JSCP 2019 38 10 811

Journal of Social and Clinical Psychology, Vol. 38, No. 10, 2019, pp.
811-835
ONLINE HELP PREFERENCE AND SUICIDE IDEATION
WILKS ET AL.
EXPLORING PREFERENCE TO AVOID OR SEEK

HELP IN PERSON AND ONLINE AMONG
COLLEGE STUDENTS WITH SUICIDAL IDEATION
CHELSEY R. WILKS
Harvard University, University of Washington
SIN YEE ANG AND XIYAO WANG

University of Washington, Behavioral Research
and Therapy Clinics
VINUSHINI ARUNAGIRI, AND ERIN F. WARD-CIESIELSKI

Hofstra University
Objectives: Suicidal thoughts, for which college students are at risk, tend to be
negatively associated with intentions to seek therapy, particularly among college-
aged men. Emerging research suggests college students may seek psychological
help online; however, factors that explain why they avoid help and/or may prefer
online help remain unknown. Method: 816 college students completed mea-
sures of suicidal ideation, help-seeking intentions, and theoretical mediators and
moderators of their relationship. Results: Suicidal ideation was associated with
stronger preference for online help among female, but not male respondents. The
indirect effect of suicidal ideation on help negation via interpersonal difficulties
was positive where self-concealment was high but negative where it was low.
This pattern, however, was not found for online help preference. Conclusions:
Online interventions can augment suicide prevention and intervention for college
students. However, suicidal male students may be less likely to utilize online help
sources. The mechanisms underlying this gender difference remain unclear. More
research is needed to understand how help-negation in college-aged men can be
addressed in online intervention platforms.
Keywords: suicidal ideation, help-seeking college students, treatment

preference, online treatment
Address correspondence to Chelsey R. Wilks, PhD, Harvard University, Department

of Psychology, 33 Kirkland Street, Cambridge, MA 02138;
E-mail: chelseywilks@fas.harvard.edu
wilks_2ndPass.indd 811 12/20/2019 4:19:45 PM

812 WILKS ET AL.
Suicide, ranking as the second highest cause of death for college-

aged students both worldwide and in the United States (Centers
for Disease Control and Prevention, 2017; World Health Organi-
zation, 2016), stands as a pressing concern for college campuses.
An international survey by Bruffaerts et al. (2019) found that
nearly 10% of undergraduate students report suicidal ideation,
7.8% endorse a plan for suicide, and approximately 1% report
attempted suicide in the preceding 12 months. Past-year preva-
lence rates from college students in the U.S. for ideation, plan,
and attempt are comparable at 10%, 6.1%, and 3.2%, respectively
(Mortier, Cuijpers, et al., 2018). However, college students expe-
riencing psychological distress rarely enroll in treatment (e.g.,
American College Health Association, 2017; Auerbach et al.,
2016; Eisenberg, Hunt, Speer, & Zivin, 2011; Substance Abuse and
Mental Health Services Administration, 2018). A national survey
of college counseling centers in the U.S. found that 86% of stu-
dents who had died by suicide in the past year had not sought
assistance from college counselors (Gallagher, 2014). According
to the study by Bruffaerts et al. (2019), only approximately 20%
of students experiencing suicidal ideation, 37.8% with a suicidal
plan, and 45.1% who have attempted suicide, reported receiv-
ing past-year treatment. This substantial treatment gap calls for
a more thorough understanding of factors underlying avoiding
help among suicidal college students, and how they can be ad-
dressed in programs designed to intervene with suicidal ide-
ation on college campuses.
While treatment-engaging behavior among college students
is low, the ubiquity of computing technology has given rise to
novel methods of treatment delivery. In particular, emerging
research has found promising results regarding interest in in-
terventions delivered online for college students experiencing
psychological distress and suicidal ideation (e.g., Lungu & Sun,
2016; Ryan, Shochet, & Stallman, 2010; Seward & Harris, 2016;
Wilks, Coyle, Krek, Lungu, & Andriani, 2018). Online platforms
may thus be leveraged to improve service receipt for suicidal
college students.
The task of improving the acceptability and efficacy of such ef-
forts requires additional research on why at-risk students might
avoid seeking professional help, and whether these factors can
be addressed through online interventions. Insights about the
help-seeking process engaged by suicidal and help-avoiding col-

ONLINE HELP PREFERENCE AND SUICIDE IDEATION 813
lege students would inform the development and delivery of on-

