Help-seeking attitudes among AfricanAmerican college students.
Previous studies of the general population's attitudes and behaviors toward seeking help for mental health problems (e.g. Kushner & Sher, 1991) have documented a general underutilization of mental health services. Factors contributing to such underutilization include limited access to mental health services (Leaf, Bruce, Tischler, & Holzer, 1987), inadequate recognition or acknowledgment of problems (Yokopenic, Clark, & Aneshensel, 1983), fears (Kushner & Sher, 1991), and submissive authoritarianism (Furr, Usui, & Hines-Martin, 2003). Although attitudes toward seeking psychological help have been studied generally, relatively little is known about African American college students' attitudes towards seeking help for psychological difficulties. Specifically, an examination of the literature addressing help-seeking attitudes revealed that African Americans are underrepresented in this area of research. The lack of knowledge about African American help-seeking attitudes is significant given the contention that ethnic minorities are embedded within unique and different cultural experiences.
The limited extant research in this area suggests that, compared to Whites, Blacks are less willing to visit mental health clinics (e.g. Temkin-Greener & Clark, 1988). Black college students, in particular, (e.g. Gibbs, 1975) report unwillingness to seek help for psychological difficulties and more negative help-seeking attitudes, relative to their White same-aged peers (Gloria, Hird, & Navarro, 2001). Much is unknown about the reasons why many African American college students are reluctant to seek help from mental health professionals. Regardless of socio-economic level and mental health needs, African Americans in general are less likely than Whites to receive mental health services (Robins & Regier, 1991; Swartz, Wagner, Swanson, Burns, George, & Padgett, 1998). Instead, they are more likely to seek treatment in primary care setting (Pingitore, Snowden, Sansome, & Klinkman, 2001), emergency facilities (Hu, Snowden, Jerrell, & Nguyen, 1991), or only under coercion or to meet legal obligations (Takeuchi & Cheung, 1998). African Americans in need of mental health services are also more likely than Whites to terminate mental health treatment prematurely (Sue, Zane, & Young, 1994).
To account for people of color's limited use of mental health services, researchers have suggested that culture may play an important role in contributing to help-seeking attitudes and behaviors. Through socialization, one's culture sets the subjective standards for determining the levels of tolerance for, and reporting of negative affect and symptoms (Kleinman, 1980). Culture also influences help-seeking through people's communication patterns, interpersonal relationships, and reaction to the environment (Watanabe, 1973). Using Bronfenbrenner's (1979) ecological model, Cauce et al. (2002) argued that the ethnic minority pathway into mental health services is itself affected by cultural and contextual influences.
Using a racial identity paradigm, some researchers (e.g., Parham & Helms, 1981) have found that differences in Black racial identity correlated with preferences for Black counselors and that differences in cultural commitment among Blacks and the availability of culturally similar counselors together affects counseling service utilization (e.g., Atkinson, Jennings, & Liongson, 1990). Similarly, Blacks' cultural mistrust of Whites predicts Blacks' premature termination from counseling (Terrell & Terrell, 1984) and negative help-seeking attitudes (Nickerson, Helms, & Terrell, 1994). Similarly, a pro-Black orientation tends to relate to more negative attitudes toward professional psychological services (Delphin & Rollock, 1995).
Culture-specific stigma of mental illness also reduces African Americans' willingness to seek mental health services. African Americans have been found to be less kind toward mental patients, and more likely to reject them and think they are inferior (Silva De Crane & Spielberger, 1981). African Americans are also less likely than Whites to find psychotherapy efficacious (Hall & Tucker, 1985). They are also more likely than Whites to seek help for psychological problems from family members or community or spiritual leaders (e.g. Miller & Weisz, 1996). Cauce et al. (2002) argued that culture might influence behavioral definitions and patterns of acceptance. For instance, supernatural, spiritual, and religious theories of behavior and emotions have been found to be particularly prominent among African American families with strong ethnic affiliations (Cheung & Snowden, 1990). Consequently, prayer and spirituality are used by members of many ethnic minority cultures as coping resources in lieu of counseling or psychotherapy.
Past research has assessed the impact of education and age on predicting attitudes toward help-seeking behavior. Research addressing level of education generally indicates that that a higher level of education predicts more positive attitudes toward seeking help (Surgenor, 1985). In a study by Kligfeld and Hoffman (1979), male medical students exhibited increases in positive help-seeking attitudes as they progressed from the first to the fourth year of medical school. Together, these studies support the notion that help seeking attitudes are associated with a high level of education. However, without studies that control the professional help received during the course of education, it remains unclear whether education alone contributes to positive attitudes toward seeking help for psychological problems since the longer one is in school, the increased likelihood that one will seek help, in turn, may lead to more positive attitudes.
