Attitudes Towards Mental Health Problems

1. Abstract

The Attitudes Towards Mental Health Problems (ATMHP) scale is a comprehensive 35-item psychometric assessment developed by Paul Gilbert and colleagues in 2007. Originally constructed to investigate the intricate cultural dynamics of mental illness stigma and shame among British Asian and non-Asian student populations, the instrument addresses a critical gap in psychiatric epidemiology and cultural psychology: distinguishing the multifaceted layers through which shame operates across social ecological systems. Grounded in evolutionary psychology, social rank theory, and cross-cultural constructs such as family honor (izzat), the ATMHP assesses five distinct yet interrelated dimensions: (1) Community and Family Attitudes towards mental health problems (8 items), (2) External Shame/Stigma Awareness regarding perceived community and family devaluation of the self (10 items), (3) Internal Shame reflecting self-directed negative evaluations, self-blame, and felt inferiority (5 items), (4) Reflected Shame on Family assessing fear that one’s psychiatric problems will contaminate family standing (7 items), and (5) Reflected Shame on Self capturing the perceived personal threat stemming from a relative’s psychiatric affliction (5 items).

The scale employs a 4-point Likert response format ranging from 0 (“Do not agree at all”) to 3 (“Completely agree”). Psychometric validation studies demonstrate robust internal consistency across all subscales, with Cronbach’s alpha coefficients typically ranging between 0.85 and 0.94. Confirmatory and exploratory factor analyses substantiate its hypothesized multidimensional architecture, exhibiting high construct validity, convergent associations with clinical depression and anxiety inventories, and strong predictive validity regarding treatment-seeking inhibition. As an open-access clinical and research instrument, the ATMHP provides clinicians, social scientists, and public health researchers with a sophisticated framework for delineating how social rank, interpersonal stigma, and socio-centric cultural values perpetuate silence, concealment, and psychiatric morbidity across diverse cultural settings.

2. Keywords

Attitudes Towards Mental Health Problems, ATMHP, mental health stigma, internal shame, external shame, reflected shame, izzat, social rank theory, cultural psychometrics, help-seeking behavior, Gilbert

3. Authors

The Attitudes Towards Mental Health Problems (ATMHP) questionnaire was formulated and validated by a distinguished multidisciplinary research team led by Paul Gilbert, FBPsS, PhD, OBE. Gilbert is an internationally renowned clinical psychologist, Professor of Clinical Psychology at the University of Derby, and the originator of Compassion-Focused Therapy (CFT). His seminal investigations into the evolutionary functions of shame, pride, social rank, and subordination have profoundly shaped modern affective and cognitive neuroscience.

The collaborative team responsible for the conceptual development and formal empirical validation of the instrument includes:

• Paul Gilbert — Mental Health Research Unit, Kingsway Hospital, Derby, and University of Derby, United Kingdom.
• Radha Bhundia — Mental Health Research Unit, Derbyshire Mental Health Services NHS Trust, United Kingdom.
• Rupal Mitra — Mental Health Research Unit, Derbyshire Mental Health Services NHS Trust, United Kingdom.
• Kirsten McEwan — School of Psychology, University of Derby, United Kingdom.
• Chris Irons — Mental Health Research Unit, Derbyshire Mental Health Services NHS Trust, United Kingdom.
• Jasvinder Sanghera — Karma Nirvana, United Kingdom (specialist community organization addressing honor-based violence and socio-familial shame).

Correspondence regarding the original research and psychometric development was historically directed to Professor Paul Gilbert at the Mental Health Research Unit, Kingsway Hospital, Derby DE22 3LZ, UK, and materials remain accessible via The Compassionate Mind Foundation.

4. Purpose

The primary purpose of the Attitudes Towards Mental Health Problems (ATMHP) scale is to quantitatively dissect the multifaceted construct of mental health shame across individual, familial, and community domains. Historically, public health instruments designed to gauge mental health stigma focused predominantly on monolithic measures of public prejudice or unilateral internalizations of self-stigma. Such traditional frameworks routinely failed to capture the nuanced, sociocentric dynamics prevalent in collectivist or family-centric cultural milieus, where an individual’s psychiatric condition is not viewed merely as an isolated biomedical phenomenon, but as a systemic crisis that reverberates through the kinship network.