line interventions to more effectively reach and address the tar-
geted needs of this population. More research, as such, is needed
to better elucidate (a) why college students may avoid help in
general and (b) whether the same reasons that they avoid face-
to-face help facilitate a preference toward online help.
Help seeking, as conceptualized by Rickwood, Deane, Wilson,
and Ciarrochi (2005), is a transaction between the personal and
interpersonal domains that can be enhanced by facilitators or
disrupted by barriers. Help-negation, or the refusal or avoidance
of available help when needed, can thus be viewed as a conse-
quence of barriers that disrupt the interpersonal process of help-
seeking. Help-negation has been consistently demonstrated in
studies on help-seeking for suicidal thoughts and behaviors (e.g.,
Carlton & Deane, 2000; Deane, Wilson, & Ciarrochi, 2001; Wilson
& Deane, 2010; Yakunina, Rogers, Waehler, & Werth, 2010). Sui-
cidal individuals may avoid disclosing suicidal ideation due to
fears of undesired consequences such as social ostracism, being
seen as weak, and/or not being taken seriously (Hom, Stanley,
Podlogar, & Joiner, 2017). Suicidal college students who avoid
treatment have indicated, for instance, that they would “deal
with the problem on their own,” rather than seek out external
help (Bruffaerts et al., 2011).
While precise reasons for help-negation remain varied and un-
certain, internalized stigma—defined by the application of nega-
tive stereotypes to oneself characterized by devaluation, shame,
secrecy, and withdrawal—has been identified as a barrier that
can inhibit help-seeking (Barney, Griffiths, John, & Christensen,
2006; Clement et al., 2015; Corrigan, 1998; Corrigan, 2004; Holmes
& River, 1998). For instance, avoiding disclosure and treatment
for suicidality out of an anticipation of social disapproval (e.g.,
Hom et al., 2017) may stem from stigmatized perceptions about
the meanings of suicidal ideation. Studies have demonstrated
that internalized stigma can inhibit help seeking for psychologi-
cal distress (Ben-Zeev, Corrigan, Britt, & Langford, 2012; Downs
& Eisenberg, 2012; Eisenberg, Downs, Golberstein, & Zivin, 2009;
Reynders, Kerkhof, Molenberghs, & Van Audenhove, 2014; Vo-
gel, Wade, & Haake, 2006; Yakunina et al., 2010), and particularly
in males (Batterham, Calear, & Christensen, 2013; Hammer, Vo-
gel, & Heimerdinger-Edwards, 2013). Men have evidenced par-
ticularly low rates of treatment in general (Addis & Hoffman,

814 WILKS ET AL.
2017; Galdas, Cheater, & Marshall, 2005). This has been attrib-
uted by some researchers to stronger societal pulls to internal-
ize distress (Addis, 2008; Seidler, Dawes, Rice, Oliffe, & Dhillon,
2016). Therefore, we propose that the association between suicid-
al ideation and help negation would be stronger among students
experiencing higher levels of internalized stigma, and that this
effect would be more pronounced in male students. Differences
in help-seeking behavior has also been observed across cultures,
particularly among Asians where despite having a suicide at-
tempt history, they prefer to seek help from non-professional
sources (Chu, Hsieh, & Tokars, 2011). While little is known about
the link between stigma and preferences for online help, we sur-
mised that online platforms, with the level of anonymity they
can provide, would be perceived as a more acceptable resource
for suicidal college students, particularly for those experiencing
more acute levels of internalized stigma.
As it relates to help-seeking in the context of interpersonal re-
lationships, friends and family are often the first recipients of
help-seeking behavior (Oliver, Pearson, Coe, & Gunnell, 2005).
Low interpersonal effectiveness, or the ability to adeptly man-
age conflict within interpersonal relationships, has been linked
to an individual’s desire to die (Kazan, Calear, & Batterham,
2016; Van Orden et al., 2010), and some studies have found that
the heightened level of distress resulting from relational disrup-
tions can also motivate help-seeking behaviors (Cramer, 1999).
In an early study on this topic, Cramer (1999) posited a model
for help-seeking contingent on positive help-seeking attitudes
and distress associated with impaired social support and self-
concealment. Self-concealment, conceptualized as a disposition
toward withholding distressing and potentially embarrassing
personal information (e.g., Larson & Chastain, 1990), has yielded
mixed findings in the literature on help seeking. While Cramer
(1999) found that self-concealment and impaired social rela-
tions are correlates of distress that prompt help-seeking, these
variables are potentially barriers for the process of help-seeking
conceptualized by Rickwood and colleagues (2005). Indeed, self-
concealment has been found to predict negative attitudes toward
psychotherapy and actual help-seeking behaviors in other stud-
ies (Cepeda-Benito & Short, 1998; Kelly & Achter, 1995; Vogel &
Wester, 2003; Masuda, Anderson, & Edmonds, 2012; Mendoza,
Masuda, & Swartout, 2015). In addition, concealing distress may

be more valued in certain cultures, such as those from collectiv-

ist cultures; for example, Asians were more likely to hide their
distress compared to White college students (Wong, Brownson,
Rutkowski, Nguyen, & Becker, 2014). Moreover, given the an-
onymity of online help-seeking, these patterns may map onto
one’s preference toward online platforms. To clarify these asso-
ciations, we will explore how interpersonal difficulties interact
with self-concealment to mediate the relationship between sui-
cidal ideation and help-seeking. Specifically, we seek to deter-
mine whether interpersonal effectiveness explains the relation-
ship between suicidal ideation and help-seeking preference, and
how self-concealment affects that relationship.
The aim of the current study was to examine the role of inter-
actions between suicidal ideation, internalized stigma, interper-
sonal problems, and self-concealment in help-seeking patterns
associated with suicidal ideation in college students. While these
variables have been assessed in studies on help-negation, it is
not known whether established relationships could map on to
intentions to seek help, specifically from online sources. Given
prior research (e.g., Harris, McLean, & Sheffield, 2009; Seward &
Harris, 2016), we proposed the following hypotheses:
(1) a. Suicidal ideation would be significantly correlated with
intentions to seek online help as well as to negate help and
b. the effect of suicidal ideation on these help-seeking prefer-
ences would differ by gender.
(2) The associations between suicidal ideation and help seeking
would be moderated by internalized stigma in both male and
female students.
We proposed a final exploratory hypothesis to examine whether:
(3) Interpersonal ineffectiveness would mediate the relationship
between suicidal ideation and help-seeking intentions, mod-
erated by self-concealment.
METHOD
Participants were 816 college students between the ages of 18

and 24 (64.3% identified as female, 35.7% as male). With regard
to ethnic background, 67.8% of participants identified as Asian/

