could not solve.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree  Strongly Agree 10. I would feel worse about myself if I could not solve my own problems.  Strongly Disagree  Disagree  Agree and Disagree Equally  Agree         100   Strongly Agree INSTRUCTIONS: People at times find that they face problems that they consider seeking help for. This can bring up reactions about what seeking help would mean. Please use the 5-point scale to rate the degree to which each item describes how you might react in this situation. 1. Seeing a psychologist for emotional or interpersonal problems carries social stigma.  Strongly Disagree  Disagree  Agree  Strongly Agree 2. It is a sign of personal weakness or inadequacy to see a psychologist for emotional or interpersonal problems.  Strongly Disagree  Disagree  Agree  Strongly Agree 3. People will see a person in a less favorable way if they come to know that he/she has seen a psychologist.  Strongly Disagree  Disagree  Agree  Strongly Agree 4. It is advisable for a person to hide from people that he/she has seen a psychologist.  Strongly Disagree  Disagree  Agree  Strongly Agree         101  5. People tend to like less those who are receiving professional psychological help.  Strongly Disagree  Disagree  Agree  Strongly Agree Demographics Gender  Female  Male  Other Location (Province or State) Please type the Province or State you live in   Age Must be between the ages of 21 and 64 to participate.   Ethnicity (Check all that apply)  Black/African American  East Asian  Hispanic  MIddle Eastern  South Asian  White/Caucasian  Other, please specify... ______________________ Employment  Unemployed  Disability Benefits/Other Benefits         102   Employed - Part Time  Employed - Full Time  Student Relationship Status  Single  Dating  Married or Commonlaw  Separated  Divorced  Widowed Education (Please indicate highest level completed)  High School  Some College/University  Two Year Degree  College University Degree  Masters Degree  PhD or Post Doctoral Degree Visual Diagnosis For example: Stargardt's Disease, Retinitis Pigmentosa, Cone-Rod Dystrophy    Visual Acuity (to the best of your knowledge, with best corrected vision, for example you must be at 20 over 200 when wearing glasses, if you wear them)  20 over 200 to 20 over 600 ie: legally blind  20 over 600 or less ie: up to and including no vision Age of Visual Impairment Diagnosis (a number for age in years) For you this may mean birth if you have been visually impaired since birth, which can be represented by a zero. This may mean 5 if you were diagnosed at the age of 5. If unknown please estimate age of first symptoms or diagnosis.         103    Have you ever accessed counselling services from a counsellor or therapist?  Yes  No Have you ever sought low vision rehabilitation services? For example those offered at the CNIB, like for cane usage, daily living skills, etc.  Yes  No If you were considering seeing a counsellor/therapist would prefer:  A visually impaired counsellor/therapist  A sighted counsellor/therapist  No preference Prize Draw Thank you for completing this survey. When you click submit, you will be redirected to a separate survey page where you will have the option of entering your email address for a chance to win one of three 25$ gift cards.             104  APPENDIX E Prize Draw Instructions – Participant Version Prize Draw Prize Draw Please enter your email address in order to be entered into the prize draw for one of three 25$ gift cards. We thank you for your participation in this survey.             105  APPENDIX F  Frequencies – Demographics (n = 193)  Mean Range Age  41.88 21-64  f % Gender Female 113 58.5% Male 78 40.4% Other 2 1.0% Country Canada 107 56.0% United States 84 44.0% Ethnicity Black/African American 3 1.6  East Asian 4 2.1  Hispanic 2 1.0  MIddle Eastern 2 1.0  South Asian 4 2.1  White/Caucasian 125 64.8  Other 8 4.1  Multiple Ethnicities 45 23.3 Employment Status Unemployed 24 12.4% Disability Benefits/Other Benefits 71 36.8% Employed - Part Time 32 16.6% Employed - Full Time 45 23.3% Student 21 10.9% Relationship Status Single 71 36.8% Dating 27 14.0% Married or Commonlaw 73 37.8% Separated 3 1.6% Divorced 16 8.3% Widowed 3 1.6% Level of Education High School 19 9.8% Some College/University 58 30.1% Two Year Degree 18 9.3% College University Degree 68 35.2% Masters Degree 27 