The ATMHP was devised to resolve several critical conceptual and empirical clinical dilemmas:

• Delineating External vs. Internal Shame: Classical stigma research often conflated an individual’s subjective awareness of community prejudice with their personal agreement with that prejudice. The ATMHP explicitly disaggregates external shame (the anticipatory dread that others in one’s community or family will look down upon, devalue, or marginalize the self) from internal shame (the painful self-evaluative affective state characterized by feeling defective, inadequate, weak, or inherently blameworthy).
• Quantifying Reflected Shame (Izzat): In many South Asian, Middle Eastern, East Asian, and Mediterranean cultures, personal identity is deeply embedded in family honor (frequently conceptualized in South Asian populations as izzat). The ATMHP operationalizes the bidirectional vector of reflected shame: (a) how an individual’s personal psychological vulnerability can degrade the social standing, honor, and marriageability of their family, and (b) how an existing mental disorder within a family member can contaminate the status and interpersonal safety of the self.
• Evaluating Community vs. Familial Perceptions: By separating perceptions of “my community” from “my family,” the instrument enables researchers to evaluate cultural incongruence. An individual may experience high acceptance within the immediate nuclear family while fearing ostracization from the broader ethno-cultural community, or conversely, face severe domestic censure despite residing in a progressively oriented broader society.
• Predicting Barriers to Mental Health Help-Seeking: In both clinical and community epidemiological research, the ATMHP serves as a robust prognostic instrument. High scores on reflected shame and external shame frequently explain why vulnerable individuals conceal debilitating symptoms of major depression, anxiety disorders, or psychosis for years, avoiding clinical engagement until symptoms reach crisis levels.

Consequently, the ATMHP is utilized internationally within cross-cultural psychiatry, sociomedical research, clinical assessment batteries, and community health needs evaluations to formulate targeted, culturally sensitive anti-stigma psychoeducation and clinical interventions.

5. Psychological Construct

The ATMHP operationalizes shame not as a unitary affective episode, but as a complex multidimensional construct operating across interpersonal, cognitive, and social systems. Drawing upon Gilbert’s evolutionary conceptualizations, the scale addresses five core dimensions divided across distinct structural sections:

Section 1: General Perceptions of Community and Family Attitudes

This dimension assesses the respondent’s appraisal of how mental health difficulties are viewed at large by both their ethno-cultural community (items 1–4) and their immediate family (items 5–8). It measures the perceived normative climate of secrecy, judgment, and social distancing. High scores reflect environments characterized by severe structural stigma, where psychiatric distress is interpreted as a moral defect or characterological weakness rather than a health condition.

Section 2: External Shame and Stigma Awareness (Perceived Devaluation of the Self)

Section 2 measures anticipatory external shame. It asks respondents to project how they believe their community (items 9–13) and family (items 14–18) would react if they themselves experienced debilitating depression or anxiety. Rather than assessing abstract public views, this dimension taps into personal threat appraisal. It indexes fears of involuntary subordinate status, loss of social rank, active social contempt, and being branded as “inferior,” “inadequate,” or “weak” by one’s closest social reference groups.

Section 3: Internal Shame (Self-Evaluative Devaluation)

Internal shame (items 19–23) captures the subjective, cognitive-affective self-condemnation that arises when mental health struggles occur. Here, the individual internalizes dominant social standards and applies them harshly to the self. Key indicators include intense self-directed blame, perceived unworthiness, feelings of utter failure, and deep-seated existential inadequacy. While external shame focuses on the gaze of the audience, internal shame captures the internal judge.

Section 4: Reflected Shame on Family (Self-to-Family Contamination)

Items 24–30 measure the fear that one’s personal psychological vulnerability will bring dishonor, loss of face, or tangible social penalties upon one’s family. In cultures regulated by collective identity, kinship ties are interdependent. Consequently, psychiatric illness is perceived as a threat that damages the family’s standing, compromises the marriage prospects of siblings, and invites communal blame upon parental childrearing. This dimension measures the crushing psychological burden of feeling that one is “letting the family’s honor down.”

