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Attitudes toward seeking professional counseling services among Chinese international students: acculturation, ethnic identity, and English proficiency.

The authors examined the help-seeking attitudes of 109 Chinese international students studying in the United States. Results revealed that significant relationships exist among acculturation, ethnic identity, English proficiency, and attitudes toward seeking professional counseling services. Limitations and recommendations for future research are discussed.

Keywords: acculturation, ethnic identity, English proficiency

Los autores examinaron las actitudes hacia la busqueda de ayuda de 109 estudiantes internacionales chinos cursando estudios en Estados Unidos. Los resultados revelaron que existen relaciones significativas entre la aculturacion, la indentidad etnica, el dominio del idioma y las actitudes hacia la busqueda de servicios profesionales de consejerfa. Se discuten las limitaciones y recomendaciones para investigaciones futuras.

Palabras clave: aculturacion, identidad etnica, dominio del ingles


With the rapid development of global economies, the affordability and accessibility of international transportation, and the advent of access to the Internet, an increasing number of international students choose to continue their education in the United States. In the 2013-2014 academic year, 886,052 international undergraduate, graduate, and nondegree students enrolled at U.S. colleges and universities--an increase of 8.1% from the previous academic year (Institute of International Education [HE], 2014). Of these students, 62.9% were from Asian countries (viz., China, India, Saudi Arabia, South Korea, Taiwan, Japan, and Vietnam; HE, 2014). China was the leading place of origin for international students, accounting for 31.0% of the total international student popula tion (HE, 2014). Research with Chinese international students suggests that they are at great risk of developing mental health problems caused by cross-cultural adjustment (Han, Han, Luo, Jacobs, & Jean-Baptiste, 2013; Li, Liu, Wei, &, Lan, 2013). However, these students generally do not seek counseling, even if universities provide free counseling services (Tang, Reilly, & Dickson, 2012).

The underutilization of mental health services by international students has been well documented (Austin, Carter, & Vaux, 1990; Khawaja & Stallman, 2011; Mori, 2000). Over the past several decades, many scholars have noted that acculturation, ethnic identity, language barriers, and help-seeking behaviors contribute to whether individuals seek counseling services (Berry, 1997; Marbley, 2011; Parr, Bradley, & Bingi, 1992; Sue & Sue, 2013). As indicated by Berry's (2005) acculturation theory, acculturation and ethnic relations are two major domains identified in the process of cultural and psychological change. Thus, acculturation may result in "outcomes that can range from conflict and stress to harmony and effectiveness" (Berry, 2005, p. 698). Likewise, poor language proficiency (e.g., nonstandard English) appears to affect the quality of communication and increase the potential for misunderstanding between counselors and clients (Sue & Sue, 2013). Finally, unique characteristics of Asian cultures (e.g., stigma, collectivism) raise the possibility of factors militating against Chinese international students' motivation to seek professional psychological help (Luu, Leung, & Nash, 2009; Wu, 2012).


By definition, acculturation refers to "a dual process of cultural and psychological change that takes place as a result of contract between two or more cultural groups and their individual members" (Berry, 2005, p. 698). According to Berry (2005), acculturation usually occurs at both the group and individual levels with a focus on intercultural interactions within social structures and personal behavior. More specifically, the theory states that any individual in the process of cross-cultural adaptation can be identified as a user of four different acculturation strategies: (a) integration (i.e., individuals maintain their home cultural identity and accept the host culture), (b) assimilation (i.e., individuals accept the host culture but abandon their home cultural identity), (c) separation (i.e., individuals maintain their home cultural identity but reject the host culture), and (d) marginalization (i.e., individuals abandon their home cultural identity and reject the host culture; Berry, 2005). Research has shown that different acculturation strategies result in different attitudes toward seeking professional counseling services (ATSPCS; Miller, Yang, Hui, Choi, & Lim, 2011). The higher individuals' levels of acculturation are, the more positive attitudes they hold toward seeking professional counseling services (Zhang & Dixon, 2003).

