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https://doi.org/10.1177/07311214211042856
Sociological Perspectives
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DOI: 10.1177/07311214211042856
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Student
How Cultural Capital Shapes
Mental Health Care Seeking
in College
Katie R. Billings1 and Kathryne M. Young1
Abstract
First-generation and working-class undergraduates not only experience mental health problems at
higher rates than their more affluent peers, but are also less likely to seek treatment. We administered a
mixed-methods survey to undergraduates at two institutions to investigate the relationship between
cultural capital and mental health decision-making. Using two measures of cultural capital, we find
that students with high cultural capital are more likely to seek mental health treatment than those
with limited cultural capital. Additionally, analysis of our qualitative results reveals that while students
with limited cultural capital make treatment decisions through a collectivistic lens (considering other
people’s needs and opinions), those with high cultural capital tend to view treatment decisions
through an individualistic lens (considering their own needs and opinions). These lenses capture
both the barriers and facilitators to mental health care that students cite to explain their decision-
making. Understanding how cultural capital shapes orientations to mental health care is necessary to
facilitate help-seeking for students from all social class backgrounds.
Keywords
mental health, social psychology, medical sociology, inequality, poverty and mobility, education
Introduction
Social Class and the College Mental Health Crisis
The mental health crisis on college campuses has grown acute in recent years; the number of col-
lege students screening positive for anxiety has increased from 17 to 31 percent just in the last six
years (Eisenberg and Lipson 2019), and suicide is now the second leading cause of death among
college students (National Institute of Mental Health 2021). Alarmingly, two thirds of college
students who faced mental health problems pursued no treatment in the past year (Eisenberg et al.
2011). First-generation and working-class undergraduates are more likely to experience mental
health challenges in college, and less likely to seek treatment (Eisenberg, Golberstein, and
Gollust 2007; Hunt and Eisenberg 2010; Weitzman 2004). This disparity in help-seeking is not a
function of different rates of self-perceived need; people from more modest backgrounds are
equally likely to identify particular symptoms as mental health problems, and equally likely to
perceive a need for care (Eisenberg et al. 2007; Mojtabai, Olfson, and Mechanic 2002).
1University of Massachusetts Amherst, Amherst, MA, USA
Corresponding Author:
Katie R. Billings, University of Massachusetts Amherst, Amherst, MA 01003, USA.
Email: krbillings@umass.edu
1042856SPXXXX10.1177/07311214211042856Sociological PerspectivesBillings and Young
research-article2021
2 Sociological Perspectives 00(0)
Most colleges publicize the availability of mental health care through targeted programming,
and by incorporating information about campus-based psychological services into student orien-
tation (Brown 2020). Many colleges have reduced or eliminated monetary costs for student men-
tal health services as well (Lipson et al. 2019). Nonetheless, class-based disparities in mental
health prevalence and service use persist (Eisenberg et al. 2007; Hunt and Eisenberg 2010), with
far-reaching consequences, including college attrition (Auerbach et al. 2016), lower educational
attainment (Mojtabai et al. 2015), and reduced likelihood of securing housing (Hammel 2017)
and employment (Baert et al. 2016; Hipes et al. 2016). College’s role as a potential social equal-
izer is undercut if students from first-generation and working-class backgrounds receive inade-
quate support after matriculating. Yet, the social mechanisms that underlie the class-based
disparity in mental health treatment seeking in college remains largely a puzzle. Why do stu-
dents’ social class backgrounds predict whether or not they will seek mental health care in col-
lege? How does privilege shape the ways people approach mental health care decisions? And for
those working class and first-generation college students who do seek care on campus, how and
why did they make that decision? This article explores the socio-cultural processes that deter-
mine college students’ pursuit—or lack of pursuit—of mental health care.
Mental Health Care Seeking
Mental health decision-making is a social process (Pescosolido 1992; Pescosolido and Boyer
1999; Thoits 2011; Vogel et al. 2007; West et al. 2012). Though medical care utilization theories
assume a certain degree of rational choice on clients’ part (see Pescosolido 1992), the reality of
how people actually seek mental health services is much more complex and socially determined
(Pescosolido and Boyer 1999; Vogel et al. 2007). The Network-Episode Model (NEM) of care
seeking “targets the importance of social influence (exerted through ‘community’ networks) on
when, how and if individuals receive care” (Pescosolido, Gardner, and Lubell 1998: 276).
Individuals’ orientations toward their communities are partly determined by class background.
Working-class people are more likely to express collectivistic, rather than individualistic, views,
and are more attuned to others’ distress than their upper-class counterparts (Kraus and Keltner
2009; Kraus et al. 2012; Piff et al. 2010; Stellar et al. 2012). The NEM acknowledges that indi-
viduals are situated within, and respond to, their social connections. It also allows for varied
service entry, including choice and coercion as pathways to mental health care. After all, social
networks can bolster individual agency in decision making for some people, but for others, social
actors (family members, friends, etc.) may make decisions on an individual’s behalf regarding
mental health treatment. Put simply, the NEM acknowledges the social and cultural processes
that underlie individuals’ varied pathways to mental health treatment.
Indeed, David L. Vogel et al. (2007) find that personal relationships can both hinder and facili-
tate mental health help-seeking; knowing someone who has sought care or being advised to seek
care are both predictive of positive expectations about mental health care. The vast majority of
people in their study who sought treatment either knew someone who sought care and/or were
advised to seek care by someone in their social network (Vogel et al. 2007).
Given the social and cultural dimensions of mental health service use, it is unsurprising that
likelihood to seek treatment varies with individuals’ social identities. Previous researchers docu-
ment the underutilization of mental health services among communities of color, men and boys,
young people, rural residents, and people in lower socioeconomic positions (Biddle et al. 2007;
Eisenberg et al. 2007; Lindsey et al. 2010; Neighbors et al. 2007; Stewart et al. 2015). Structural
barriers and a lack of culturally appropriate care contribute to these disparities (Williams, Rosen,
and Kanter 2019), but sociocultural barriers are also partly responsible for these disparities in
mental health care seeking (Horwitz et al. 2020; Statz et al., 2021). Indeed, the literature on men-
tal illness stigma demonstrates that stigma is a context-dependent social process that remains one
Billings and Young 3
of the most cited barriers to seeking mental health care (Clement et al. 2015; Gaddis, Ramirez,
and Hernandez 2018, 2020; Horwitz et al. 2020; Pescosolido and Martin 2015; Pietrzak et al.
2009). Our work builds on the findings of Pescosolido and colleagues to develop a better under-
standing of the social processes that underlie decisions about whether to seek mental health care,
including the roles of social connections, community contacts, and cultural contexts. Specifically,
we are interested in the ways that cultural capital shapes these experiences.