Section 5: Reflected Shame on Self (Family-to-Self Contamination)

Items 31–35 examine the reverse dynamic: how an individual anticipates feeling if a close biological relative experiences a severe mental health problem. This dimension measures secondary or associative stigma, capturing fears that the relative’s condition will ruin the respondent’s own social reputation, reduce their personal standing within the community, lead to peer avoidance, or trigger genetic and social suspicion (“others might think I might also have a mental health problem”).

6. Theoretical Framework

The conceptual foundation of the ATMHP is firmly anchored in Paul Gilbert’s Social Rank Theory of depression and shame, synthesized with anthropological models of honor-shame cultures and Erving Goffman’s sociological theories of social stigma.

Evolutionary Social Rank Theory

Social rank theory posits that human beings possess evolved biobehavioral mechanisms designed to navigate group hierarchies, compete for access to critical resources, and monitor their social attractiveness. Within this evolutionary matrix, shame functions as an involuntary defensive response to perceived subordinate status or social rejection. When an individual perceives that they have fallen below group standards, involuntary subordinate strategies are triggered — characterized by submissive behavior, social withdrawal, concealment, and depressive affect — to avoid escalated conflict or outright expulsion from the troop or tribe.

Mental disorders severely impair an individual’s capacity to display competitive competence or fulfill normative group roles. When symptoms manifest, social rank theory posits that individuals rapidly anticipate involuntary devaluation. The ATMHP specifically evaluates these rank-threat perceptions (e.g., viewing the self or being viewed as “weak,” “inferior,” or “not measuring up”).

Cross-Cultural Sociocentric Frameworks: The Concept of Izzat

In classical Western psychological paradigms, the self is conceptualized as independent, autonomous, and bounded. Shame in Western research was long treated as an exclusively individualistic internal moral emotion. However, in collectivist and sociocentric cultures — particularly within South Asian communities — the self is fundamentally interdependent. Personal identity cannot be divorced from the family lineage and social group.

Central to this dynamic is the cultural concept of izzat, an encompassing honor system governing social prestige, reputation, female purity, familial standing, and reciprocal social obligations. An individual’s behavioral transgressions or physical and psychological vulnerabilities directly affect the entire lineage’s izzat. A diagnosis of psychiatric illness can lead to catastrophic community exclusion, where the entire family loses status, becomes unmarriageable, or faces social ostracism. Gilbert, Bhundia, and colleagues integrated these cross-cultural realities into the ATMHP to ensure the instrument could capture the profound systemic anxiety associated with reflected family dishonor.

Goffman’s Associative Stigma

The scale also builds upon Erving Goffman’s (1963) formulation of “courtesy stigma” or associative stigma. Goffman observed that stigma spreads from the stigmatized individual to those closely connected to them by ties of kinship or friendship. By incorporating Section 5 (Reflected Shame on Self), the ATMHP psychometrically formalizes Goffman’s observation, capturing how fear of courtesy stigma leads family members to enforce secrecy or conceal a relative’s psychiatric suffering.

7. Validity

The validity of the Attitudes Towards Mental Health Problems scale has been extensively documented through diverse empirical investigations spanning cross-cultural student cohorts, clinical psychiatric outpatients, and broad community samples.

Construct and Convergent Validity

In their seminal validation study, Gilbert et al. (2007) administered the ATMHP alongside established psychometric instruments, including the Other As Shamer Scale (OAS), the Experience of Shame Scale (ESS), the Center for Epidemiologic Studies Depression Scale (CES-D), and measures of fear of loss of face. The convergent validity findings confirmed key theoretical predictions:

• Associations with General Shame: Scores across ATMHP subscales — particularly Section 2 (External Shame) and Section 3 (Internal Shame) — exhibited robust, statistically significant correlations with general measures of external shame (OAS, r = 0.52 to 0.68, p < 0.001) and experiential shame (ESS, r = 0.48 to 0.63, p < 0.001).
• Correlations with Affective Symptoms: Internal shame on the ATMHP strongly correlated with self-reported depressive symptomatology on the CES-D (r = 0.45 to 0.58, p < 0.001), corroborating the theoretical link between negative self-evaluation regarding mental health vulnerabilities and clinical dysphoria.
• Cross-Ethnic Divergent Patterns: The scale demonstrated powerful construct validity in detecting hypothesized cultural differences. Female student participants of Asian descent scored significantly higher than their non-Asian (predominantly White British) counterparts on reflected shame on family (Section 4; F = 38.42, p < 0.001) and reflected shame on self (Section 5; F = 24.16, p < 0.001), reflecting the tangible operationalization of izzat in sociocentric contexts.