ethnic identity

Ethnic identity has been regarded as an important factor in examining an individual's commitment to a particular ethnic group in a culturally diverse society (Helms, 1993; Phinney, 1992). According to Helms (1993), ethnic identity is defined as "a sense of group or collective identity based on one's perception that she or he shares a common heritage with a particular racial group" (p. 3). Over the past several decades, much of the research has focused on the way in which adults and youth have interpreted their ethnicity (Phinney, 1992; Phinney & Ong, 2007). In particular, Phinney (1996) highlighted three sequential stages in which individuals, especially adolescents and young adults, identify with their own and other groups. These stages of ethnic identity development are (a) the preencounter stage (i.e., unexamined ethnic identity), (b) the resistance stage (i.e., exploration of ethnic identity), and (c) the internalization stage (i.e., achieved ethnic identity). Likewise, numerous studies have indicated that ethnic identity is closely associated with psychosocial adjustment in different ethnic groups, including the psychological well-being of Asian Americans and Asian international college students (Li, Wang, & Xiao, 2014), race-related stress in African American students (Johnson & Arbona, 2006), and self-stigma of seeking psychological help among racial and ethnic minorities (Cheng, Kwan, & Sevig, 2013; Soorkia, Snelgar, & Swami, 2011).

English proficiency

In addition to acculturation and ethnic identity, English proficiency serves as another significant component of studies on the utilization of mental health services among international students and immigrants. Many scholars have contended that individuals' language competence (e.g., speaking, listening) influences the way they interpret psychological stressors and act on them (Marbley, 2011; Sue & Sue, 2013). The research suggests that limited English proficiency can be a barrier to seeking professional counseling services (Furnham & Bochner, 1986; Wu, 2012). According to Sentell, Shumway, and Snowden (2007), for example, the effect of language barriers on clients' help-seeking behaviors is influenced by the fact that much of mental health diagnosis and treatment depends on direct communication. These authors found that limited English proficiency among clients prevented them from seeking needed mental health services. Non-English-speaking Asian and Latino clients had significantly lower odds of receiving services compared with Asian and Latino clients who spoke only English. In another study, Shi, Lebrun, and Tsai (2009) found that English-language competency may also be associated with health literacy. In their analysis of 29,868 families, they found that Asians with limited English proficiency were more likely to be less acculturated to Western health care and depended more heavily on complementary and alternative help.

Sue and Sue (2013) considered counselors' use of standard English as a barrier for clients seeking mental health services who do not speak English or are bilingual. For example, when working with a client who has limited English proficiency, a counselor who speaks a different language may misunderstand the client's problems or motives (Sue & Sue, 2013). In this scenario, a client risks being seen as "uncooperative, sullen, negative, nonverbal, or repressed on the basis of language expression alone" (Sue & Sue, 2013, p. 153).

After conducting a thorough review of the literature and identifying gaps in the research, we designed this study to examine the relationship between Chinese international students' acculturation, ethnic identity, English proficiency, and their ATSPCS. On the basis of the previous research, we hypothesized that (a) acculturation, ethnic identity, and English proficiency would be statistically significant predictors for ATSPCS among Chinese international students and (b) the three predictors would predict ATSPCS with differing levels of significance.



Participants were Chinese international students pursuing baccalaureate or graduate degrees in a large southwestern research institution in the United States. We selected participants for the current study on the basis of a specific set of criteria: (a) possession of a valid student visa, (b) current enrollment in the target university, and (c) place of origin reported as Mainland China. The participants were recruited by e-mails sent to student organizations at the targeted university. The e-mails contained a hyperlink that directed respondents to an online survey, which they completed anonymously. A convenience sample of 135 participants (57 men, 78 women) resulted from the recruitment.