Cultural Capital
Cultural capital includes knowledge, skills, values, mannerisms, and interactional styles that
can be accrued through socialization and education and leveraged for mobility (Bourdieu 1974,
1984). It is a primary means through which status-based inequalities, often rooted in economic
inequalities, manifest. Bourdieu coined the term “cultural capital” as a theoretical tool to exam-
ine how class-based inequalities are reproduced. Lamont and Lareau (1988) define cultural
capital as “institutionalized, i.e., widely shared, high status cultural signals (attitudes, prefer-
ences, formal knowledge, behaviors, goods and credentials) used for social and cultural exclu-
sion” (p. 156). Though many quantitative examinations operationalize the concept as interaction
with particular indicia of “highbrow” culture, we draw instead on the “Lareau tradition,” which
defines cultural capital as embodied forms of capital that are differentially rewarded by society
(Davies and Rizk 2018). Within this tradition, researchers understand cultural capital as inti-
mately connected with the various ways social class can manifest in a person’s life (Calarco
2018; Jack 2019; Lareau and Weininger 2003).
Some markers of cultural capital are clear and relatively universal, such as attending the
Dalton School or Andover Academy. (Although, note that even within this, there is considerable
variation.) Other markers are subtler, based on habits or mannerisms, and may or may not be leg-
ible to people outside of particular groups, such as the fabric of a person’s suit, the cadence of a
person’s speech, or even the way they sit. Indeed, hailing from a higher social class—that is,
having more cultural capital—is associated with greater success in “gateway” interactions, such
as professional job interviews (Ridgeway and Fisk 2012). Many qualified working-class people
are excluded from white-collar jobs because they lack the networking relationships employers
prioritize in hiring decisions (D. Lee 2011). Even if they get to the interview stage, their demeanor,
clothing, and interactional styles are devalued by evaluators, because employers favor candidates
who signal upper-class experiences and values (Rivera 2011, 2012, 2015). Put simply, cultural
capital is rewarded with social, economic, educational, and employment advantages (Armstrong
and Hamilton 2013; Calarco 2011, 2014, 2018; Jack 2016, 2019; Khan 2010; Lareau 2011;
Marteleto and Andrade 2014; Thiele 2016).
Cultural Capital and Health Outcomes
Numerous studies have found associations between cultural capital and favorable health out-
comes; this work has operationalized cultural capital using educational attainment (Albert and
Davia 2010; Herd, Goesling, and House 2007) or participation in cultural activities (Bygren et al.
2009; Nummela et al. 2008; Wilkinson et al. 2007). Some of these associations are simply due to
financial disparities: people with more money can access health-enhancing benefits like healthier
food, more exercise options, and better care providers (see Abel 2008). But beyond access, cul-
tural capital also affects the nature of the interactions people have with institutions and institu-
tional gatekeepers. Lareau (2002) explains the process through which cultural capital creates
unequal medical treatment by shaping patients’ dispositions, assumptions, and interaction styles.
The middle-class children she observed were encouraged to advocate for their well-being by
answering doctors’ questions and asking their own. In contrast, working-class children were taught
4 Sociological Perspectives 00(0)
to approach doctor-patient interactions with apprehension and distrust, answering questions briefly
and sharing minimal information. As a result, doctors provided more accurate and detailed health
information to middle-class families. In this way, embodied cultural capital is parlayed into a more
positive healthcare relationship—and in turn, better health outcomes.
In 2010, Shim proposed a theoretical construct to name the process Lareau (2002) described:
“cultural health capital.” Cultural health capital includes cultural skills, behaviors, and interac-
tional styles that facilitate advantages in healthcare settings. Others have applied Shim’s con-
struct to investigate the ways that interpersonal interactions can produce health disparities
(Chang, Dubbin, and Shim 2016; Dubbin, Chang, and Shim 2013; Madden 2015). Janet K. Shim
(2010) argues that due to differences in their social backgrounds, people with more cultural capi-
tal are better equipped to consume biomedical data, self-surveil for risky behaviors, and build
rapport with providers. Cultural health capital may explain why people from lower socioeco-
nomic backgrounds are less likely to use general health services (Blackwell et al. 2009) and
mental health services (Wang et al. 2005).
Even in contexts where mental health care is widely accessible and financial barriers are
removed—like college campuses (Eisenberg et al. 2007; Hunt and Eisenberg 2010) and countries
with national health care systems (Garrido-Cumbrera et al. 2010)—social class disparities in men-
tal health care use remain, suggesting that money cannot fully explain mental health care seeking
disparities. We draw on the cultural capital literature to investigate the mechanisms that give rise
to mental health service disparities among college students from differing class backgrounds.
The Present Study
Publicizing mental health services and making them affordable have proven insufficient steps to
remedy the class-based mental health service use gap on college campuses (Aries 2008;
Armstrong and Hamilton 2013; E. M. Lee and Kramer 2013). In order to support students from
less privileged backgrounds, we need to understand how they approach mental health care deci-
sions. Here, we ask: Does cultural capital affect how college students make decisions about
mental health care seeking, and if so, how? Based on the previous literature on mental health care
use and cultural capital, we propose the following hypotheses:
Hypothesis 1: Students with higher cultural capital will be more likely to seek mental health
treatment on campus compared to students with limited cultural capital.
Hypothesis 2: Cultural capital will determine the frameworks with which students approach
mental health care decisions.
Most centrally, we examine the social processes that underlie observed class-based disparities
in mental health service utilization, with an eye toward understanding how students from differ-
ent class backgrounds experience both barriers and facilitators to mental health care.
Method
Site Selection and Sampling Strategy
We surveyed students at two private universities that we selected for specific similarities and dif-
ferences. Both colleges are located in rural New England, enroll fewer than 5000 undergraduates,
and offer mental health care for undergraduates. Specifically, each college (1) requires health
insurance for enrollment; (2) offers free, short-term, on-campus counseling based on the coun-
selor’s discretion; (3) requires no co-pay for these sessions; (4) promotes their campus mental
health services during undergraduate student orientation. Despite these similarities, the two uni-
versities differ in important ways—prestige and selectivity chief among these.
Billings and Young 5
The more selective university, which we call “Ivy League University” (“ILU”), is ranked as a
top-20 university nationally by U.S. News and World Report. It accepts about 10 percent of appli-
cants, generally with SAT scores in the 95th–99th percentile, and close to 90 percent of enrollees
graduate, usually within four years. Less than 15 percent of ILU’s students receive Pell Grants
(a proxy for identifying low-income students [Engle and Tinto 2008]).
By contrast, the less selective university, which we call “Non-Ivy League University”
(“NILU”) is not ranked in the top 100 universities in its region by U.S. News and World Report.
It accepts 80 percent of applicants, most with SAT scores ranging from the 30th to the 65th per-
centile. Its four-year graduation rate is around 40 percent, and over 30 percent of its students
receive Pell Grants.