14.0% PhD or Post Doctoral Degree 3 1.6% Visual Impairment Status Legally Blind 84 43.5% Severely Visually Impaired 109 56.5%         106  Age of Visual Impairment Diagnosis 0 to 10 128 66.3% 11 to 21 20 10.4% 22 to 32 25 13.0% 33 to 43 9 4.7% 44 to 54 8 4.1% 55 to 64 3 1.6% Sought Counselling Before No 41 21.2% Yes 152 78.8% Sought LVRS Before No 31 16.1% Yes 162 83.9% Counsellor Preference A visually impaired counsellor/therapist 40 20.7% A sighted counsellor/therapist 10 5.2% No preference 143 74.1%          107  APPENDIX G  Attitudes Toward Seeking Professional Psychological Help–Short Form Note. Straight items (S) are scored 3-2-1-0, and reversal items (R) 0-1-2-3, respectively, for the response alternatives agree, partly agree, partly disagree, and disagree.                                                                                                        Item Correspondence to Original Version  Scoring     1. If I believed I was having a mental breakdown, my first inclination would be to get professional attention.  Same as Item 12  S     2. The idea of talking about problems with a psychologist strikes me as a poor way to get rid of emotional conflicts.  Same as Item 19  R     3. If I were experiencing a serious emotional crisis at this point in my life, I would be confident that I could find relief in psychotherapy.  Same as Item 23  S     4. There is something admirable in the attitude of a person who is willing to cope with his or her conflicts and fears without resorting to professional help.  Item 24 (change of personal pronoun)  R     5. I would want to get psychological help if I were worried or upset for a long period of time.  Item 18 (slightly modified)  S     6. 1 might want to have psychological counseling in the future. Item 25 (modified) S     7. A person with an emotional problem is not likely to solve it alone; he or she is likely to solve it with professional help.  Item 16 (change of personal pronoun)  S     8. Considering the time and expense involved in psychotherapy, it would have doubtful value for a person like me.  Same as Item 6  R     9. A person should work out his or her own problems; getting psychological counseling would be a last resort.  Item 26  (change of personal pronoun)  R     10. Personal and emotional troubles, like many things, tend to work out by themselves.                                                                           Item 9 (modified)  R             108  APPENDIX H Social Responsibility about Blindness Scale  Social Responsibility about Blindness Scale  Please answer each of the following statements with how strongly you agree or disagree. You may respond with: Strongly Agree (SA); Agree ; don’t know/Unsure (*); Disagree (d); or Strongly Disagree (SD). SA a * d SD   1. I am uncomfortable using the word "blind" when referring to someone's sight loss. SA  A  *  D  SD   2. Blind people are best suited for jobs in which they can be stationary like sitting and answering the phone.   SA  A  *  D  SD   3. Blindness is just a normal characteristic like being tall or short.  SA  A  *  D  SD    4. Being totally blind is worse than being visually impaired.   SA  A  *  D  SD   5. The word "blind" is negative and should be avoided whenever possible.   SA  A  *  D  SD   6. Families should assume responsibility for taking care of their blind relatives.   SA  A  *  D  SD   7. I am concerned when I see blind people walking around alone in public.   SA  A  *  D  SD   8. I believe that someone who is blind could be a good elementary school teacher.  SA  A  *  D  SD    9. I believe that having vision is related to greater happiness.  SA  A  *  D  SD   10. If I were blind I would give almost anything to get my sight back.  SA  A  *  D  SD   11. I believe that totally blind pedestrians can be just as safe as the general public when crossing streets.         109  SA  A  *  D  SD    12. Blindness is such an overwhelming condition that it affects every aspect of one's life.  SA  A  *  D  SD   13. Blindness does not affect one's ability to be a good parent.  SA  A  *  D  SD    14. I think it is very courageous of blind people to try to be independent.   SA  A  *  D  SD   15. I would hire a blind accountant to manage my taxes.  SA  A  *  D  SD    16. I would hire a blind person to baby-sit my children.  SA  A  *  D  SD    17. It must be very frustrating living life without being able to see.  