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In Germany, the lifetime prevalence of suicidal suicide (NSSI) in adolescents is 26% (Plener et al., 2009). Suicidal, self-harming behavior occurs in the context of various mental disorders, including depression (Cloutier et al., 2010). The prevalence rates for depression in adolescence are high at 10-18% (Crockett et al., 2020; Kessler et al., 2012), yet only 23-50% seek help (Lu, 2020; Lyons et al., 2013). The behavior is often used as a dysfunctional strategy for regulating (minimizing) aversive feelings and is perceived as uncontrollable by those affected (Nock, 2010). However, NSSI is a behavior that is highly stigmatized and often misunderstood, for example with attitudes that NSSI is an attention-seeking or manipulative behavior (Lewis et al., 2011; Lloyd et al., 2018). The fear of stigmatization and the internalization of negative stereotypes of NSSI therefore represents an inhibition threshold to seek help for many people affected by NSSI (Chandler, 2014). The way we use language can implicitly create or remove stigmata, even if we are not aware of it (Kelly et al., 2016). One way to change stigmatization is to use a person-centered language ("person with a depressive disorder") rather than noun language ("depressed person") (Broyles et al., 2014). People with high empathy and low stigmatizing attitudes tend to use noun language more than people with low empathy and high stigmatizing attitudes (Kryzanowsky et al., 2019). Knowledge transfer, for example about the reasons of NSSI, can leads to stigma reduction (Pinfold et al., 2003) Another aspect in connection with stigma reduction is the perception of the controllability of self-injury within the framework of attribution theory (Betancourt, 1990; Weiner, 1980). People with less trait empathy tend to experience self-injury as controllable and avoidable compared to people with higher trait empathy (Betancourt, 1990; Sheens et al., 2016).

Despite the high prevalence rates of trauma-related disorders caused by sexualized violence, the use of mental health services is low (Simon, Barnett, Smith, Mucka & Willis, 2017). Early treatment of trauma-related disorders is important, as non-treatment of mental disorders often leads to chronicity or increase of symptoms, an increased risk of suicide and self-harm, and a reduction in quality of life (Hawton et al., 2013; Kalafat, 1997; Lambert et al ., 2013; Merikangas et al., 2010; Simon et al., 2017). Self-stigma and the fear of public stigmatization are one of the thresholds for accepting professional help in young people with mental health problems (Aguirre-Velasco et al., 2020, Gulliver et al., 2010). Adolescents affected by sexual violence often report specific self-stigma and fear of stigmatization, which increase psychological stress as well as the risk of revictimization and inhibit the willingness to self-disclosure (Alix et al., 2017; Dworkin et al., 2017; Kennedy & Prock, 2016). There is evidence of gender differences in stigmatization of mental disorders with higher stigma scores for mental disorders in male adolescents compared to female adolescents (Chandra & Minkovitz, 2006; Gonzalez et al., 2005). So far, there is a lack of studies that assesses different types of stigma as a barrier of seeking mental health care differentiating between adolescents and young adults with and without trauma-related disorders after the event of sexual violence. In a first step we present a definition of sexualized violence and ask if participant experienced sexualized violence based on the definition. Participants without a history of sexualized violence are given a case- vignette. The vignette describes a situation in which either a male or a female protagonist experiences sexualized violence developing a post-traumatic stress disorder as a reaction of the sexualized violence. We assessed if participants identify the situation as sexualizd violence as well as the acceptance of gender specific rape myths, victim- blame and attributed shame towards the protagonist in the vignette. We also assess if participants think that the symptoms in the vignette fulfill the criteria of mental disorder and if they think that the person in the vignette needs professional help, followed by a rating of adequate help-seeking sources. Perceived public stigma and personal stigma of the PTSD symptoms described in the vignette are also assessed. We also assessed social desirability and sociodemographic variables. Participants with a history of sexualized violence are asked about their own experiences without receiving the vignette. We assessed shame and self-blame with regard to the sexualized as well as the acceptance of rape -myths. We assessed PTSD symptoms and their recovery as well as disorder specific stigmatizing attitudes (perceived public stigma, personal stigma and self-stigma). A major focus of the study is the assessment of self- stigmatizing attitudes, barriers to seek help and experienced stigma with a qualitative design (open response format). We assessed if they sought professional help, latency of help-seeking and help-seeking sources as well as sociodemographic variables and social desirability.