In 2016, we distributed our survey to the undergraduate population of both universities. This
was done via email with the consent and collaboration of both university administrations.1
Participation was voluntary, and respondents were not offered compensation. The response rates
were almost identical: 14 percent at ILU and 13 percent at NILU.2 We used chi-square tests to
verify that the samples were demographically representative of their respective student bodies in
terms of race, sex, and proportion of students in each class year. In total, 757 undergraduates
completed our 20-minute survey.
Measures
Culture capital is notoriously difficult to operationalize, and there is no universally agreed-upon
measure to capture the concept. In qualitative work, it is widely operationalized simply as social
class (Lareau and Weininger 2003), which is commonly measured using only income or educa-
tion. Since our understanding of cultural capital aligns with the “Lareau tradition” of the concept
(Davies and Rizk 2018), we selected two measures that would capture differentially valued
embodied ways of being.
Our first independent measure is whether a respondent attended ILU or NILU. Although
enrolling in any college requires some amount of cultural capital, enrollment in NILU marks a
more limited amount. Enrolling in ILU typically requires some level of cultural capital to begin
with. Attendance at ILU also confers some amount of cultural capital. Anthony Abraham Jack
(2019), for example, identifies high-status school attendance as a critical mode of cultural capital
transmission. In addition, Shamus Rahman Khan (2010) explains how elite academic institutions
socialize students to participate in elite culture, giving them tools that allow them to procure
social advantages after they leave, and preparing them for occupations that require cultural capi-
tal (Binder, Davis, and Bloom 2016; Rivera 2011, 2012, 2016). Previous work has also used
school attendance to operationalize cultural capital among college students (Young and Billings
2020).
Our second measure of cultural capital is subjective social status (SSS), measured using the
MacArthur Scale of Subjective Social Status (Adler and Stewart 2007; Cundiff et al. 2013).3
Compared to singular measures of social class (i.e., income or education), SSS more closely
approximates individuals’ hierarchical placements within societies. This is because it encapsu-
lates multiple axes of social status (e.g., income, wealth, education, and occupational prestige) in
one measure (Billings 2020). For the SSS measure, participants indicated their position on a
10-rung “social hierarchy” ladder. The original MacArthur Scale prompts respondents to rank
themselves on a social ladder relative to the U.S. population. We modified the referent category
to respondents’ college peers to capture social status distinctions within respondents’ local social
environments (Andersson 2018; see the appendix). In this way, we are able to capture the micro-
interactional processes whereby individuals’ behaviors, language, materials, and ways of being
are differentially valued in society (Lareau and Weininger 2003).
6 Sociological Perspectives 00(0)
Our choice of measures necessarily approximates a complex idea; these cannot, and should
not, be understood as “absolute” quantifications of cultural capital. Nonetheless, our opera-
tionalization represents a step forward in quantitative work on cultural capital. First, we offer
two measures of cultural capital to more fully approximate a complex concept while most
previous work uses only one measure (see Jaeger 2011; Wildhagen 2009; Yamamoto and
Brinton 2010; Young and Billings 2020 for exceptions). Additionally, we use Lareau’s more
holistic definition of cultural capital, which focuses on embodied forms of capital that are
differentially rewarded by society, to quantitative work. Former quantitative studies have
reduced cultural capital to knowledge of “highbrow” aesthetic culture. We agree with Annette
Lareau and Elliot B. Weininger (2003) who critique this approach: “[T]he highbrow’ interpre-
tation was not essential to Bourdieu’s conceptualization of cultural capital. We therefore
assert that it has unnecessarily narrowed the terrain upon which cultural capital research oper-
ates” (pp. 568–69).
Finally, we have two dependent measures of a person’s likelihood to seek mental health treat-
ment. First, we asked: “If you were struggling with a mental health problem, how likely would
you be to seek mental health services?” Respondents were given five options: (1) not at all likely;
(2) not very likely; (3) somewhat likely; (4) likely; (5) very likely. We followed this question with
an open-ended question: “Explain why you chose your answer.” We chose an open-ended depen-
dent variable in part because of the complexity of cultural capital itself. That is, we wanted to be
sure that the reasons for and against help-seeking were generated by respondents themselves, not
by a preset list of possibilities we generated ahead of time.
Data Analysis
Quantitative Analysis
We ran a series of ordinal logistic regressions to determine how our measures of cultural capital
predicted changes in likelihood to seek treatment for all respondents (N = 757). Table 1 reports
the demographic characteristics of respondents from Ivy League University and Non-Ivy League
University.
We coded open-ended justifications for limited and high cultural capital respondents
(N = 455). Table 2 reports the demographic characteristics of respondents from the limited and
high cultural capital groups.
Qualitative Analysis
Our qualitative analyses focused on the extremes of the cultural capital spectrum. We focus on
respondents with the least cultural capital (NILU students with low subjective social status
scores, n = 110) and the most cultural capital (ILU students with high subjective social status
scores, n = 345).4 We refer to these groups as the “limited cultural capital” and “high cultural
capital” groups. The rest of our respondents possessed various amounts of cultural capital along
these axes. We illustrate this division in the table below. The bolded quadrants—the limited and
high cultural capital groups—indicate the respondents whose open-ended responses we coded.5
This two-quadrant approach follows Kathryne M. Young and Katie R. Billings’s (2020) method
for qualitative analysis of cultural capital in the legal context.
MacArthur score 1–5 MacArthur score 6–10
Non-Ivy League University attendance Limited cultural capital Mixed cultural capital
Ivy League University attendance Mixed cultural capital High cultural capital
Billings and Young 7
We omitted 19 blank or nonsensical responses, leaving us with 436 explanations. After ran-
domizing their order to blind ourselves to the cultural capital groupings, we open-coded responses
using a modified grounded theory approach (McDermott 2006). Themes related to attitudes
about mental illness, barriers to mental health care, and beliefs about mental health care emerged
from the data; we then created subcodes within these themes. To ensure inter-coder reliability, we
created a codebook with definitions and examples of all codes and subcodes. Then, both authors
separately coded the qualitative data and compared the analyses. We discussed each response for
which our codes differed, and jointly decided which code(s) fit best. Using this collaborative
analysis, we were able to reach agreement about the coding of all qualitative responses.
Results
Likelihood of Seeking Mental Health Treatment
We ran a series of ordinal logistic regressions to assess which factors best predicted undergradu-
ates’ responses about seeking mental health treatment (see Table 3). Two variables significantly
predicted treatment-seeking: having previously sought treatment and subjective social status.6
In support of Hypothesis 1, subjective social status—our first measure of cultural capital—
significantly predicted treatment-seeking and remained significant across all models. For each
Table 1. Demographic Characteristics of Respondents from Ivy League University and Non-Ivy League
University.