Additionally, several studies suggest that different coping strategies, such as help seeking for problems, are related to age and maturity (Aldwin, 1991, 1994; Aldwin, Sutton, Chiara, & Spiro, 1996; Kliewer, Lepore, Broquet, & Zuba, 1990). For example, an investigation by Gould and Mazzeo (1982) found a positive relationship between students' age and the likelihood of seeking support, advice, and information about their problems. However, the research in this area has been inconsistent. Yeh (2002) reported that age had no predictive effect on Taiwanese college students' attitudes toward seeking professional psychological help.
The present study attempted to explore the relationship of education level and help-seeking attitude among African American college students. We sought to investigate how the awareness of one's problems, stigma related to mental health, and trust in professionals are related to a student's level of education. We expected a positive relationship between personal development and more positive attitudes toward seeking mental health services, as has been previously found in the general population.
Participants and procedure
Our sample included one hundred thirty-four self-identified African American undergraduate students at a private, historically Black university in an East Coast city. These students were enrolled in an undergraduate psychology course, but were not necessarily psychology majors. The female predominance (84%) of our sample is similar to the 2:1 female-to-male ratio among African-American college enrollment nationally, and highly resembles that of the social science and humanities fields. Slightly more than one-third of the sample was college seniors (37.5%), followed by sophomores (26.8%), juniors (24.1%), and freshmen (11.6%). Although we did not ask for the participants' age for this survey, the average age of students enrolled at the college is between 18 and 22. All participants were of African descent because we did not include other students in our analyses.
Participants were given the brief measures and were told that the survey sought information for improving psychological services for students. The self-administered measures took approximately ten minutes to complete. Participants were told that their participation was voluntary and anonymous, they could withdraw without prejudice, and they submit the survey before departing the classroom. The response rate of approximately 70% suggests a good representation of the participant pool.
Brief Demographic Questions. We first asked students about their gender and the number of credits received in college. Due to the limited time for this survey, no other demographic information about participants was obtained. The number of credits accumulated prior to that semester was used to determine the participants' class in college: freshmen (0-30), sophomores (3160), juniors (61-89), and seniors (90 and higher).
Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; Fisher & Turner, 1970). Participants' attitudes toward help-seeking were assessed using this scale which consists of 29 Likert items such as, "Although there are clinics for people with mental troubles, I would not have much faith in them (item 1)", and "Emotional difficulties, like many things, tend to work out by themselves (item 9)." Participants rated the items on a 4-point scale (1 = disagree strongly; 4 = agree strongly). After the reverse-scoring of 18 items (1, 3, 4, 6, 8, 9, 10, 13, 14, 15, 17, 19, 20, 21, 22, 24, 26, & 29), a summation of the scores for all the 29 items nets the total score, a composite measure of participants' help-seeking attitude. A high total score represents a positive attitude toward seeking professional help in mental health services.
In the present study, we chose the ATSPPHS for its reliability and validity. Fisher and Turner (1970) reported an internal reliability of .86 for the standardization sample (n = 212) and .83 for a later sample (n = 406). These numbers indicate moderately good consistency of response within the entire scale. Test-retest reliabilities (r) at varying intervals of five days, two weeks, four weeks, six weeks, and two months were .86 (n = 26), .89 (n = 47), .82 (n = 31), .73 (n = 19), and .84 (n = 20) respectively. Overall, the ATSPPHS scores remained consistent over a 2-month period. The ATSPPHS has been among the most widely used and researched tool to measure help-seeking attitudes among people of color (e.g. Delphin & Rollock, 1995; Yeh, 2002). This scale has four distinct subscales that measure these following factors.
Factor I--Recognition of need for psychological help. This 8-item factor (4, 5, 6, 9, 18, 24, 25, & 26) taps into the participants' awareness of need for professional psychological help. Examples of the items include: "Emotional difficulties, like many things, tend to work out by themselves (item 9)" and "At some future time, I might want to have psychological counseling (item 25)" Low-scorers do not see the necessity to seek psychotherapeutic help for emotional problems, expecting psychological problems to resolve themselves. High-scorers believe that emotional stress and troubles should be resolved with psychotherapeutic help.
Factor II--Stigma tolerance. This 5-item factor (3, 14, 20, 27, & 28) estimates one's forbearance of the shame attached to psychological help-seeking. An example includes "Having been mentally ill carries with it a burden of shame (item 20)". This factor assesses participants' ability to forebear the stigma associated with psychotherapy. Low scorers are less able to forebear such stigma. High scorers are more indifferent to such stigma, indicating a stronger tendency to seek psychological help.