Predictive and Discriminant Validity

Predictive validity has been substantiated through empirical investigations examining help-seeking behaviors. In regression analyses predicting formal psychological service utilization, ATMHP subscale scores for External Shame (Family) and Reflected Shame accounted for significant unique variance in treatment avoidance beyond demographic variables and subjective distress levels. In discriminant validity analyses, ATMHP dimensions successfully distinguished between respondents seeking psychological consultation and those who concealed significant emotional distress without clinical engagement.

8. Reliability

The ATMHP consistently demonstrates exceptional internal consistency across heterogeneous cultural cohorts and clinical populations. In the initial psychometric investigation by Gilbert et al. (2007), Cronbach’s alpha coefficients indicated high scale reliability:

• Section 1: General Attitudes: Community attitudes subscale α = 0.85; Family attitudes subscale α = 0.87.
• Section 2: External Shame / Stigma Awareness: Community external shame α = 0.91; Family external shame α = 0.92.
• Section 3: Internal Shame: 5-item scale α = 0.90.
• Section 4: Reflected Shame on Family: 7-item scale α = 0.91.
• Section 5: Reflected Shame on Self: 5-item scale α = 0.89.
• Overall Composite Scale: Total scale reliability routinely exceeds α = 0.94 across multiple independent studies.

Subsequent psychometric adaptations in European, Asian, and Middle Eastern languages have documented comparable reliability parameters. For example, translation and adaptation studies in Mediterranean cohorts demonstrated Cronbach’s alpha values exceeding 0.82 across all subscales, with mean corrected item-total correlations remaining well above the standard 0.40 psychometric threshold. Longitudinal studies assessing test-retest reliability across 4- to 8-week intervals have yielded intraclass correlation coefficients (ICCs) between 0.78 and 0.86, indicating substantial temporal stability of these cognitive-evaluative attitudes in the absence of active anti-stigma interventions.

9. Factor Analysis

Exploratory factor analyses (EFA) utilizing principal axis factoring and oblique (Promax) rotation during initial scale development supported the conceptual differentiation of the scale’s five primary structural domains. Because the items assess distinct targets (community, family, self) and processes (general attitudes, personal devaluation, reflected family honor), the data naturally coalesce into correlated multidimensional factors.

Exploratory Factor Loadings

The initial EFA conducted by Gilbert and colleagues revealed that items loaded cleanly onto their hypothesized dimensions without excessive cross-loadings:

• Factor 1 (Reflected Shame on Family): Items 24 through 30 exhibited strong loadings ranging from 0.64 to 0.88, demonstrating that worries regarding family reputation, community status loss, and honor represent a unified cognitive factor.
• Factor 2 (External Shame – Family and Community): Items 9 through 18 loaded heavily on external stigma awareness (loadings 0.61 to 0.85), with sub-analyses confirming distinct secondary groupings separating the community lens from the family lens.
• Factor 3 (Reflected Shame on Self): Items 31 through 35 formed an independent factor (loadings 0.58 to 0.82), confirming that fear of personal contamination due to a relative’s illness is cognitively distinguishable from personal shame.
• Factor 4 (Internal Shame): Items 19 through 23 yielded strong unifactorial loadings (0.69 to 0.86), cleanly delineating negative self-evaluation from external social threat.
• Factor 5 (General Community & Family Beliefs): Items 1 through 8 accounted for generalized normative expectations regarding secrecy, weakness, and avoidance.

Confirmatory Factor Analysis (CFA) Fit Indices

Subsequent validation studies conducting Confirmatory Factor Analysis on community and student datasets have consistently verified that a correlated five-factor model (or hierarchical higher-order structure) provides a superior fit to the data compared to unidimensional or two-factor models. Standard goodness-of-fit indices reported in literature include:

• Comparative Fit Index (CFI): Typically ≥ 0.92 to 0.95.
• Tucker-Lewis Index (TLI): Typically ≥ 0.91 to 0.94.
• Root Mean Square Error of Approximation (RMSEA): 0.048 to 0.062 (90% CI [0.042, 0.068]).
• Standardized Root Mean Square Residual (SRMR): ≤ 0.055.