Characteristic
Ivy league
(N = 542)
Non-ivy league
(N = 215)
Total
(N = 757)
n (%) n (%) n (%)
Race/ethnicity
White* 333 (61) 193 (90) 526 (69)
Hispanic/Latino* 38 (7) 6 (3) 44 (6)
Asian* 80 (15) 2 (<1) 82 (11)
Black/African American 37 (7) 8 (4) 45 (6)
Other 54 (10) 6 (3) 60 (8)
Sex
Female 362 (67) 150 (70) 512 (68)
Male 175 (32) 64 (30) 239 (32)
Other 5 (<1) 1 (<1) 6 (<1)
Class year
First-year 127 (23) 57 (26) 184 (24)
Sophomore 127 (23) 47 (22) 174 (23)
Junior 142 (26) 58 (27) 200 (26)
Senior 146 (27) 53 (25) 199 (26)
Subjective social status
Low (1–5)*** 197 (36) 110 (51) 307 (41)
High (6–10)*** 345 (64) 105 (49) 450 (59)
Previous experience
Sought treatment*** 226 (41.7) 54 (25.1) 280 (37.0)
Note. Chi-square tests were used to compute significant differences in proportions of characteristics by type of
institution. Mean = 2.0. Average SSSM = 5.8. SDSSS score for the total sample was score at Ivy League University
was M = 6.0 (SD = 2.1) and M = 5.3 (SD = 1.9) at NILU. A t-test demonstrated that the difference in SSS means
was statistically significant across schools (t = 4.5, p < .0001). SSS = subjective social status.
*p < .05. **p < .01. ***p < .001.
8 Sociological Perspectives 00(0)
one-step increase on the subjective status ladder, individuals’ likelihood of being in the most-
likely-to-seek-treatment category, versus any other category, is 1.11 times greater, with other
variables held constant.7 School membership—the second measure of cultural capital—was not
significantly predictive of treatment-seeking, which was inconsistent with Hypothesis 1.
However, a post hoc t-test of the average likelihood to seek treatment across schools was
approaching significance in the expected direction.8
To interpret the magnitude of the results from Model 3 (Table 3), we ran a series of predicted
probabilities of five SSS values (1, 3, 5, 7, and 9) on each “likelihood to seek treatment” outcome
(1 = not at all likely; 2 = not very likely; 3 = somewhat likely; 4 = likely; 5 = very likely) for
both schools (Figures 1 and 2).9 Other than the manipulated SSS values, each respondent retained
individual values on all other covariates in each simulation. This series of predicted probabilities
allowed us to examine the magnitude of the effect of a one-rung move up or down the subjective
social status ladder on individuals’ likelihood to seek treatment scores at both schools.
The predicted probabilities of a student’s likelihood to seek treatment are similar at both
schools. Lower SSS is related to a greater likelihood of responding “not at all likely” or “not very
likely” to seek treatment for students from both colleges. Correspondingly, higher SSS is related
to a greater likelihood of answering “likely” or “very likely” for students at both schools.
Movements on the SSS ladder did not affect respondents’ probabilities of selecting “somewhat
likely” to seek treatment at either institution.
Being in the lowest subjective social status position (SSS = 1) at ILU corresponds to a 15.76
percent chance of being “not at all likely” to seek treatment. The probability of being in this cat-
egory decreases as SSS increases at ILU; having an SSS of nine corresponds to a 7.68 percent
chance of answering “not at all likely.” In other words, we observe an 8.08 percentage point drop
Table 2. Demographic Characteristics of Respondents from the Limited and High Cultural Capital
Groups.
Characteristic
Limited cultural capital
(N = 110)
High cultural capital
(N = 345)
n (%) n (%)
Race/ethnicity
White*** 97 (88.2) 243 (70.4)
Hispanic/Latino 3 (2.7) 10 (2.9)
Asian*** 1 (0.9) 52 (15.1)
Black/African American 5 (4.6) 16 (4.6)
Other 4 (3.6) 24 (7)
Sex
Female 85 (77.3) 235 (68.1)
Male 25 (22.7) 108 (31.3)
Other 0 (0) 2 (0.6)
Class year
First-year 30 (27.3) 80 (23.2)
Sophomore 25 (22.7) 83 (24.1)
Junior 30 (27.3) 87 (25.2)
Senior 25 (22.7) 95 (27.5)
Experience with mental health system
Previously sought treatment** 28 (25.5) 144 (41.7)
Note. Chi-square tests were used to compute significant differences between proportions by cultural capital groups.
*p < .05. **p < .01. ***p < .001.
Billings and Young 9
in the chance of answering “not at all likely” from an SSS of one to an SSS of nine. Similarly,
being in the lowest subjective social status position (SSS = 1) at NILU corresponds to an 18.16
percent chance of being “not at all likely to seek treatment.” As SSS increases, the probability
of NILU students being in this category decreases. Having an SSS of nine corresponds to an
8.99 percent chance of being “not at all likely” to seek treatment. Put simply, there is a 9.17
percentage point drop in answering “not at all likely” to seek treatment from an SSS of one to
an SSS of nine.
We see the opposite trend for the highest two likelihood to seek treatment options at both col-
leges. At ILU, when SSS = 1, a respondent’s likelihood of being “very likely” to seek treatment
is 8.55 percent. As SSS scores increase, the predicted probabilities for a “very likely” response
increases. At ILU, an SSS score of nine corresponds to a 17.4 percent chance to respond “very
likely” to seek treatment—an 8.85 percentage point increase. At NILU, we see the exact same
trend: when SSS = 1, a respondent’s likelihood of being “very likely” to seek treatment is 7.29
percent. When SSS = 9, then the NILU respondent’s likelihood of responding “very likely”
increases to 15.07 percent—a 7.78 percentage point increase.
Quantitative Differences between the High and Limited Cultural Capital Groups
As described above, we analyzed open-ended responses for students with the most and least
cultural capital: those who attended ILU and had a SSS score of 6–10 (the high cultural capital
group, n = 345) and respondents who attended NILU and had a SSS score of 1–5 (the limited
cultural capital group, n = 110). While the other two quadrants represent people with varying
Table 3. Ordered Logistic Regression Models of Likelihood to Seek Mental Health Services (Odds
Ratios).
Independent variables
Model 1 Model 2* Model 3***
Coefficient SE Coefficient SE Coefficient SE
Socio-demographics
Sex (omitted: male)
Female 1.24 .18 1.30 .19 1.15 .17
Sex Other 1.23 .91 1.29 .97 0.81 .61
Race (omitted: white)
Hispanic/Latinx .82 .24 0.94 .30 1.07 .33
Asian .76 .16 0.72 .15 0.86 .19
Black/African American 1.03 .28 1.10 .30 1.18 .33
Race Other .87 .21 0.90 .23 0.94 .24
Class year (omitted: first-year)
Sophomore 1.21 .23 1.20 .23 1.17 .22
Junior 1.35 .25 1.36 .25 1.19 .22
Senior 1.29 .24 1.29 .24 1.13 .21
Cultural capital
Social status
Subjective social status 1.10** .04 1.11** .04
School (omitted: non-ivy)
Ivy League University 1.30 .21 1.03 .17
Experience with mental health system
Previously sought treatment 2.98*** .44
*p < .05. **p < .01. ***p < .001.