Factor III--Interpersonal openness. This 7-item factor (7, 10, 13, 17, 21, 22, & 29) describes one's willingness to reveal one's personal problems to others. For instance, included in this factor are "There are experience in my life I would not discuss with anyone (item 21)", and "It is probably best not to know everything about oneself (item 22)". Participants rate their willingness to reveal problems to others, including a mental health practitioner. High scorers on this factor reveal to others their personal problems more readily than low scorers, indicating their belief that one should speak to others about personal problems.
Factor IV-Confidence in mental health practitioner. This 9-item factor (1, 2, 8, 11, 12, 15, 16, 19, & 23)assesses participants' trust in the mental health profession. Items include "Although there are clinics for people with mental troubles, I would not have much faith in them (item 1)", and "If I believed I was having a mental breakdown, my first inclination would be to get professional attention (item 12)". Fischer and Turner (1970) noted that Factor IV correlated fairly high (.58) with Factor I and that a combination of these two factors make up the essence of an attitude toward seeking professional psychological help, and would be most directly related to actual help seeking behavior. In other words, one's inclination to get psychological help requires recognizing the need (Factor I) and trusting the psychologist (Factor IV).
Pearson product-moment correlations were computed to assess the relation between the four ATSPPHS factors, the total ATSPPHS score, and the number of credits accumulated. In our intercorrelational analysis of the ATSPPHS factors (see Table 1), we found the more students recognized their need for psychotherapeutic help, the greater their stigma tolerance, interpersonal openness, and confidence in mental health practitioners. Additionally, the greater the students' stigma tolerance, the more interpersonally open and confident they were in the mental health profession. Finally, the more students reported being interpersonally open, the more confidence they reported in the mental health profession.
More relevant to the purpose of this study is the significant finding of a positive relation between the Confidence in the Mental Health Profession factor and the number of credits accumulated (r = .64, p = .03). Simply, the more credits students have accumulated or the further along they are in college, the greater is their confidence in the mental health profession.
This study has contributed to a small but growing empirical literature that is dedicated to investigating the relation between education level and help-seeking attitudes among African American college students. We replicated Fischer and Turner's (1970) finding of the high correlation between need-recognition and confidence in the helper: our data showed similar results in our African American college sample that Factor IV (Confidence in Mental Health Professions) correlated fairly high (.66) with Factor I (Need Recognition) and that a combination of these two factors are particularly essential to African American college students' attitude toward seeking professional psychological help. Our study showed that African American college students' inclination to get psychological help requires their cognizance of their personal need (Factor I) as well as their trust in the psychological services (Factor IV).
More important, this study was based on the premise that college education and its impact on personal development may help predict a more positive attitude toward seeking mental health services. As our analysis suggested, years in college increase African American college students' confidence in the mental health profession. These results are consistent with the findings on other populations (e.g. Kligfeld & Hoffman, 1979; Surgenor, 1985). Independently, these researchers offered the hypothesis that over the years, college students acquire more knowledge about mental health services on campus and consequently develop more positive attitudes toward psychological help-seeking. We are able to suggest the same in our African American college sample. In addition, we speculate that students who have been in school longer may have experienced greater exposure to university counseling services, including outreach workshops, help for test anxiety, or counseling for personal or interpersonal difficulties. This greater exposure may consequently have contributed to more positive attitudes towards psychological services. Future studies should also ask about students' contact with psychological services in order for the researchers to ascertain the impact of such exposure.
While African American college students in our study reported greater confidence in the mental health profession, there was no apparent increase in help-seeking stigma tolerance, recognition of need for psychological help, or interpersonal openness over the years. These findings may suggest that although African American college students develop more confidence in the mental health profession, there remains a general apprehension toward seeking psychological help. This is not surprising, given previous research suggesting that African Americans hold less favorable attitudes toward mental health services and are less willing to utilize mental health services (e.g., Gibbs, 1975; Silva De Crane & Spielberger, 1981).
Several other precautions should be made for interpreting our results and planning future research. First, our results cannot be generalized to all African American college students since a large percentage of this population does not attend historically Black college or universities (HBCUs). However, it might have under-represented the African Americans attending predominantly White colleges. Additionally, future research on this topic should assess whether students at higher levels of education have been exposed to psychological services to a greater extent than students at lower levels of education to determine the precise factors that contribute to more positive help-seeking attitudes as one's education progresses.