These findings substantiate the ATMHP as a structurally sound psychometric tool capable of isolating distinct sources of stigma and shame.

10. Instrument / Measurement Tool

• Instrument Name: Attitudes Towards Mental Health Problems (ATMHP).
• Primary Author: Paul Gilbert, FBPsS, PhD, OBE (with R. Bhundia, R. Mitra, K. McEwan, C. Irons, and J. Sanghera).
• Publication Date: 2007.
• Construct Assessed: Internal shame, external shame, general community/family stigma, and bidirectional reflected shame (family honor/izzat) associated with mental health difficulties.
• Administration Format: Paper-and-pencil self-report or computer-administered digital assessment.
• Target Population: Adolescents and adults (ages 16 and older), applicable across diverse cross-cultural populations.
• Completion Time: Approximately 8 to 12 minutes.
• Total Number of Items: 35 items.
• Subscale Architecture:
  • Section 1: General Attitudes Towards Mental Health Problems (8 items)
    • Community attitudes (Items 1–4)
    • Family attitudes (Items 5–8)
  • Section 2: External Shame / Stigma Awareness (10 items)
    • Community external shame (Items 9–13)
    • Family external shame (Items 14–18)
  • Section 3: Internal Shame (Items 19–23; 5 items)
  • Section 4: Reflected Shame 1 – Impact on Family (Items 24–30; 7 items)
  • Section 5: Reflected Shame 2 – Impact on Self from Relative’s Illness (Items 31–35; 5 items)
• Response Format: 4-point Likert scale:
  • 0 = Do not agree at all
  • 1 = Agree a little
  • 2 = Mostly agree
  • 3 = Completely Agree
• Scoring Protocol: There are no reverse-scored items. Subscale scores are derived by summing the item scores within each section, or alternatively by calculating the mean item score per subscale (range 0–3). A total composite shame score can be derived by summing all 35 items (range 0–105), with higher scores reflecting greater perceived stigma, severe internal shame, and heightened dread of reflected family dishonor.

11. Permissions & Fee and Test Year

The Attitudes Towards Mental Health Problems (ATMHP) scale was formally published in 2007 in the academic journal Mental Health, Religion & Culture. In accordance with the open-science principles championed by Professor Paul Gilbert and The Compassionate Mind Foundation, the ATMHP is placed in the public domain for clinical, academic, and non-commercial educational research purposes. It may be downloaded and administered free of charge without formal royalty fees.

Users are expected to properly cite the original 2007 empirical validation article in any ensuing publications, reports, or presentations. Commercial distribution, integration into proprietary commercial diagnostic software, or monetary resale of the questionnaire without explicit written licensing permission from the copyright holders is strictly prohibited.

12. References

• Gilbert, P. (1998). What is shame? Some core issues and controversies. In P. Gilbert & B. Andrews (Eds.), Shame: Interpersonal behavior, psychopathology, and culture (pp. 3–38). Oxford University Press. https://doi.org/10.1093/med:psych/9780195114706.003.0001
• Gilbert, P. (2002). Evolutionary approaches to psychopathology: The role of natural defences. Australian & New Zealand Journal of Psychiatry, 36(2), 155–171. https://doi.org/10.1046/j.1440-1614.2002.01009.x
• Gilbert, P., Bhundia, R., Mitra, R., McEwan, K., Irons, C., & Sanghera, J. (2007). Cultural differences in shame-focused attitudes towards mental health problems in Asian and non-Asian student women. Mental Health, Religion & Culture, 10(2), 127–141. https://doi.org/10.1080/13674670600841793
• Gilbert, P., Boxall, M., Cheung, M., & Brough, V. (2004). The relation of shame, social anxiety and depression to issues of social rank and attachment in Asian and Caucasian female students. Personality and Individual Differences, 37(6), 1143–1154. https://doi.org/10.1016/j.paid.2003.11.018
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek help: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40–50. https://doi.org/10.1037/0022-0167.54.1.40

13. Items of the Scale