816 WILKS ET AL.
Pacific Islander, 20.8% as Caucasian, 5.1% as Hispanic, 1.6% as

African American, and 4.8% as Biracial/Others (see Table 1). Par-
ticipants were recruited from the online subject pool for psychol-
ogy students in exchange for course credit. All procedures were
conducted in accordance with the institutional review board at
the University of Washington.
MEASURES
Demographics. We assessed students’ self-reported age, sex, ra-

cial and ethnic background, country of birth, education, marital
status, and income.
Suicidal Ideation. Suicidal ideation was assessed using the Beck’s
Scale for Suicidal Ideation (BSS; Beck, Kovacs, & Weissman,
1979). The BSS contains 19 items assessing severity of suicidal
intention, ideation, and plans during the past week. Scores range
from 0–38, scores above 3 representing a significantly higher risk
for suicide (Brown., Beck, Steer, & Grisham, 2000; Guerra and
Calhoun, 2011; Youssef et al., 2013). This instrument has demon-
strated moderate internal consistency (α = .84–.89) and high in-
terrater reliability (r = .83–.98; Beck, Brown, & Steer, 1997; Beck,
Kovacs, & Weissman, 1979).
Help Seeking Intentions. Help seeking intentions were assessed
using the General Help Seeking Questionnaire (GHSQ; Rick-
wood et al., 2005), which has demonstrated high internal reli-
ability (α = .83) and test-retest reliability (r = .88) in assessing
help-seeking for suicidal problems (Wilson, Deane, Ciarrochi, &
Rickwood, 2005). In the original GHSQ (Rickwood et. al., 2005),
participants were asked to rate, on a 7-point Likert scale from
1 (Extremely Unlikely) to 7 (Extremely Likely), their intentions
to seek help from each of four informal (partner, friend, parent,
relative) and four formal (mental health professional, phone
help line, doctor, teacher) help sources, someone else not listed,
and no one. The present study used a modified version of this
questionnaire that included the following options: online psy-
chotherapy; social media platforms including Tumblr, Reddit,
and Facebook; and online education.
Help avoidance or negation, operationalized as preference for
no help over any face-to-face help, was computed as the ratio
of each participant’s rating on the single item “I would not seek

help from anyone” over their average rating for all in-person
help resources. Scores range from 0.14 to 7.00, with higher scores
indicating a lower intention to seek face-to-face help. A score
of 1.2, for instance, would mean that the participant’s rating on
the help-negation item is 1.2 times higher than their average en-
dorsement for face-to-face help. Online help preference, opera-
tionalized as intentions to seek online over in-person help, was
computed by dividing the average of each participant’s ratings
on the three sources of online help (online psychotherapy, so-
cial media, online education) over their average rating for all in-
person help sources. Scores range from 0.14 to 7.00, with higher
scores indicating a greater preference toward online help relative
to face-to-face help. Thus, both help negation and online help
preference are derived as ratio scores reflecting preferences rela-
tive to each individual’s overall intentions to engage in-person
help sources. Although these ratios do not reflect absolute differ-
ences across the help negation and online help items, we were
primarily interested in each individual’s relative scores as they
provide a more comprehensive account of their unique help
preferences. For instance, in comparing between an individual
who endorsed a high intention to avoid help and low intentions
to seek help (help negation item = 7; face-to-face help preference
= 1), and another selecting an equally high rating for help avoid-
ance, but greater positive intentions to seek help (help nega-
tion item = 7; face-to-face help preference = 3), these differences
would be reflected in the ratio score (help-negation risk = 7 vs.
2.33), but not their single-item ratings (7 for both). Hence, ratio
scores were used as they provide a more holistic accounting of
each individuals’ unique help-seeking profile, than can the item
scores taken alone. These types of scores have implemented in
previous research (e.g., Shrira et al., 2011). Internal reliability for
all help preference measures used in this study were computed
and found to be within an acceptable range (Cronbach’s α = .80
for face-to-face help; Cronbach’s α = .78 for online help).
Internalized Stigma. The Internalized Stigma of Mental Illness
Scale (ISMIS; Ritsher, Otilingam, & Grajales, 2003) is a 29-item
questionnaire designed to assess subjective experience of stigma.
In the ISMIS, participants are asked to rate on a 4-point Likert
scale from 1 (strongly disagree) to 4 (strongly agree) the extent to
which they agree with statements, about experiences of stigma