10 Sociological Perspectives 00(0)
amounts of cultural capital, we were interested in differences between the two greatest extremes.
In line with Hypothesis 1, the limited cultural capital group was significantly less likely to
report willingness to seek treatment (M = 2.682) compared to the high cultural capital group
(M = 3.064) (p = .002), and the qualitative responses shed light on the sources of these
differences.
Qualitative Analysis of Open-ended Responses
As Hypothesis 2 predicted, we found that cultural capital determined the orientations students
used to approach mental health care decisions. Seven key themes emerged in our open-ended
responses: past experiences with mental health, structural barriers; perceived stigma; skepti-
cism; alienation, positive perceptions of mental health care; and self-care frameworks. In the
sub-sections below, we provide more detail about each theme’s substance and frequency. Table 4
Figure 1. Ordered logistic simulated probabilities of Ivy League University students’ likelihood to seek
mental health treatment by subjective social status (SSS).
Figure 2. Ordered logistic simulated probabilities of Non-Ivy League University students’ likelihood to
seek mental health treatment by subjective social status (SSS).
Billings and Young 11
summarizes the chi-square results comparing proportions of our codes between the high and
limited cultural capital groups.
Past Experience with Mental Health
First, numerous students cited their own or others’ experiences with mental health services in
their explanations about seeking treatment. We coded references to past experiences—one’s own
or someone else’s—that guided respondents’ decisions. Then we created subcodes to indicate
whether the student talked about their own experiences or another person’s. For a self-reference,
a student might write, “I’ve been to therapy before and it helped.” For an other-reference, a stu-
dent might say, “I have a friend who got better after seeking help.” Importantly, self- and other-
references could justify seeking treatment or not seeking treatment, depending whether the past
experience was positive or negative. We subcoded for positive, negative, or ambiguous past
experiences.
We found no differences between students’ cultural capital and the likelihood that they drew
on others’ experiences with mental health, and this was true across both positive and negative
past experiences (see Table 4). However, we found differences between the two groups among
students who cited their own experiences. Those in the limited cultural capital group (22 out of
110, or 20.0 percent) were less likely to justify their answers by discussing a past experience with
mental health care compared to those in the high cultural capital group (98 out of 345, or 28.41
percent). This difference approached statistical significance (χ2 = 3.031, p = .082).
When we examined the character of the past experience, we again found differences between
groups. High cultural capital respondents (15 out of 345, or 4.35 percent) were more likely to
mention positive past experiences compared to limited cultural capital respondents (0 out of 110,
Table 4. Justifications for Seeking Mental Health Treatment Decisions, by Cultural Capital Group.
Theme
Limited cultural
capital
High cultural
capital Chi-square p-value
Past experience with
mental health
23/110 (20.91%) 113/345 (32.75%) 5.568 .018*
Other-reference 3/110 (2.73%) 15/345 (4.35%) 0.575 .449
Positive 1/110 (0.91%) 8/345 (2.32%) 0.853 .356
Negative 0/110 (0%) 1/345 (0.29%) 0.319 .572
Ambiguous 2/110 (1.82%) 6/345 (1.72%) 0.005 .944
Self-reference 22/110 (20.0%) 98/345 (28.41%) 3.031 .082
Positive 0/110 (0%) 15/345 (4.35%) 4.937 .026*
Negative 5/110 (4.55%) 10/345 (2.90%) 0.71 .399
Ambiguous 17/110 (15.45%) 72/345 (20.87%) 1.554 .213
Structural barriers 11/110 (10.0%) 30/345 (8.70%) 1.206 .272
Expense/knowledge 11/110 (10.0%) 14/345 (4.06%) 7.411 .007**
Time/inconvenience 0/110 (0%) 12/345 (3.48%) 3.923 .048*
Perceived stigma 16/110 (14.55%) 16/345 (4.64%) 12.496 <.001***
Skepticism 7/110 (6.36%) 26/345 (7.54%) 0.172 .678
Alienation 17/110 (15.45%) 30/345 (8.70%) 5.103 .024*
Positive perceptions of
mental health care
4/110 (3.64%) 49/345 (14.20%) 8.36 .004**
Self-care frameworks 17/110 (15.45%) 65/345 (18.84%) 0.647 .421
*p < .05. **p < .01. ***p < .001.
12 Sociological Perspectives 00(0)
or 0 percent). We found no significant differences between groups for negative or ambiguous past
individual experiences.
Barriers to Care-seeking
Structural barriers. We use the term “structural barriers” to refer to structural or practical barriers,
such as expense, knowledge, or time. Members of the limited and high cultural capital groups
were equally likely to report structural barriers to mental health care (11 out of 110 limited cul-
tural capital individuals, or 10.0 percent, and 26 out of 345 high cultural capital individuals, or
7.54 percent), (χ2 = 0.674, p = .412). However, the types of structural barriers cited differed
between the groups.
All structural barriers cited by the limited cultural capital respondents involved expense
(“money”; “cost of health services”) or knowledge (“I don’t know how”; “I wouldn’t really be
sure where to go or how to reach out”). Conversely, only half of high cultural capital respondents
who reported structural barriers cited expenses or lack of knowledge. Instead, they cited struc-
tural barriers related to time and inconvenience. Twelve high cultural capital respondents, com-
pared to zero limited cultural capital respondents, reported that time or inconvenience would
prevent them from seeking care (χ2 = 3.923, p = .048) (e.g., “Too much time and hassle”).
Among all respondents who mentioned expense barriers, the nature of these expense barriers
differed between groups. Recall that both colleges offer free services requiring no co-payment.
Nonetheless, respondents from the limited cultural capital group sometimes reported factually
erroneous expense barriers, such as stating that mental health care was not covered as part of their
student health care, or that there were no mental health professionals in their area. In contrast,
high cultural capital respondents who reported expense barriers simply said they did not want to
pay for care (e.g., “[I h]ate paying for things”).
Perceived stigma. Responses coded as “perceived stigma” included the belief that other people
would be ashamed, disappointed, disturbed, or disapproving if they learned that the respondent
had a mental health problem or sought treatment (see Corrigan 2004). These explanations
included: “. . . I didn’t want my family or friends to view me differently” and, “I would be afraid
to be labelled/stigmatized by society as mentally ill.”