It is imperative to consider that the measures used in the present study were completed by self-report of respondents' attitude. Because our attitudinal measures are self-reported, our sample may have under-reported, or not acknowledged, that they hold negative attitudes toward seeking mental health services. In essence, students who were interested in selecting socially desirable responses might have biased the results of the study. Moreover, in future studies, attitudinal measures should be accompanied by objective measurements of help-seeking behaviors, such as report of frequency of use. Future studies may need to include those objective measurements or be conducted in more anonymous settings than a college classroom to circumvent the potential for self-report bias. In our study, because the majority of the counseling staff is African American, we gathered no racial information about the counselors and mental health professionals that serve our African American college sample. This information would be important in other non-HBCU studies because, as may be recalled, many African Americans appear to particularly mistrust White counselors. Thus, the help-seeking attitudes of students attending HBCUs may be influenced, in part, by their expectation of having a counselor with similar ethnic background were they to seek help at the university counseling service. Future research might examine if African American students' help-seeking attitudes are dependent on whether the counselors' ethnic background is the same as theirs, and whether the African American college students are enrolled at an HBCU or a predominantly White institution. Future studies must examine factors that continue to maintain negative mental help-seeking attitudes. Research in this area can play an important role in identifying and removing impediments to utilization, and, ultimately, enabling African Americans to utilize mental health services when they need them.
Implications and Conclusion
Despite the interpretive precautions suggested above, our findings nonetheless have contributed to understanding African American attitudes toward seeking mental health services. Although African American college students in our sample gained confidence in the mental health profession during their years in school, their general apprehension about seeking psychological help persisted. Many students may not personalize the potential benefits for themselves. In other words, they may continue to feel that psychotherapy is "good for others, but not for me." This information is vital to psychologists, health educators, college administrators, and health providers serving college students. Simply offering African American mental health care providers may not in itself increase African American students' utilization of mental health services.
Based on our finding, we suggest that college personnel use outreach programs specifically targeted toward African American college students when they enter college. We recommend that college personnel expose African American students to the college counseling services early on in the students' college career, so the students, regardless of their level of seniority, can learn about the importance of mental health services for their success in college. College personnel may outreach to these students in College Freshmen Seminars or Orientation courses and Black student organizations. They may use interactive guest-lectures in classes to build students' confidence in the counseling staff. They may also use more advanced African American students or alumni who were users of mental health services, to lead peer chat groups / rap sessions or individual-advising programs designed to cover issues facing less advanced students. The key is not only to foster these students social support system and to provide early outreach to prevent issues at the beginning of a college career, but also to help refer new students for psychological services. These peers can also help students to follow through with the recommended counseling services. Other cultural adaptations of existing programs on college campuses may include the use of audio-visual materials, such as multimedia, culturally sensitive promotional material; social and cultural events, such as movie viewing and Black history month celebration; consultation and collaboration with spiritual/religious organization and leaders in identifying/referring students of color to mental health services. These presentations should work together to help younger students recognize the need and confidence for counseling and mental health services on college campuses, so as to enhance the help-seeking behaviors of younger African American college students.
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DOMINICUS W. SO * & STEFANIE GILBERT
* Author note
Reprint request should be directed to Dominicus W. So, Ph.D., Department of Psychology, Room N-269, CB Powell Building, Howard University, 525 Bryant Street NW, Washington, DC 20059; (202) 806-9462; (202) 806-4873 (fax); e-mail firstname.lastname@example.org.
Preparation of this paper was supported in part by one Howard University grant (HU02-13) to the first author (DWS). All opinions expressed are those of the authors. I (DWS) want to express my sincere thanks to my colleagues who gave comments on an earlier version of this paper, and to my students and assistants, especially Karen Saunders, who assisted in the data entry process or participated in the project in many different ways.
Table 1 Intercorrelations among the ATSPPHS and its four factors 1. 2. 3. l. Recognition of Need for -- .27 ** .43 ** Psychotherapeutic Help (I) 2. StigmaTolerance (II) -- .25 * 3. Interpersonal Openness (III) -- 4. Confidence in Mental Health Practitioner (IV) 5. Total ATSPPHS 6. Credits Received 4. 5. 6. l. Recognition of Need for .66 ** .85 ** .44 Psychotherapeutic Help (I) 2. StigmaTolerance (II) .28 ** .57 ** -.03 3. Interpersonal Openness (III) .36 ** .66 ** .51 4. Confidence in Mental Health -- .84 ** .64 * Practitioner (IV) 5. Total ATSPPHS -- .51 6. Credits Received -- ** p < .01; * p < .05
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|Author:||So, Dominicus W.; Gilbert, Stefanie; Romero, Sergio|
|Publication:||College Student Journal|
|Date:||Dec 1, 2005|
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