Participants were asked to provide demographic information regarding their gender, age, academic degree, Test of English as a Foreign Language (TOEFL) scores, and the amount of time (in months) residing in the United States. On the basis of the self-reported data, the average age was 27.55 years (SD = 5.89). Participants identified their degree as a bachelor's (11.1%, n = 15), a master's (31.1%, n = 42), or a doctorate (50.4%, n = 68). Ten participants (7.4%) did not report their degrees. The average amount of time residing in the United States was 20.15 months and ranged from 1 to 84 months. Self-reported TOEFL score averages were 89.77 (SD = 10.53) for male students and 90.22 (SD = 10.60) for female students.


Suinn-Lew Asian Self-Identity Acculturation Scale. To measure acculturation, we used the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA; 21 items; Suinn, Ahuna, & Khoo, 1992) and its additional items (five items; Suinn, n.d.). The 21-item version (SL-ASIA) is scored on a 5-point Likert scale ranging from 1, reflecting a high Asian identity (or low acculturation; e.g., "prefer to speak Asian only") to 5, which is indicative of a high Western identity (or high acculturation; e.g., "prefer to speak English only"). All of the psychometric evidence for the SL-ASIA pertains to the original version. Suinn et al. (1992) reported an internal consistency reliability of .88.

Multigroup Ethnic Identity Measure. The Multigroup Ethnic Identity Measure (MEIM; Phinney, 1992) is a 15-item instrument designed to assess behavioral and attitudinal aspects of ethnic identity. A sample item is "I have a clear sense of my ethnic background and what it means for me." The MEIM's original structure was composed of three factors: Ethnic Identity Search (five items); Affirmation, Belonging, and Commitment (seven items); and Identification and Categorization by Ethnicity (three items). Twelve items ask about aspects of the participants' ethnic identity and are rated on a 4-point Likert scale (1 = strongly disagree, 4 = strongly disagree), with higher scores indicating higher levels of the construct measured. The MEIM has consistently shown good reliability, with alphas typically greater than .80 across a wide range of ethnic groups and ages (Phinney, 1992; Yasuda & Duan, 2002). Yasuda and Duan (2002) reported a Cronbach's alpha of .89 for Asian American students and .80 for Asian international students in their use of the MEIM.

Attitudes Toward Seeking Professional Psychological Help Scale-Short Form. The Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPHS-SF; Fischer & Farina, 1995) is a 10-item unidimensional scale, which is based on Fischer and Turner's (1970) 29-item measure. Respondents rate each item on a 4-point Likert scale (0 = strongly disagree, 3 = strongly agree), and a total score, ranging between 0 and 30, is obtained by summing the scores of the individual items. Scores on the ATSPPHS-SF reflect respondents' general ATSPCS.

The original scale has an internal consistency reliability of .86 and a retest reliability coefficient of .83 (Fischer & Turner, 1970). Fischer and Farina (1995) found that the ATSPPHS-SF has an internal consistency reliability of .84 and is highly correlated (r= .87) with the original scale. They also reported a retest reliability coefficient of .80 over a 1-month interval.

TOEFL. TOEFL scores have been shown as a reliable and valid measurement of English proficiency of individuals learning English as a foreign language (Educational Testing Service, 2011). The TOEFL has been used by more than 9,000 colleges, agencies, and other institutions as a measure of international students' ability to use and understand English at the university level (Educational Testing Service, 2015). The Internet-based TOEFL includes four sections (i.e., reading, listening, speaking, and writing). Scores for each section have three levels: (a) high (22-30), (b) intermediate (15-21), and (c) low (0-14). The TOEFL total score ranges from 0 to 120. In the current study, we used students' self-reported TOEFL scores as the measure of their English proficiency.


Upon institutional review board approval, we recruited prospective participants using the directory of the university's Chinese Student and Scholar Association (CSSA). We used the CSSA's electronic mailing list to send out approved invitation e-mails to all members on the list. Participants were directed to an online survey containing a cover letter, an informed consent form, a demographic questionnaire, and the instruments. Participants were required to read and submit the informed consent form before answering the survey. All of the survey information was provided in both Chinese and English. The Chinese translation and adaptation of the instruments were completed by the first and fourth authors. No incentive was provided for participating in the study.