Compared to the high cultural capital group, members of the limited cultural capital group
were significantly more likely to discuss perceived stigma: 16 out of 110 limited cultural capital
respondents (14.55 percent), compared to 16 out of 345 high cultural capital respondents (4.64
percent) (χ2 = 12.496, p < .001). The nature of the perceived stigma varied, but respondents
with limited cultural capital were more likely to use emotionally charged language to describe the
stigma they faced. For example, they words like “shame,” “ashamed,” “weak,” “freak,” “scary,”
and “embarrassing.” These descriptors were invoked to describe how respondents thought other
people saw mental illness, as well as to describe how respondents themselves would feel if other
people found out they had a mental illness. For example, one student stated, “Most times it’s
embarrassing to have to admit that you may have a mental illness and need help. No one WANTS
to have a mental illness and to admit to having one would be ‘social suicide’ and [you] may be
treated differently from then on.” Even though we did not ask respondents how they thought
other people perceived mental illness, many respondents—particularly those in the limited cul-
tural capital group—framed their responses in terms of these perceptions.
Skepticism. “Skepticism” describes responses that suggest that mental health treatment is illegiti-
mate or unhelpful. We coded skepticism broadly to include explanations that mental health treat-
ment was not “worth the effort,” that particular forms of treatment were ineffective, or that mental
health professionals were untrustworthy or unhelpful. These responses included statements like,
Billings and Young 13
“I don’t always feel as though mental health services will be helpful” or “I have been through it
[therapy] before and I feel as though they [therapists] cannot help.”
Though we found no differences in the frequency of skepticism responses between the groups
(6.36 percent of limited cultural capital respondents versus 7.54 percent of high cultural capital
respondents, χ2 = 0.172, p = .678), the content of their skepticism differed. Only respondents
from the high cultural capital group talked about distrusting the mental health care system in
general or connected their distrust of counseling to distrust of their college. Although some peo-
ple in both groups said that they did not find counseling helpful, only high cultural capital respon-
dents gave statements like, “I don’t really trust my college enough to trust them with my own
issues.” That is, these high cultural capital respondents viewed mental health services as operat-
ing within a larger university system that was untrustworthy or may not have their best interests
in mind. Specifically, high cultural capital respondents—but no limited cultural capital respon-
dents—expressed fear of being removed from college, involuntarily hospitalized, or compromis-
ing their careers by seeking mental health treatment. And only respondents with high cultural
capital framed mental health services as an “arm” of their institution.
Alienation. “Alienation” responses included explanations related to isolation, including statements
that the respondent was private, did not want to bother anyone, feared others would not under-
stand, or had an ability or desire to handle problems alone. We included statements that indicated
that the student would self-isolate or feel isolated because of a mental health problem. Since isola-
tion from others and lack of social support are associated with poor mental health (Cacioppo,
Hawkley, and Thisted 2010; Moak and Agrawal 2009), we wanted to capture numerous types of
isolation. These responses included, “I’m a very private person”; “I’m not comfortable asking for
that kind of help”; and “I can deal with [mental health problems] myself.” Members of the limited
cultural capital group were significantly more likely to give alienation responses, 17 out of 110
(15.45 percent) versus 30 out of 345 (8.70 percent), (χ2 = 5.103, p = .024).
Facilitators of Care-seeking
Positive perceptions of mental health care. This category of responses included endorsements of
specific treatments like therapy or medication, trust of care providers, and statements about the
importance of maintaining mental health. These responses included statements like “Mental ill-
ness can improve with appropriate care” and “I had a bout of depression my freshmen year and
going to a counselor totally helped!” We also included analogies between mental and physical
illnesses (e.g., “Mental health is health. Sick is sick. Illness needs treatment”). Significantly more
students with high cultural capital endorsed mental health care in their explanations: 49 out of
345 (14.20 percent) versus 4 out of 110 (3.64 percent), (χ2 = 8.36, p = .004).
Self-care frameworks. We coded responses as “self-care” if respondents framed mental health
treatment as part of caring for one’s self generally. We coded self-care broadly to include justifi-
cations like, “It’s hard to get better by yourself” and “I care about myself.” Given this broad
coding scheme, many self-care responses were also coded as endorsements of mental health care.
For example, if a respondent justified care-seeking with, “Because mental health treatment
works,” we coded it as an endorsement of mental health care and as self-care. Despite some
overlap, we kept both codes because they sometimes captured distinct phenomena.
Recall that endorsements of mental health care differed significantly between the groups. We
found no such difference for self-care statements. Seventeen out of 110 (15.45 percent) limited
cultural capital respondents and 65 out of 345 (18.84 percent) high cultural capital respondents
gave self-care explanations—a difference in proportion that is not statistically significant
(χ2 = 0.647, p = .421). However, the content of the self-care statements differed between the
14 Sociological Perspectives 00(0)
groups. Some students from the limited cultural capital group talked about other people when
explaining their reasons for self-care—for example, stating that they needed to improve their
mental health for the benefit of the people they loved. For example: “I would want to get help
for a mental illness to help me and the people around me,” and “I need to ensure my safety, see
what’s wrong with me, and ensure the safety of those around me who care about me.” By con-
trast, when members of the high cultural capital group referenced other people in their self-care
responses, it was only to explain that failing to seek care could impact their own experience of
these relationships—for example, “I would want it [my mental health problem] addressed
immediately lest it affect my personal relationships and my academic life.” Only the limited
cultural capital respondents wrote explicitly about their desire to care for others when address-
ing their own mental health concerns.
Discussion
Our results suggest that attitudinal and behavioral differences in seeking mental health care are
significantly rooted in cultural capital. Just as cultural capital shapes students’ willingness to ask
for help or attend office hours in college (Jack 2016, 2019), it powerfully shapes their responses
to their mental health problems—problems that are particularly acute among first-generation and
working-class students (Eisenberg et al. 2007; Hunt and Eisenberg 2010; Weitzman 2004). A
deeper understanding of the sources of variation in students’ relationship to mental health care is
a crucial part of supporting students’ mental health in college.
Cognizance of Others’ Perceptions as a Barrier and Facilitator to Care
Respondents with limited cultural capital were more likely to reference other people when con-
sidering care-seeking decisions. This difference manifested across multiple themes: perceived
stigma, alienation, and self-care. For students with limited cultural capital, cognizance of others
functioned as both a barrier and a facilitator to care. This group was more likely to cite stigma as
a justification for not seeking care, which echoes previous findings about the relationship between
social class and stigma (Eisenberg et al. 2009; Golberstein, Eisenberg, and Gollust 2008; Steele,
Dewa, and Lee 2007). Students with limited cultural capital also associated mental health con-
cerns with feelings of loneliness and alienation. They preferred the idea of suffering alone to the
prospect of “burdening” other people, and—perhaps as a consequence—were more likely to say
they would feel disconnected from others and isolate themselves if they experienced a mental
health problem. Social isolation is related to poor mental health outcomes and is an important
risk factor for mood disorders (Cacioppo et al. 2010; Moak and Agrawal 2009). These results
point to one important mechanism through which cultural capital may exacerbate mental health
problems for first-generation and working-class students. Their comparative reluctance to seek
help from mental health care providers, or to seek out others for help when they experience men-
tal health problems, may parallel their reluctance to “burden” teachers with requests for help in
the classroom (Jack 2016, 2019; see also Aries 2008; Armstrong and Hamilton 2013; Calarco
2011, 2014, 2018). In both contexts, students with less cultural capital believe that dealing with
personal obstacles is their own responsibility.