818 WILKS ET AL.
associated with mental illness. The overall average score, rang-

ing from 1 to 4, was used. Higher scores indicate higher levels of
internalized stigma. The full-scale score has demonstrated mod-
erate to high internal consistency (Cronbach’s α = .80 to .92), as
well as high test-retest reliability (r = .92; Boyd et al., 2014) across
multiple studies.
Self-Concealment. The Self-Concealment Scale (SCS; Larson &
Chastain, 1990) is a ten-item scale that measures an individual’s
tendency to conceal potentially negative or distressing personal
information (e.g., “there are lots of things about me that I keep to
myself,” and “my secrets are too embarrassing to share with oth-
ers”). Each question is answered on a 1–5 point Likert scale from
1 (strongly agree) to 5 (strongly disagree”). Scores range from
10–50 with higher scores indicating higher self-concealment.
This measure has high internal consistency (Cronbach’s α = .83;
Larson & Chastain, 1990).
Interpersonal Problems. Participants’ interpersonal problems
were assessed using the Inventory of Interpersonal Problems-
Personality Disorder scale 25 (IIP-PD-25; Stern, Kim, Trull, Scar-
pa, & Pilkonis, 2000; Harfst, Dirmaier, Koch, & Schulz, 2004). The
IIP-PD-25 consists of 25 5-point Likert-type questions that are
averaged to create a score ranging from 0 to 4 with 0 (Not at all)
and 4 (Extremely) and higher scores indicate a higher degree of
interpersonal problems (e.g., “I argue with people too much,”
and “I am too sensitive to criticism”). The measure has high in-
ternal consistency with Cronbach’s α = .93 (Stern et al., 2000).
ANALYTICAL PLAN
All statistical analyses were performed using SPSS v.24.0 (IBM,

2016). First, descriptive statistics were computed for all study
variables. Three variables—SI, online help seeking, and help-ne-
gation—were found to be positively skewed (skew = .088, 1.29,
and 3.10, respectively). Consequently, bootstrapping with 5,000
resamples were used to generate 95% confidence intervals (CI)
for correlation and regression models tested in this study. Boot-
strapping, which computes bias-corrected confidence intervals
by repeated sampling from the original data set, has been recom-
mended as a method of choice for moderation and mediation

TABLE 1. Sample Characteristics

Characteristics N (%) M (SD)
Age 19.3
Female 520 (64.3)
Race
Asian/Pacific Islander 542 (67.8)
Caucasian 166 (20.8)
Hispanic 41 (5.1)
African American 13 (1.6)
Biracial/Others 38 (4.8)
Income
<10,000 725 (91.4)
10,001–25,000 38 (4.8)
25,001–50, 000 19 (2.4)
50,001–100,000 11 (1.4)
Marital Status
Single 678 (85.0)
Committed relationship 118 (14.8)
Married 2 (.251)
Never sought help from mental health professional 580 (75.8)
Suicidal ideation (SI) 6.13 (7.08)
Internalized Stigma (ISMI) 1.74 (.454)
Interpersonal Problems (IP) 1.28 (.665)
Self-Concealment (SC) 29.3 (9.75)
Online Help Preference .703 (.390)
Help Negation .800 (.827)
analyses where normal parametric assumptions may not hold

(Preacher, Rucker, & Hayes, 2007; Russell & Dean, 2000). Boot-
strapped CIs were generated using SPSS for bivariate correla-
tions performed to determine the relationships between model
variables, and to test for positive correlations between SI and (i)
help-negation, as well as (ii) online help-seeking as proposed in
hypothesis 1a.
Moderation and moderated mediation models were then
tested using bootstrapping strategies available in the PROCESS
Macro (Version 3; Hayes, 2017). For hypothesis 1b, gender was
assessed as a moderator of the relationship between SI and the
two help-seeking outcomes (Model 1; Hayes, 2017). Hypothesis

820 WILKS ET AL.
TABLE 2. Pearson’s r Correlations Between Model Variables with 95% Bootstrapped

Confidence Intervals
2 3 4 5 6
Suicidal ideation .326* [.248, .395* [.331, .357* [.294, .224* [.149, .345*[.252,
95% CI .401] .454] .419] .295] .439]
Internalized — .282* [.205, .287* [.211, .137* [.062, .157* [.057,
stigma 95% CI .356] .361] .213] .266]
Self-concealment — .434* [.367, .174* [.093, .204* [.102,
95% CI .494] .253] .298]
Interpersonal — .135* [.056, .252* [.069,
problems .213] .269]
95% CI
Online help — .372* [.276,
preference .463]
95% CI
1. Help-negation
*p < .05.
2 was tested by assessing the moderating effect of internalized

stigma (ISMI) on these relationships in male and female college
students (Model 3; Hayes, 2017). Finally, hypothesis 3 was as-
sessed with a moderated mediation model (Model 14; Hayes,
2017; Hayes, 2015), with interpersonal problems (IP) mediating
the relationship between SI and help-seeking, and self-conceal-
ment (SC) moderating the effect of IP on help-seeking. Signifi-
cant interactions were probed for conditional effects either at
all values of discrete moderators (i.e., gender), or at low (Mean-
1SD), moderate (Mean), and high (Mean+1SD) values of contin-
uous moderators (ISMI and SC). Unless already included in the
proposed model, gender, race, and previous help-seeking were
entered as a priori covariates across all models. Unstandardized
coefficients were reported for all model results.
RESULTS
HYPOTHESIS 1A: SI IS CORRELATED WITH INTENTIONS TO

