Why Some People Don’t Seek Mental Health Services

Why Some People Don’t Seek Mental Health Services

A new study points to heightened concerns about stigma and one’s reputation.

Posted January 22, 2021 |  By: Lawrence T. White Ph.D.

StockSnap from Pixabay

Source: StockSnap from Pixabay

Many of us know someone who is depressed or anxious yet reluctant to seek professional help. While every case is unique, a new study sheds light on the reasons why some individuals, often men, resist seeing a psychiatrist or counselor.

Several years ago, researchers at the University of Oklahoma uncovered a curious pattern. They discovered that American children with mental health needs were less likely to receive counseling or treatment if they lived in one of the so-called honor states (Brown, Imura, & Mayeux, 2014). Honor states are found in the South and Mountain West regions of the United States.

The researchers offered two plausible explanations for the curious pattern. First, parents in honor states may have ambivalent feelings about seeking psychological help. As a result, their emotionally distressed children are less likely to receive treatment. Second, honor states may offer fewer mental health services than non-honor states. Parents in honor states may want to get psychological help for their children, but they live in a state that has relatively few mental health clinics and counselors.

Why might people in honor states have ambivalent feelings about seeking psychological help? Some experts believe the answer can be found by examining cultural values.

Many people in the South and Mountain West regions have grown up in a culture of honor that values self-reliance, toughness, and a readiness to respond aggressively to personal affronts. They also can trace their lineage to ancestors, often in Scotland or Ireland, who lived as herders (Nisbett & Cohen, 1996).

Why is a culture of honor associated with a history of herding? In herding societies, a family’s wealth—a flock of sheep, for example—can be stolen overnight by a single thief. To safeguard their precarious livelihood, herding families established a reputation for toughness and self-sufficiency. They also developed a heightened sensitivity to social slights and demonstrated a willingness to use violence to punish someone who insulted them. “Don’t mess with me or my family. If you do….”

The ramifications of honor culture are manifold. Dueling to defend one’s honor was a common practice in the South, even after it disappeared in the North. Honor states have higher rates of domestic abuse and higher rates of homicide, especially honor-related killings. Every southern state has a “stand-your-ground” law that says a person can defend one’s self against threats or perceived threats, with lethal force if necessary, even if the person can retreat safely from the threatening situation.

With all this in mind, a team of researchers led by psychologist Stephen Foster at Penn State York University conducted a study to better understand why individuals living in honor states are less likely to use mental health services. They hypothesized that people who are motivated to maintain a reputation for toughness and self-reliance will be less likely to seek mental health services because they worry that others will see it as a sign of weakness (Foster, Carvallo, Lee, & Bernier, 2020).

The researchers recruited 156 students at a university in the southern United States. (Their sample was not large enough or diverse enough to be representative, but it was large enough to test the validity of a theory-based prediction.) The students completed questionnaires designed to measure four pertinent variables.

  1. Approval of honor concerns was indicated by agreement with statements such as “I think honor is one of the most important things I have as a human being” and “A real man is seen as tough in the eyes of his peers.”
  2. Concern for one’s reputation was indicated by agreement with statements such as “I often think about things I could do to enhance or maintain my reputation.”
  3. Stigma associated with seeking psychological help was indicated by agreement with statements such as “I would feel inadequate if I went to a therapist for psychological help” and “People will see a person in a less favorable way if they come to know that he/she has seen a psychologist.”
  4. Intention to seek psychological help was indicated by agreement with statements such as “I would be willing to set up an appointment with a psychological counselor in the future.”

Foster and his team discovered that, as a group, the students in their study who strongly endorsed honor concerns were less likely to say they would seek psychological help. They also determined, through statistical analyses, that the reason for this relationship could be traced to students’ concerns about maintaining their reputation and their belief that persons who seek psychological help are viewed less positively by others.

Putting it all together, a clearer picture emerges. People who grow up in honor states are especially concerned that their reputation for self-reliance and toughness will be damaged if they seek psychological help. The unfortunate consequence of this culture-based belief is an underutilization of mental health services in honor states.

Beliefs and values associated with a culture of honor are acquired effortlessly at a young age, with little or no explicit instruction. Such beliefs and values are often difficult to change. Nevertheless, public health officials would be well advised to consider the roles played by perceived stigma and concern for one’s reputation when thinking about ways to deliver mental health services to the individuals who need them.


Brown, R. P., Imura, M., & Mayeux, L. (2014). Honor and the stigma of mental healthcare. Personality and Social Psychology Bulletin40(9), 1119-1131.

Foster, S., Carvallo, M., Lee, J., & Bernier, I. (2020). Honor and seeking mental health services: The roles of stigma and reputation concerns. Journal of Cross-Cultural Psychology, DOI: 10.1177/0022022120982070

Nisbett, R. E., & Cohen, D. (1996). Culture of Honor: The Psychology of Violence in the South. Boulder, CO: Westview Press.