Interestingly, though, note that when the frame of reference is reversed, these students’ sensi-
tivity to burdening others can also work in favor of seeking treatment. Students with limited
cultural capital were more likely than those with high cultural capital to say they would seek
mental health care in order to get better for their friends and family. One reason for this orienta-
tion may be cultural. Compared to upper-middle class individuals, working-class individuals
tend to express collectivistic, as opposed to individualistic, values: to be more attuned to others’
needs and have more acute physiological reactions to others’ distress (Kraus and Keltner 2009;
Kraus et al. 2012; Piff et al. 2010; Stellar et al. 2012). Scholars have theorized that these
Billings and Young 15
differences may owe to each group’s material conditions (Lareau 2011; Stephens, Markus, and
Phillips 2014; Triandis 2018); “[R]esponding effectively to the conditions of working-class con-
texts requires . . . adjusting to the social context, being aware of one’s position in social hierarchy,
and relying on others for material assistance and support” (Stephens et al. 2014: 614).
Advertence to others’ emotional states among students with lower cultural capital is also con-
sistent with this group’s use of more intensely charged emotional language when discussing
stigma, and with their sensitivity to stigma as a significant barrier to seeking care (Corrigan 2004;
Horwitz et al. 2020). People in lower status positions tend to stigmatize mental illness more, and
to perceive that others do the same, which is negatively associated with help-seeking (Eisenberg
et al. 2007; Givens and Tjia 2002; Sirey et al. 2001). Overall, students with limited cultural
capital—whether they decided to seek care or not—approached mental health decision-making
with a collectivistic, other-focused, lens.
Cognizance of One’s Own Needs as a Barrier and Facilitator to Care
While students with limited cultural capital were more attuned toward other people’s needs and
views when thinking about whether to seek mental health care, students with high cultural capital
were more attuned to their own current and future needs, and tended to contemplate care-seeking
in more individualistic terms. For example, in the comparatively rare cases that students with
high cultural capital spoke about other people in their decision-making processes, they tended to
talk about the importance of preserving their own positive experiences of these relationships.
Similarly, when they justified not seeking care, high cultural capital respondents expressed a
future-oriented concern that if their college learned about their mental health, it could jeopardize
their educational or professional goals. Michael W. Kraus et al. (2012) offer a possible explana-
tion for this orientation: “abundant resources and elevated rank create contexts that enhance the
personal freedoms of upper-class individuals and give rise to . . . an individualistic focus on one’s
own internal states, goals, motivations, and emotions” (p. 546). In our study, students with high
cultural capital expressed a future-oriented and individualistically-focused risk aversion even at
the expense of their own health concerns, saying it was important to err on the “safe side” by
limiting their institution’s knowledge of their mental health.
At first, it may seem surprising that respondents with high cultural capital would express
skepticism or distrust in the education or health care systems. After all, people from upper-mid-
dle-class backgrounds tend to trust healthcare providers more than people from working-class
backgrounds do (Lareau 2011; Levine 2013). Given Lareau’s (2002) findings that middle-class
children and middle-class parents are more likely to trust physicians, we might imagine that cul-
tural capital would be positively associated with trust of mental health services. Our qualitative
responses shed light on this apparent puzzle. What appears to manifest as skepticism actually
turns out to reflect educational self-advocacy. That is, students with high cultural capital are not
merely “distrusting” the system, but weighing perceived risks and tradeoffs and prioritizing
future opportunities. For these students, even though care-seeking might help them resolve an
important mental health problem, it came with the unacceptable risk of disrupting their educa-
tional progress (e.g., “[M]any counseling services will suggest or force you to take time off”) or
harming their professional prospects (“. . . I wouldn’t jeopardize my future by seeking psych help
or medication”). Some high cultural capital students even suggested a workaround, explaining
that to protect their privacy and retain their autonomy, they would only see a mental health pro-
fessional unaffiliated with their university.
Structural and Practical Barriers: Time, Money, and Past Experience
Colleges’ efforts to address students’ mental health needs tend to respond to perceived structural
barriers—most importantly, cost. Our findings suggest that extant quantitative research about
16 Sociological Perspectives 00(0)
barriers to mental health care may oversimplify the barriers’ complexity. Superficially, structural
barriers stymied students’ care-seeking at equal rates. But students’ understanding and experi-
ence of the substance of these barriers hinged largely on cultural capital.
Respondents with less cultural capital were more likely to report barriers related to knowl-
edge about the health care system, as well as barriers related to financial expense. Notably, they
cited the latter even when no such barriers existed, and assumed that mental health care was
something they could not afford. Presumably, this response is due to a lifetime of socialization
growing up in a country where mental health care tends to be prohibitively expensive for work-
ing-class people (Walker et al. 2015). Students with high cultural capital, on the other hand,
were more deterred from care-seeking by barriers related to time and convenience. They saw
their time as valuable and were reluctant to expend it. These contrasting findings demonstrate
the importance of understanding the precise nature of the barriers people perceive in order to
create policies that target their subjective orientations and assumptions about different possible
barriers.
Another structural factor that arose in our qualitative responses was students’ past experience
with mental health care as a reason for seeking or not seeking future care. This, too, varied based
on students’ cultural capital. None of our limited cultural capital respondents, but several of our
high cultural capital respondents, cited past positive experiences with mental health care as a
reason to seek treatment. This finding has at least three possible explanations: first, people with
limited cultural capital may tend not to have any experience with mental health care, positive or
negative (Eisenberg et al. 2007; Hunt and Eisenberg 2010). Second, people with limited cultural
capital may be less likely to perceive experiences with mental health professionals as positive
(which may or may not reflect the quality of services they receive). Third, students with limited
cultural capital may be more likely to view mental health needs as discrete episodes, as opposed
to ongoing challenges or conditions. Without further research about the relationship between
cultural capital and past mental health care experiences, it is impossible to know which explana-
tion, or combination of explanations, is responsible. For example, if students with less cultural
capital have more negative experiences with providers, future research should evaluate why the
texture of these experiences differs across cultural capital.
The Importance of Cultural Capital to Creating Equal Access to Care
Understanding how people define and orient themselves toward mental health services is crucial
to facilitating help-seeking. Extant work identifies the relationship between demographic and
experiential factors and individuals’ likelihood of seeking mental health treatment (Andrade et al.