SEEK ONLINE HELP AS WELL AS TO NEGATE HELP
Table 1 presents demographic and descriptive statistics for all

variables. As predicted, suicidal ideation (SI) was significantly
and positively correlated with help negation (r = .35, 95% CIbootstrap

wilks_2ndPass.indd 821
TABLE 3. Bootstrap Results for Moderating Effects of Gender and ISMI on the Relationship Between BSI and Help-Seeking Preferences
2-Way Moderation 3-Way Moderation
Online Help Preference (N = 712) Help Negation (N = 716) Online Help Preference (N = 681) Help Negation (N = 716)
Variables b1 SE 95% CI b SE 95% CI b1 SE 95% CI b SE 95% CI
Suicidal ideation (BSI) .002 .003 [−.003, .008] .023* .006 [.012, .035] −.010 .014 [−.031, .023] .028 .025 [−.018, .081]
Gender2 −.014 .033 [−.080, .050] −.0565 .071 [−.199, .076] −.058 .144 [−.338, .235] .549 .294 [−.064, 1.07]
Gender × SI .014* .015 [.006, .023] .023* .009 [.005, .042] .040 .018 [−.001, .070] −.0558 .0461 [−.137, .044]
SI in males3 .002 .003 [−.004, .008] .024* .006 [.014, .034]
SI in females .017* .003 [.011, .033] .045* .007 [.031, .059]
Internalized Stigma (ISMI) .042 .066 [−.083, .175] .086 .106 [−.119, .306]
SI × ISMI .007 .007 [−.011, .017] −.002 .012 [−.028, .021]
SI × ISMI × Gender -.014 .009 [−.028, .008] .039 .024 [−.011, .081]
ISMI × Gender .029 .083 [−.143, .187] −.333 .169 [−.642, .013]
Covariates
Race .024 .004 [−.007, .053] .039 .032 [−.026, .102] .023 .016 [−.009, .054] 039 .032 [−.026, .102]
Prior help receipt4 .073 .037 [−.001, .146] .036 .078 [−.122, .184] .090 .038 [.013, .165] .036 .078 [−.122, .184]
ONLINE HELP PREFERENCE AND SUICIDE IDEATION
R2 .077 .122 .088 .158

F 11.69** 20.76** 7.21** 14.68**
(p < .001) (p < .001) (p < .001) (p < .001)
Notes. Bootstrap samples = 5,000. 1Unstandardized coefficients are reported. 20 = male, 1 = female. 3Effects conditioned by gender, reported where interaction effect is
significant.40 = have sought help from mental health professional, 1 = no history of seeking help from mental health professional. *p < .05.
821
12/20/2019 4:19:46 PM
822 WILKS ET AL.
[.252, .439]), as well as online help preference (r = .22, 95% CIbootstrap

[.149, .295]). See Table 2 for correlations between all continuous
variables.
HYPOTHESIS 1B: SI AND HELP-SEEKING PREFERENCES WILL

DIFFER BY GENDER
To assess gender differences in the effect of SI on both (1) help-

negation and (2) online help preference, gender was tested as a
moderator of these effects. Results (Table 3, 2-way moderation)
revealed that the effect of the interaction between gender and SI
(Gender × SI) on help negation was significant (b = .023, SEbootstrap
= .009, 95% CIbootstrap [.005, .042]), and that the relationship between
SI and help negation was stronger in female (b = .046, SE = 0.05,
95% CI [.036, .055]) compared to male (b = .023, SE = .007, 95%
CI [.010, .037]) participants. The effect of Gender x SI on online
help preference was also significant (b = .014, SEbootstrap =.004, 95%
CIbootstrap [.001, .023]), with SI exerting a significant effect on online
help preference in females (b = .017, SE = .003, p < .001, 95% CI
[.012, .022]), but not males (b = .002, SE = .004, p = .505, 95% CI
[−.005, .009]). Further testing in the female sample revealed that SI
was significantly associated with preferences for all three sources
of online help (social media, online psychotherapy or self-help
applications, and online education) over in-person help in female
participants, with online education receiving greatest endorse-
ment across SI scores (see Figure 1). Among male participants, SI
was not significantly associated with preferences for social media,
online psychotherapy, or online education.
HYPOTHESIS 2: SI AND HELP-SEEKING WILL BE MODERATED

BY INTERNALIZED STIGMA IN BOTHŹMALE AND FEMALE
STUDENTS
To examine hypothesis 2, we tested a 3-way moderation (Pro-

cess Model 3, Hayes 2017) with ISMI moderating the relation-
ship between SI and the two help-seeking outcomes, and gender
as secondary moderator. As shown in Table 3, the effect of the
interaction between ISMI and help-negation on SI was non-sig-
nificant in the overall model (b = −.002, SEbootstrap = −.002, 95%

FIGURE ONE
to come
FIGURE 1. Relationships between suicidal ideation and intentions to

utilize social media, online psychotherapy, and online education as
help-seeking platforms over offline help-sources in males and females.
CIbootstrap [−.028, .021), and did not differ significantly by gender

(b = .039, SEbootstrap = .036, 95% CIbootstrap [−.011, .081]). Also incon-
sistent with hypothesis 2, the effect of ISMI × SI on online help
preference did not reach significance in the combined sample (b
= .007, SEbootstrap = .007, 95% CIbootstrap [−.011, .017]) or differ signifi-
cantly between genders (b = −.014, SEbootstrap = .009, 95% CIbootstrap
[.028, .008]). Further testing in male and female samples showed
that the moderating effects of ISMI on the relationships between
SI and help negation, as well as SI and online help preference,
were non-significant for both gender groups (see Table 3).
EXPLORATORY HYPOTHESIS 3: INTERPERSONAL