From the pool of 1,158 registered Chinese international students, we received 135 completed surveys for a response rate of 11.7%. Twenty-six participants who did not respond to one or more items were removed from the analysis, resulting in a sample of 109 participants.


We conducted a power analysis using G*Power 3.1.2 (Erdfelder, Faul, & Buchner, 1996) to determine the number of participants needed in the present study. With the predetermined power of .80, an alpha level of .05, a medium effect size of .15, and three predictors, the analysis indicated that a minimum sample size of 76 was required for the chosen effect size.



No outliers were found in the preliminary analysis on the basis of the chi-square critical value for a p value of .001 and four degrees of freedom. We assessed the reliability of each measure using the internal consistency method. The reliability coefficients in the current study were as follows: SL-ASLA (.83), MEIM (.82), and ATSPPHS-SF (.82). All of the reliability coefficients were above the commonly acceptable reliability level of .70.

We used a hierarchical multiple regression analysis to analyze the criterion variable of ATSPCS and the three predictors (i.e., acculturation, ethnic identity, and English proficiency). Means, standard deviations, and regression results for the main variables are presented in Table 1.


To answer the first hypothesis, we used the "enter" method in SPSS 20 for the regression analysis, which forced the collective contribution of the three predictors--regardless of the significance level of the relationship between individual predictors and the criterion--to predict ATSPCS. The combination of the predictors significantly predicted Chinese international students' ATSPCS, F(3, 105) = 3.02, p = .03. The result, therefore, supported the hypothesis that acculturation, ethnic identity, and English proficiency are statistically significant predictors for ATSPCS among Chinese international students. Furthermore, the relationship between ethnic identity and ATSPCS was negative, which suggests that Chinese international students with a strong Chinese identity are less likely to seek professional counseling services.


To answer the second hypothesis, we used the "forward" method in SPSS 20 for the regression analysis, thus allowing us to select the only significant predictor for ATSPCS while statistically holding other predictors as constants. Results indicated that ethnic identity was the only significant predictor among the selected independent variables to predict the criterion variable of Chinese international students' ATSPCS (p = .02). This finding suggests that Chinese international students with a strong ethnic identity are less likely to seek professional counseling than those with a weak ethnic identity. Acculturation and English proficiency were not significant predictors of the criterion variable. The result, therefore, supported the hypothesis that there is at least one significant predictor for Chinese international students' ATSPCS among acculturation, ethnic identity, and English proficiency.


The results of this study helped sort out the relationship between acculturation, ethnic identity, English proficiency, and help-seeking attitudes among Chinese international students. Contrary to our expectations, we found that ethnic identity was the only significant predictor for ATSPCS. However, ethnic identity was inversely related to ATSPCS, thus indicating that a stronger Chinese identity reflected being less likely to seek professional counseling services. In line with previous research findings (Hamid, Simmonds, & Bowles, 2009; Price & McNeill, 1992; Soorkia et ah, 2011; Zhang & Dixon, 2003), we found ethnic identity to be negatively correlated with ATSPCS. Soorkia et al. (2011) found that South Asian students generally reported negative attitudes toward seeking psychological help and that ethnic identity was a significant predictor of ATSPCS. Similarly, Price and McNeill (1992) found that American Indian students who were strongly committed to their tribal culture showed significantly less favorable overall attitudes toward seeking counseling. Their study showed that American Indian students who strongly identified with their tribal culture had less favorable attitudes toward their need for counseling and less confidence in mental health professionals than did those who identified with Western culture or with both cultures.