SA  A  *  D  SD   18. The less vision someone has, the more challenging his or her life will be.   SA  A  *  D  SD   19. It is irresponsible of blind people to have children.   SA  A  *  D  SD   20. people who have eyesight should help those with less vision whenever possible.   SA  A  *  D  SD             110  APPENDIX I Disclosure Expectations Scale  Disclosure Expectations Scale INSTRUCTIONS: For the following questions, you are asked to respond using the following scale: (1) Not at all, (2) Slightly, (3) Somewhat, (4) Moderately, or (5) Very. 1. How difficult would it be for you to disclose personal information to a counselor? 2. How vulnerable would you feel if you disclosed something very personal you had never told anyone before to a counselor? 3. If you were dealing with an emotional problem, how beneficial for yourself would it be to self-disclose personal information about the problem to a counselor? 4. How risky would it feel to disclose your hidden feelings to a counselor? 5. How worried about what the other person is thinking would you be if you disclosed negative emotions to a counselor? 6. How helpful would it be to self-disclose a personal problem to a counselor? 7. Would you feel better if you disclosed feelings of sadness or anxiety to a counselor? 8. How likely would you get a useful response if you disclosed an emotional problem you were struggling with to a counselor? Items 1,2,4, & 5 are summed for the Anticipated Risks subscale; items 3,6,7, & 8 for the Anticipated Benefits subscale (Vogel & Wester, 2003)           111  APPENDIX J Distress Disclosure Index DISTRESS DISCLOSURE INDEX - FINAL VERSION 1. When I feel upset, I usually confide in my friends. 2. I prefer not to talk about my problems. 3. When something unpleasant happens to me, I often look for some¬one to talk to. 4. I typically don’t discuss things that upset me. 5. When I feel depressed or sad, I tend to keep those feelings to myself. 6. I try to find people to talk with about my problems. 7. When I am in a bad mood, I talk about it with my friends. 8. If I have a bad day, the last thing I want to do is talk about it. 9. I rarely look for people to talk with when I am having a problem. 10. When I’m distressed I don’t tell anyone. 11. I usually seek out someone to talk to when I am in a bad mood. 12. I am willing to tell others my distressing thoughts. Note. Reverse score items 2, 4, 5, 8, 9, 10. (Kahn & Hessling, 2001)          112  APPENDIX K  Self Stigma of Seeking Help INSTRUCTIONS: People at times find that they face problems that they consider seeking help for. This can bring up reactions about what seeking help would mean. Please use the 5-point scale to rate the degree to which each item describes how you might react in this situation. 1 = Strongly Disagree 2 = Disagree 3 = Agree & Disagree Equally 4 = Agree 5 = Strongly Agree 1. I would feel inadequate if I went to a therapist for psychological help. 2. My self-confidence would NOT be threatened if I sought professional help. 3. Seeking psychological help would make me feel less intelligent. 4. My self-esteem would increase if I talked to a therapist. 5. My view of myself would not change just because I made the choice to see a therapist. 6. It would make me feel inferior to ask a therapist for help. 7. I would feel okay about myself if I made the choice to seek professional help. 8. If I went to a therapist, I would be less satisfied with myself. 9. My self-confidence would remain the same if I sought professional help for a problem I could not solve. 10. I would feel worse about myself if I could not solve my own problems.  *Items 2, 4, 5, 7, and 9 are reverse scored.          113  APPENDIX L  Stigma Scale for Receiving Psychological Help   Item Item-total Factor loading 1. Seeing a psychologist for emotional or interpersonal   problems carries social stigma. .35 .40 2. It is a sign of personal weakness or inadequacy to see a   psychologist for emotional or interpersonal problems. .40 .47 3. People will see a person in a less favorable way if they   come to know that he/she has seen a psychologist. .64 .81 4. It is advisable for a person to hide from people that   he/she has seen a psychologist. .52 .62 5. People tend to like less those who are receiving profes-   sional psychological help. .52 .65 

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