The lifetime prevalence of non-suicidal self-injury (NSSI) among adolescents is high with 26% (Plener et al., 2009). NSSI is defined as the direct, repetitive, socially unacceptable destruction or alteration of body tissues without a suicidal intention (APA, 2013). The early diagnosis and treatment of mental disorders including NSSI as a symptom is of great importance as non -treatment is for example associated with a higher risk of suicide (Kiekens et al., 2018). NSSI is strongly stigmatized and often misunderstood, as it is often seen as an attention-seeking or manipulative behavior (Klineberg et al., 2013; Lewis et al., 2014; Lloyd et al., 2018; Sandy, 2013; Scourfield et al., 2011) or a behavior with a suicidal intention (Kumar et al., 2004) or a behavior that shouldn’t be taken seriously (Mitten et al., 2016). The fear of stigmatization and the internalization of negative stereotypes of NSSI represent a major barrier of mental health care use (Chandler, 2014; Long, 2018). Attitudes towards people with NSSI differentiating between perceived public stigma, personal stigma, self-stigma and enacted stigma have not yet been systematically recorded. Knowledge about the specificity of stigmatizing attitudes as a barrier of help-seeking might be important for the further development of interventions aiming to reduce barriers of formal help-seeking for NSSI. The aim of the study is therefore to assess stigmatizing attitudes in participants who are affected and who are not affected by NSSI using a mixed method design (quantitative and a qualitative study design). Different types of stigma with items derived from a systematic literature research will be investigated.

Prevalence rates of mental disorders in adolescents, at approximately 17%–50%, are high (Gore et al., 2011; Merikangas et al., 2010), especially for depression with 10-18 % (Busch et al., 2013; Crockett et al., 2020; Kessler et al., 2012). Yet only 23%- 50% use mental health services (Burnett-Zeigler et al., 2012; Essau, 2005; Kessler et al., 2005; Lu, 2020; Lyons et al., 2013). Mental disorders first manifest mostly in childhood and adolescence (Kessler et al., 2005; Merikangas et al., 2010)..Adolescents are therefore an important target group in which to evaluate barriers to professional help seeking, especially because the delay in treatment is longer for early-onset cases of mental disorders than for onset at a later age (Christiana et al., 2000) with an average of 7 to 11 years to the beginning of treatment (Kessler et al., 2005; Wang et al., 2005). Nontreatment leads to chronicity, exacerbation of symptoms, higher impairment of life quality, a lower probability of successfully treating the disorder later, and an increased risk of suicide and self-harm ( Marshall et al., 2005; Merikangas et al., 2010). The estimated likelihood of seeking formal help for personal or emotional problems and suicidal thoughts is relatively low, and adolescents rather prefer informal help sources (Cakar & Savi, 2014; Sawyer et al., 2012; Wilson et al., 2005). Formal help is defined as help from professionals who have a recognized role and appropriate training in providing help and advice, whereas informal help sources (e.g., friends or family) lack a professional background (Rickwood et al., 2009). It has been suggested that young people do not seek formal mental health services because they harbor stigmatizing attitudes toward people with mental disorders, are fearful of seeking help, and have poor mental health knowledge (Aguirre Velasco et al., 2020; Gulliver et al., 2010). Specifically for psychotherapy as a formal help-seeking source, adolescents often report fear because of the unknown setting and procedure as a barrier to access psychotherapy (Pfeiffer & In-Albon, manuscript in preparation). Male adolescents report higher stigmatizing attitudes towards people with mental disorders compared to female adolescents (Chandra & Minkovitz, 2006; Gonzalez et al., 2005; Rickwood et al., 2005), wheras a prior history of help-seeking for mental health problems and familiarity with a person having a mental disorder have a stigma-reducing effect (Calear et al., 2011; Griffiths et al., 2008; Pearl et al., 2016; Pfeiffer & In-Albon, manuscript in preperation). Providing information about mental disorders is one intervention to increase help-seeking behavior, help-seeking