2014; Eisenberg et al. 2007; Eisenberg et al. 2011; Hunt and Eisenberg 2010), but rarely delves
into the social mechanisms underlying these trends (for exceptions, see Biddle et al. 2007;
Pescosolido and Boyer 1999). These studies also tend to examine barriers to care at the exclusion
of facilitators (Gulliver, Griffiths, and Christensen 2010). While removing barriers is important,
our findings suggest that when it comes to ensuring equal access, barrier removal is only half the
battle. For the students we surveyed, complete elimination of financial barriers to mental health
care did not eliminate cultural capital disparities in mental health care seeking.
Conclusion
Understanding the social factors that underlie differential utilization of mental health services is
a key step in making sure all students—across social class—are supported once they get to cam-
pus. Meaningful access to mental health care on college campuses means recognizing that stu-
dents from different backgrounds approach mental health care with different orientations,
attitudes, and framing strategies. While we consider these differences across class, future
Billings and Young 17
researchers must collect data with sufficient numbers to make similar comparisons across ethno-
racial groups, a key part of tailoring mental health services to diverse student needs (see
Guarnaccia and Rodriguez 1996). To reach all students, colleges need multiple strategies for
facilitating access.
Our findings suggest that students with limited cultural capital may be more responsive to
outreach that emphasizes the importance of their mental health care to the well-being of their
friends and family. When colleges educate students about mental health services, they should
frame service utilization in individualistic and collectivistic ways. Framing services solely as a
path to maximize academic success may resonate primarily for students with high cultural capi-
tal. In fact, this framing may even discourage students with less cultural capital from seeking
care. Nicole M. Stephens et al. (2012) found that exposure to individualistic cultural norms led
to higher stress hormone levels and more negative emotions for first-generation students. Our
results suggest that when students with less cultural capital do seek mental health care, they are
at special risk for isolation, which should be incorporated into treatment models. By contrast,
students with high cultural capital may be best served by outreach that emphasizes confidential-
ity and the independence of mental health care from their educational institution. Since these
students tend to view mental health challenges as threats to their long-term educational and pro-
fessional goals, it may be important to communicate the long-term benefits of early intervention
and to offer more information about privacy. Students’ differing orientations toward mental
health care means that there is no one-size-fits-all solution. Eliminating costs or publicizing ser-
vices is not enough; reaching all students requires multiple strategies that consider the breadth of
students’ backgrounds.
Colleges might consider other measures as well, such as requiring a mental health “check-in”
during their first semester, just as many colleges require a physical checkup for enrollment.
Facilitating initial contact with mental health services could have positive effects. One strong
predictor of future treatment-seeking is previous experience with mental health services (Gulliver
et al. 2010). Recall that none of our limited cultural capital respondents talked about positive past
experiences with mental health providers. If colleges could expose all students to a positive
initial experience, this contact could shape future help-seeking decisions and normalize help-
seeking behavior.
Our results offer a compelling case that colleges must acknowledge the ways that cultural
capital affects students’ mental health care seeking decisions. We provide evidence that students
with limited cultural capital approach mental health care decisions with a collectivistic frame
while students with high cultural capital approach mental health care decisions with an individu-
alistic frame. Importantly, these frames can produce both barriers and facilitators to mental health
care for limited and high cultural capital students. Colleges should adopt these frames when
advertising their mental health resources to students. Removing structural barriers to care, like
cost, will not eradicate the mental health crisis. The cultural orientations that students bring to
campus determine how they understand mental health care, and importantly, whether or not they
decide to seek help when faced with a mental health problem. Responding to these differing
cultural orientations is crucial to ensure that all students have meaningful access to mental health
resources on campus.
Appendix
Modified Macarthur Scale of Subjective Social Status
Imagine this ladder represents the social hierarchy at your college. At the bottom of the ladder are
students who come from families with the least money and lowest social status. At the top of the
ladder are students who come from families with the most money and social status.
18 Sociological Perspectives 00(0)
Now think about your family. Where would you be on this ladder compared to your college
peers?
Lowest Social Status - 1
2
3
4
5
6
7
8
9
Highest Social Status – 10.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Notes
1. At ILU, the survey email was sent from one of the researchers’ email accounts. At NILU, it was sent
from the Dean of Students. Though not ideal, this difference was necessitated by each university’s
rules regarding email distribution.
Figure A1. MacArthur scale of subjective social status.
Source. Chatelard etal. (2014).
Billings and Young 19
2. While low, our response rate is not atypical for college students, and is consistent with recommenda-
tions for reliable samples of college student populations (Fosnacht et al. 2017).
3. Subjective perceptions of inequality are better aligned with health-related outcomes than objective
measures of material inequality for physical and mental health (Demakakos et al. 2008; Goodman et al.
2007; Singh, Marmot, and Adler 2005).
4. We define “low” and “high” SSS dichotomously, as those with MacArthur scores between 1 and 5, and
6 and 10, respectively: the bottom half and top half of the status hierarchy.
5. Note that our quantitative analysis included all respondents. Our qualitative analysis included students
in the limited and high cultural capital groups, in order to focus narrowly on social mechanisms related
specifically to cultural capital differences.
6. The survey did not include the various conditions under which the respondent got mental health treat-
ment: whether it was family or individual, voluntary or involuntary, or the age at which the respondent
received treatment.
7. Race and sex were not significant in any models, indicating that our measures of cultural capital are not
a proxy for them here. We also ran models with race and sex variables interacted and school and SSS
interacted. None were significant.
8. The average likelihood to seek treatment was M = 3.03 (SD = 0.05) at ILU and M = 2.85 (SD = 0.08)
at NILU (t = 1.88, p = .06).
9. We chose odd numbers to evaluate equidistant points along the SSS scale. The observed trends were
identical in simulations which used all 10 points, and which used even numbers.
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Author Biographies
Katie R. Billings is a graduate student in the Sociology Department at the University of Massachusetts,
Amherst and a graduate fellow for the UMass Center for Justice, Law, & Societies. Her research examines
the creation and reproduction of inequality in the mental health and legal fields. Her dissertation, which is
funded by the National Science Foundation, is a qualitative study of suicide in the U.S. and includes in-
depth interviews with suicide survivors. Billings’s research is published in Social Science & Medicine, Law
& Society Review, and Sociological Perspectives. katierbillings.com.
Kathryne M. Young is an assistant professor in the Sociology Department at the University of
Massachusetts, Amherst and an Access to Justice Faculty Scholar at the American Bar Foundation. Her
areas of research include legal consciousness, parole, legal education, and access to justice. Young is an
Associate Editor for Law & Society Review and an Editorial Board Member for Law & Social Inquiry. You
can read more about her work at kathrynemyoung.com.