INEFFECTIVENESS WOULD MEDIATE THE RELATIONSHIP
BETWEEN SI AND HELP SEEKING PREFERENCES WITH
SELF-CONCEALMENT AS SECOND-STAGE MODERATOR.
As displayed in Table 4, results showed that SI is significantly

associated with IP (b = .033, SEbootstrap = .003, 95% CIbootstrap [.027,
.039]), and that the effect of the interaction between IP and SC on
help negation was significant (IP × SC; b = .020, SEbootstrap = .007,

824 WILKS ET AL.
TABLE 4. Results from the Moderated Mediation Analyses.

Interpersonal Problems Online Help Preference Help-Negation
(N = 689) (N = 689) (N = 724)
Variables b1 SE 95% CI b SE 95% CI b SE 95% CI
Suicidal Ideation (SI) .033* .003 [.027, .039] .009* .002 [.005 .014] .032* .005 [.407, 1.48]
Interpersonal
−.077 .064 [−.200, .049] −.552* .194 [−.957, −.205]
Problems (IP)
Self-Concealment
−.001 .003 [−.007, .006] −.018 .010 [−.0375, .000]
(SC)
IP × SC .003 .002 [−.001, .008] .020* .007 [.008, .034]
IP at low SC 2
−.012 .032 [−.075, .051] −.157* .064 [−.283, −-.031]
IP at mod SC .020 .025 [−.029, .069] .039 .050 [−.059, .138]
IP at high SC .052 .033 [−.013, .117] .236* .0657 [.107, .365]
Covariates
Gender3 .032 .049 [−.067, .127] .082* .030 [.024, .140] .0118 .0328 [−.054, .073]
Race .031 .023 [−.014, .077] 018 .016 [−.014, .048] .0409 .0765 [−.116, .184]
Prior help receipt 4
−.059* .056 [−.172, .048] .088 .038 [.014, .162] .0865 .0591 [−.033, .198]
R2 .135 .079 .141
F 26.73** (p < .001) 8.29** (p < .001) 29.58** (p < .001)
Moderated Mediation
Conditional indirect effect
SC BSI → IP → Help Negation SE 95% CI
Low −.005 .003 [−.011, .001]
Moderate .001 .002 [−.002, .005]
High .008 .003 [.002, .014]
Notes. Bootstrap samples = 5,000. 1Unstandardized beta-values are reported. 2Conditional indirect effects obtained by prob-
ing the BSI x ISMI interaction at low (Mean-1SD), moderate (Mean), and high (Mean+1SD) SC scores. 30 = male, 1 = female.
4
0 = have sought help from mental health professional, 1 = no history of seeking help from mental health professionals.
*p < .05.
95% CIbootstrap [.008, .034]). As depicted in Figure 2, probing analy-

ses revealed that IP is positively associated with help negation
at high levels of SC (b = .236, SE = .066, 95% CI [.107, .365]), but
was negatively associated with help negation at low levels of SC
(b = −.157, SE = .064, 95% CI [−.283, −.031]). The effect of IP × SC
on online help preference was non-significant (b=.003, SEbootstrap =
.002, 95% CIbootstrap [−.001, 0.08]).
Significant direct effects of SI on help negation (b = .032,
SEbootstrap = .005, 95% CIbootstrap [.407, 1.48]) remained, indicating
that mediation via IP was partial rather than complete. Indi-
rect effects from SI to help negation via IP were significant at
high (M+1SD) SC (b = .008, SEbootstrap = .003, 95% CIbootstrap [.002,

FIGURE 2. Effect of interpersonal problems on help preferences at high

and low levels of self-concealment (SC)
.014]), and non-significant at moderate (M) and low (M-1SD) SC

(b = −.001, SEbootstrap = .002, 95% CIbootstrap [−.002, .005]; b = −.005,
SEbootstrap = .003, 95% CIbootstrap [−.011, .001], respectively). The dif-
ferences between these indirect effects are significantly different
from zero (index of moderated mediation = .001, SEbootstrap < .001,
CIbootstrap = [.0002, .001]). Further testing showed that this index
did not differ significantly across genders (index of moderated-
moderated mediation =.0003, SEbootstrap < .001, CIbootstrap = [−.001,
.001]). Moreover, adding Gender × SI to the model revealed that
gender differences remained significant in the direct relationship
between SI and help negation (b = .019, SEbootstrap = .009, CIbootstrap
= [.002, .035]), as well as SI and online help negation (b = .013,
SEbootstrap = .004, CIbootstrap = [.005, .021]).
DISCUSSION
This study sought to replicate previous findings on the associa-

tion between suicidal ideation and inclination to seek no help
or to seek online over in-person help and to examine these as-