intentions, and to enhance positive attitudes towards mental disorders in adolescents (Howard et al., 2019, Rhughani et al., 2011, RIckwood, 2004, Ruble et al., 2013, Salerno et al., 2016). There is evidence that an increase in mental health knowledge is associated with a decrease of self-stigma in the post-evaluation (Young et al., 2013), however, there is a lack of studies evaluating the influence of psychoeducation of psychotherapy and mental disorders towards stigmatizing and self-stigmatizing attitudes using a follow-up evaluation. There is evidence that self-stigma seems to be more resistant to change and more relevant compared to public stigma (Kendra et al., 2014; Nam et al., 2013; Pfeiffer & In-Albon, manscript in preparatoin). Information booklets are a low-cost and easy- accessible intervention to provide information. There is evidence that a booklet for adolescents informing about anxiety disorders and depression increases mental health literacy (Schneider & Borer, 2003; Schiller et al., 2014), but also evidence that they have no significant impact on help-seeking (Sharpe et al., 2016) in a post-assessment. To our knowledge, there is no evaluation regarding the efficacy of a booklet informing about psychotherapy and generalized information about mental disorders, especially with regard to their influence on stigmatizing attitudes. Another medium to increase mental health knowledge are video interventions (Tsoi et al., 2020; Janouskova et al., 2017). Personal contact with people with mental disorders is associated with decreased social distance and lower stigmatizing attitudes (Corrigan et al., 2011; Yang et al., 2013) and remains a gold-standard for anti-stigma interventions (Corrigan et al., 2012; Koller & Stuart, 2016; DeLuca et al., 2020). A video interventions is able to combine education of mental health knowledge and a digital contact with peers sharing their story of having a mental disorder and their way of recovery. Especially with social media, videos in which adolescents communicate about aspects of their mental disorders often provides an easy access to mental health knowledge and a digital contact. Video intervention can equally or sometimes even be more effective in reducing social distance and stigmatizing attitudes than face-to-face interventions (Janouskova et al., 2017). Regarding the evaluation of video interventions there is a lack of evidence: for interventions outside the school setting, where adolescents can watch the video on their own and studies, which looks at long-term outcomes (Janouskva et al., 2017; Salerno, 2016), especially because findings of long term effects of interventions addressing destigmatization and increase of mental health knowledge show mixed results (Aguirre-Velasco et al., , 2020; Schiller et al., 2017).

In Germany, the lifetime prevalence of suicidal suicide (NSSI) in adolescents is 26% (Plener et al., 2009). Suicidal, self-harming behavior occurs in the context of various mental disorders, including depression (Cloutier et al., 2010). The prevalence rates for depression in adolescence are high at 10-18% (Crockett et al., 2020; Kessler et al., 2012), yet only 23-50% seek help (Lu, 2020; Lyons et al., 2013). The behavior is often used as a dysfunctional strategy for regulating (minimizing) aversive feelings and is perceived as uncontrollable by those affected (Nock, 2010). However, NSSI is a behavior that is highly stigmatized and often misunderstood, for example with attitudes that NSSI is an attention-seeking or manipulative behavior (Lewis et al., 2011; Lloyd et al., 2018). The fear of stigmatization and the internalization of negative stereotypes of NSSI therefore represents an inhibition threshold to seek help for many people affected by NSSI (Chandler, 2014). The way we use language can implicitly create or remove stigmata, even if we are not aware of it (Kelly et al., 2016). One way to change stigmatization is to use a person-centered language ("person with a depressive disorder") rather than noun language ("depressed person") (Broyles et al., 2014). People with autism often prefer the term "autistic" or "on the autism spectrum", whereas the term "person with autism tend to be rejected (Kenny et al., 2016). Among adolescents diagnosed with a mental disorder, a possible preference of the two forms of language has not yet been investigated.