The results of this study should be considered in light of its limitations. First, because we used an online survey for Chinese international students attending a large southwestern research institution, no causal relationships can be established. Thus, although we use the word predictor to demonstrate the direction of the relationships among the variables, we cannot say for a fact that they are predictors. The present findings may not generalize to Chinese international students in other areas or universities in the United States. Second, all of the instruments used in this study, including the TOEFL, have the issue of being self-reported, and, thus, social desirability bias exits. Third, the entire survey was presented to the participants in both English and Mandarin. Although we intentionally chose some instruments (e.g., the MEIM, the SL-ASIA) because they were specifically designed for use with Asian international students, it is possible that the participants had difficulty in understanding the questions and answers. Finally, convenience sampling itself is another limitation in that a greater risk of sampling bias exists (LoBiondo-Wood & Haber, 2014).


Our study has a few universally appropriate guidelines for effectively counseling Chinese international students in the United States. First, our study indicated that Chinese international students with a strong Chinese identity are less likely to seek professional counseling services. Thus, understanding Chinese international students' ethnic identity could prepare mental health counselors to become culturally sensitive and responsive to these clients. Understanding clients' ethnic identity is also consistent with some basic principles from the Multicultural Counseling Competencies (Arredondo et al., 1996; Sue, Arredondo, & McDavis, 1992). Specifically, mental health counselors should understand "how race, culture, ethnicity, and so forth may affect personality formation, vocational choices, manifestation of psychological disorders, help-seeking behavior, and the appropriateness or inappropriateness of counseling approaches" and the "sociopolitical influences that impinge upon the life of racial and ethnic minorities" (Sue et ah, 1992, p. 486). Second, stigma and shame surrounding mental illness may prevent Chinese international students from seeking counseling services (Bertram, Poulakis, Elsasser, & Kumar, 2014; Parr et ah, 1992). Mental health counselors might need to offer some opportunities for Chinese international students to discuss their beliefs about mental illness stigma in a culturally appropriate manner.


The results of this study contribute to the body of literature that addresses the relationships between acculturation, ethnic identity, English proficiency, and ATSPCS among Asian international students. The research has supported and expanded the finding that Asian international students are reluctant to utilize available counseling services (Tung, 2011; Yasuda & Duan, 2002). Although a few novel findings were reported, much more work is needed in this area of research to replicate the findings, and researchers need to shift to a new direction. For example, the current study investigated variables such as acculturation, ethnic identity, and English proficiency. However, there are other significant cultural and social variables to consider when studying the underutilization of mental health services among Asian international students. These variables include racial identity development, perceived racism and discrimination, age, social support, cultural differences between country of origin and host country, and economic status. In addition, further exploration of individual and group characteristics (e.g., gender, religion) of Asian international students might be of benefit to understanding client dropout. Overall, answers associated with the aforementioned suggestions could provide much more powerful evidence for the underutilization of mental health services and culturally appropriate treatment for Asian international students.

Received 02/14/15

Revised 06/30/15

Accepted 07/06/15

DOI: 10.1002/jmcd.12037


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Jiaqi Li, Department of Counseling, Educational Leadership, Educational and School Psychology, Wichita State University; Aretha Faye Marbley, Loretta J. Bradley, and William Lan, Department of Educational Psychology and Leadership, Texas Tech University, Lubbock. Correspondence concerning this article should be addressed to Jiaqi Li, Department of Counseling, Educational Leadership, Educational and School Psychology, Wichita State University, 1845 Fairmount Street, Box 142, Wichita, KS 67260 (email:

Descriptive Statistics and Regression Results for the Main

Variable                M      SD       B     [beta]     t       P

Acculturation          1.92    0.24    .23     .13      1.25   .214
Ethnic identity        1.82    0.47   -.25    -.28 *   -2.73   .007
English proficiency   90.35   10.55    .00     .10      1.06   .291
ATSPCS                 1.75    0.45

Note. N = 109. ATPCS = attitudes toward seeking professional
counseling services.

* p < .05.
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Title Annotation:global perspectives
Author:Li, Jiaqi; Marbley, Aretha Faye; Bradley, Loretta J.; Lan, William
Publication:Journal of Multicultural Counseling and Development
Article Type:Report
Date:Jan 1, 2016
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