826 WILKS ET AL.
sociations in the context of potential gender differences. In ad-

dition, we sought to examine how interactions between suicidal
ideation and internalized stigma, and between interpersonal
problems and self-concealment, impacted help-seeking prefer-
ences in college students. Suicidal ideation was found to be more
strongly associated with help negation in female than male par-
ticipants. Regarding online help, suicidal ideation was associat-
ed with preferences for online psychotherapy, social media, and
online education in women, but was not associated with online
help preferences in male participants. However, hypothesized
models did not yield findings that could account for this gen-
der difference. Moreover, contrary to our expectations, internal-
ized stigma did not strengthen the link between suicidal ideation
and help negation or online help preference. It is possible that
other factors, such as self-concealment, may condition how in-
ternalized stigma interacts with the association between suicidal
ideation and help-seeking. This calls for further research on the
intricate role of internalized stigma on the help-seeking process.
This study added to established findings on the association be-
tween suicidal ideation and help-seeking intentions that define
help-negation (Deane et al., 2001; Rudd, Joiner, & Rajab, 1995; Wil-
son & Deane, 2010). While previous research on the suicide help-
negation effect has explored contributions from personal and in-
terpersonal factors (e.g., Cramer, 1999; Rickwood et al., 2005), the
present study examined the effect of interactions between both
domains. Our findings revealed that interpersonal dysfunction
may not be straightforwardly linked with help-negation, as its
effect may depend on an individual’s disposition toward self-
concealment. Specifically, while interpersonal problems may
partially account for the negative relationship between suicidal
ideation and help-seeking at high levels of self-concealment,
they may also increase help-seeking among low self-concealers.
This suggests an intermediary between Cramer’s (1999) path-
model—which proposed low social support and self-conceal-
ment as correlates of distress that motivate help-seeking—and
more recent models that configure these factors in transactional
processes between help-seekers and providers (Rickwood et al.
, 2005). Distress from interpersonal problems may prompt help-
seeking behaviors in individuals less inclined toward hiding that
distress. For self-concealing individuals, however, interpersonal
dysfunction may be conversely linked with reduced, rather than

increased, help-seeking. This could be due to the difficulties ex-

perienced in the relational domain, that stand as barriers against
interpersonal transactions necessary for receiving help. It is also
plausible that individuals presenting with high self-concealment
may have experienced punishment for expressing help-seeking
behavior in the past and are subsequently discouraged from
seeking help. Finally, self-concealment may also be indicative of
social environments that are experienced as hostile or stigma-
tizing and, thus, inhibit help-seeking. While conclusions about
such directional relationships are beyond the scope of this study,
the foregoing intricacies highlight the need for further research
on the interplay between social, interpersonal, and intrapersonal
factors that can influence help-seeking in an interactive manner,
rather as isolated variables.
Interestingly, the aforementioned model did not map onto
one’s preference to seek out online treatment options. The mag-
nitude of the effect between suicidal ideation and online-help
seeking preference was small, suggesting that there may be little
variance that could have been explained. Nonetheless, women
and individuals who had attended treatment previously were
more likely to prefer online treatment than men or treatment-
naïve individuals. Internet forums, online interventions, apps,
and social media campaigns specifically targeting suicide may
be less common than other major public health campaigns (e.g.,
tobacco; Wakefield et al., 2008), potentially highlighting a deficit
in the availability or awareness of quality and/or ubiquitous re-
sources for individuals struggling with suicidal thoughts or be-
haviors. In other words, if suicidal individuals knew that these
resources existed, they may express more interest in seeking
them out. Future research should address the potential impact of
public health campaigns for availability of resources for suicidal
college students.
This study adds to the growing research suggesting that sui-
cidal individuals may be more inclined to seek out help from
online sources over face-to-face help (Seward & Harris, 2016;
Wilks et al., 2018). Our findings revealed a discrepancy in online
help-seeking preference between genders, with suicidal college
women endorsing a significantly higher likelihood to seek out
all varieties of online resources compared to men. Online in-
tervention developers can use this information to better target
and engage the population of individuals in need. However,

828 WILKS ET AL.
marketing in this way may further broaden the treatment gap

among suicidal college men. Historically, men have been found
to underuse treatment resources in general (Addis & Mahalik,
2003; Mackenzie, Gekoski, & Knox, 2006), and are at higher risk
for suicide deaths (Centers for Disease Control and Prevention,
2016). Furthermore, we found that suicidal ideation was associ-
ated with help-negation in men in general. This phenomenon
has been explored in previous studies, pointing to explanatory
factors such as masculinity (Seidler et al., 2016), stigma (DeBate,
Gatto, & Rafal, 2018), and general embarrassment and anxiety
about the help-seeking process (Yousaf, Grunfeld, & Hunter,
2015) as reasons that men tend to delay or avoid help. Encour-
agingly, preliminary research shows initial promise for gen-
dered-based motivational interviewing to increase help-seeking
behavior in men (Syzdek, Green, Lindgren, & Addis, 2016), and
these strategies could be implemented by gatekeepers not tra-
ditionally associated with mental health, such as primary care
doctors or college advisors. In addition, knowing someone who
has received treatment has been associated with receiving help
(Disabato, Short, Lameira, Bagley, & Wong, 2018). Nonetheless,
there has been surprisingly little research designed to engage
men in treatment. The gap in our findings for ways to under-
stand help-negation in male college students further under-
scores this urgent need for research to determine how to engage
men in treatment.
One noteworthy aspect to this study was that the sample was
comprised of nearly two-thirds of individuals identifying as
Asian. While racial background was included as a covariate and
did not account for a significant proportion of variance in the
models, the makeup of our population demands attention. Spe-
cifically, while men in our sample were not interested in engag-
ing in any resources for their mental help, this may be a phenom-
enon of a sample that is majority Asian and living in a U.S. city.
The mental health of Asians living in the U.S. has been studied
previously (e.g., Wong et al., 2014; Tang & Masicampo, 2018);
however, this study is unique in its focus on help-seeking using
online methods. Nonetheless, these findings are not generaliz-
able to all college experiences in the U.S., but do offer a poten-
tially unique glimpse of a minority-majority college experience
and their help-seeking patterns.

LIMITATIONS
There are several limitations in the current study that require con-
sideration when interpreting this research. For one, this study was
cross-sectional, and the direction of the effects is unclear. Future
research should examine these constructs over time, which could
elucidate a better understanding about how suicidal individuals
who deny needing help are influenced by interpersonal problems,
stigma, and self-concealment. In addition, the magnitude of the
effects was small; particularly among online help-seeking prefer-
ence. Another limitation is the use of self-report measures for all
variables of interest. It is well known that suicidal individuals are
likely to under report and conceal their level of suicidal ideation,
and that other measures that assess implicit attitudes may be more
effective at capturing one’s true level of suicidal ideation and in-
tention (Nock et al., 2010). Nonetheless, our sample endorsed a
relatively high level of suicidal thoughts (Beck Scale for Suicide
Ideation M = 6.13) compared to college students nationally (e.g.,
Mortier, Cuijpers, et al., 2018). In addition, a student’s actual help-
seeking behavior may be a better indicator of help-negation than
their help-seeking intentions, particularly over time. Longitudinal
studies, and those that assess both intentions and behaviors, will
provide valuable opportunities to further understand these com-
plex processes. Despite these limitations, this study provided in-
sight into help-seeking patterns, and provides additional avenues
for continued research in this area.
CONCLUSIONS
While our study failed to explain why some people may turn to
online forms of help-seeking, some important clinical implica-
tions may be present. For one, there is a significant proportion
of individuals who opt to go online to cope with thoughts of
suicide. More research is needed to identify where suicidal in-
dividuals go to cope, whether these sites or mobile apps are ef-
ficacious or iatrogenic, develop strategies to improve the detec-
tion of suicidal individuals online, and to develop and evaluate
ways to deploy rapid interventions for individuals at risk for
suicide. Indeed, intervention research into nimble deployment

830 WILKS ET AL.
of intervention on online platforms shows promise to encour-

age individuals to use crisis services (Jaroszewski, Morris, &
Nock, 2019). Furthermore, both intervention and public health
research is needed to increase help-seeking behavior in men,
potentially targeting factors such as stigma and embarrassment
as ways to increase treatment utilization. As men are no more
likely to use in person or online methods of treatment, it seems
reasonable to implement the most scalable way to target stig-
ma and embarrassment, such as going online. Taken together,
as suicide and technology show no sign of slowing, leverag-
ing technology to increase effective avenues of treatment are
needed. This will invariable require interdisciplinary collabo-
rations among individuals in computer science, data science,
and psychology.
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Journal of Social and Clinical Psychology, Vol. 38, No. 10, 2019, pp.

ONLINE HELP PREFERENCE AND SUICIDE IDEATION

EXPLORING PREFERENCE TO AVOID OR SEEK

SIN YEE ANG AND XIYAO WANG

VINUSHINI ARUNAGIRI, AND ERIN F. WARD-CIESIELSKI

Keywords: suicidal ideation, help-seeking college students, treatment

Address correspondence to Chelsey R. Wilks, PhD, Harvard University, Department

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Suicide, ranking as the second highest cause of death for college-

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lege students would inform the development and delivery of on-

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be more valued in certain cultures, such as those from collectiv-

Participants were 816 college students between the ages of 18

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Pacific Islander, 20.8% as Caucasian, 5.1% as Hispanic, 1.6% as

Demographics. We assessed students’ self-reported age, sex, ra-

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associated with mental illness. The overall average score, rang-

All statistical analyses were performed using SPSS v.24.0 (IBM,

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TABLE 1. Sample Characteristics

analyses where normal parametric assumptions may not hold

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TABLE 2. Pearson’s r Correlations Between Model Variables with 95% Bootstrapped

2 was tested by assessing the moderating effect of internalized

HYPOTHESIS 1A: SI IS CORRELATED WITH INTENTIONS TO

Table 1 presents demographic and descriptive statistics for all

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R2 .077 .122 .088 .158

[.252, .439]), as well as online help preference (r = .22, 95% CIbootstrap

HYPOTHESIS 1B: SI AND HELP-SEEKING PREFERENCES WILL

To assess gender differences in the effect of SI on both (1) help-

HYPOTHESIS 2: SI AND HELP-SEEKING WILL BE MODERATED

To examine hypothesis 2, we tested a 3-way moderation (Pro-

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FIGURE 1. Relationships between suicidal ideation and intentions to

CIbootstrap [−.028, .021), and did not differ significantly by gender

EXPLORATORY HYPOTHESIS 3: INTERPERSONAL

As displayed in Table 4, results showed that SI is significantly

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TABLE 4. Results from the Moderated Mediation Analyses.

95% CIbootstrap [.008, .034]). As depicted in Figure 2, probing analy-

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FIGURE 2. Effect of interpersonal problems on help preferences at high

.014]), and non-significant at moderate (M) and low (M-1SD) SC

This study sought to replicate previous findings on the associa-

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sociations in the context of potential gender differences. In ad-

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increased, help-seeking. This could be due to the difficulties ex-

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marketing in this way may further broaden the treatment gap

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of intervention on online platforms shows promise to encour-