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Rates and predictors of counseling center use among college students of color.

A comparison of institutional enrollment data and counseling center service utilization data at 66 universities showed that neither ethnic minority students nor European American students under- or overutilized counseling services (Study I). Data from Study 2 examining students in the general campus bodies at 45 institutions indicated that utilization of counseling center services for students of various ethnicities was predicted by the ethnic composition of the counseling center staff. Among students of color, utilization of campus counseling services was predicted by greater psychological distress, less family support, and a history of previous psychological problems.

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College student mental illness represents a significant public health issue in the United States. Almost half of college-age individuals have a psychiatric disorder, and the prevalence of psychiatric disorders is equally high among young adults who attend college and those who do not (Blanco et al., 2008). According to Hunt and Eisenberg (2010), the number of college students with mental illness is increasing. Eating disorders (Kurth, Krahn, Nairn, & Drewnowski, 1995), self-injurious behavior (Serras, Saules, Cranford, & Eisenberg, 2010), anxiety-related problems (Eisenberg, Gollust, Golberstein, & Hefner, 2007), and alcohol abuse (Cranford, Eisenberg, & Serras, 2009) are common among college students. In fact, evidence has suggested that alcohol use disorders are more prevalent among college students than among adults of similar ages who are not enrolled in college, although college students are less likely than their peers who do not attend college to receive treatment for alcohol use disorders (Blanco et al., 2008). Furthermore, each year 10% of college students seriously consider suicide; 1.5% attempt suicide; and 1,100 commit suicide, making it the second leading cause of death among college students (American College Health Association, 2008; Suicide Prevention Resource Center, 2004). Depression also is prevalent on college campuses. Approximately 10% of college students are diagnosed with or treated for depression on an annual basis, and more than 30% of students report feeling too depressed to function at least once during the past year (American College Health Association, 2008).

Because of the psychological distress they experience, approximately 1.8 million college students seek help from university counseling centers each year (American College Health Association, 2008). Research has indicated that the services provided by college counseling centers are effective at relieving students' psychological distress, facilitating academic functioning, and aiding campus retention efforts (Minami et al., 2009; Vonk & Thyer, 1999; Wilson, Mason, & Ewing, 1997). However, there is some evidence suggesting that utilization of university counseling center services is inconsistent across student racial/ethnic groups. For example, one study found that African American and Latino(a)/ Hispanic students tended to underutilize university counseling center services (Davidson, Yakushka, & Sanford-Martens, 2004). It should be noted, however, that data from this study were gathered only from a single university. Nonetheless, it is important to determine whether barriers exist for ethnic and racial minority students regarding the utilization of college counseling centers. One reason that university counseling center service utilization may be inconsistent across racial and ethnic groups is that some minority students prefer to seek treatment from racial/ethnic minority providers, who often are in short supply (Barksdale & Molock, 2009; Thompson, Bazile, & Akbar, 2004; Townes, Chavez-Korell, & Cunningham, 2009). Racial/ethnic minority students may be hesitant to seek treatment from European American providers because of factors such as cultural mistrust, peer norms related to self-reliance, family norms pertaining to privacy, "double stigma" related to racism and mental illness, and doubts about the availability of culturally sensitive services (Barksdale & Molock, 2009; Braithwaite, Taylor, & Treadwell, 2009; Whaley, 2001). When racial/ ethnic minority patients do seek services from European American treatment providers, some researchers have suggested that those patients are at increased risk for premature termination (Kearney, Draper, & Baron, 2005; Terrell & Terrell, 1984; Wade & Bernstein, 1991), although this finding has not been replicated uniformly (Maramba & Hall, 2002; Shin et al., 2005). Research to date on university counseling center service utilization among racial/ethnic minority students has been hampered by several factors. First, most studies on service utilization measure students' intentions to seek counseling or attitudes toward seeking counseling rather than actual help-seeking behavior (e.g., Duncan, 2003; Gim, Atkinson, & Whiteley, 1990; Gloria, Hird, & Navarro, 2001; Sheu & Sedlacek, 2004; Solberg, Ritsma, Davis, Tara, & Jolly, 1994; Tara & Leong, 1994). To clearly establish service utilization patterns among racial/ethnic minority students, researchers need to examine actual, rather than intended, behavior. Second, current knowledge regarding the extent to which university counseling centers meet the psychological needs of racial/ethnic minority students, both in terms of service utilization and actual treatment effectiveness, is built on studies that tend to have small, local samples whose findings are difficult to generalize. One solution to this problem is to utilize a large, nationally representative research network among university counseling centers to conduct research on service utilization patterns. The Center for Collegiate Mental Health (CCMH) provides just such a network.

As discussed earlier, previous research has suggested that racial/ethnic minority students may underutilize university counseling center services because they mistrust European American treatment providers and because they have concerns about the availability of culturally sensitive services. Some studies have indicated that when racial/ethnic minority students do seek help at university counseling centers, they may prefer to seek services from racially or ethnically similar treatment providers. The availability of racial/ethnic minority treatment providers may, therefore, predict the utilization of counseling center services by racial/ethnic minority students. This possibility was examined in the studies described in this article. Also, by comparing institutional enrollment data for racial/ethnic minority students with data on service utilization by racial/ethnic minority students, we sought to determine whether students of various races and ethnicities tend to underutilize counseling center services.

Method

Data Analysis

Data from the CCMH pilot study conducted during the fall 2008 semester (see Hayes, Locke, & Castonguay, 2011; this issue) were used to examine university counseling center utilization rates for students of various racial/ ethnic groups. These groups were Whites/Caucasians, Blacks/African Americans, Asian Americans, Latino(a)s/Hispanics, and American Indians. Institutional enrollment data pertaining to student race/ethnicity were obtained from publicly available university websites. Chi-square tests of independence were conducted to assess whether there were differences between overall student body representation of ethnic groups and representation in counseling centers. Institution-level data and counseling-center-level data were used to conduct these analyses. Pairwise deletion was performed because missing data were sparse in the data set. Individual multiple regression analyses were conducted to examine whether ethnic composition of counseling center staff (i.e., the percentage of counselors of various ethnicities at each institution) predicted service utilization of students of specific ethnic groups, by themselves as well as relative to the general student body.

Data from the CCMH--Student Affairs Administrators in Higher Education (NASPA) survey of the general student bodies at 45 institutions (see Hayes, Locke, & Castonguay, 2011) were used to conduct exploratory analyses on possible variables that could differentiate help seekers from non-help seekers among students of various ethnic minority groups. These analyses consisted of pairwise chi-square tests of independence and t tests. Pairwise deletion was performed because missing data were sparse in the data set. To prevent alpha inflation, we applied a Bonferroni correction for multiple comparisons, so all effects are reported at a .003 level of significance.

The ethnic groups included in these analyses were Asian/Pacific Islander, Black/African American, Latino(a)/Hispanic, Middle Eastern, indigenous/ Native American, and multiracial. Help seekers were defined as students who reported currently receiving counseling or other therapeutic services on campus.

Results

Service Utilization for Students of Various Ethnicities

The utilization rates of Whites/Caucasians, Blacks/African Americans, Asian Americans, Latino(a)s/Hispanics, American Indians, and others in counseling centers did not differ by institutional enrollment, [chi square] (5, N= 65) = 1.11, p = .95. In other words, the students of various ethnicities neither overutilized nor underutilized counseling center services. (See Figure 1 for a depiction of ethnic representation in the general student body of these institutions and in counseling centers.)

Predictors of Service Utilization

Hierarchical multiple regression analyses revealed that the ethnicity of counseling center staff significantly predicted utilization rates of counseling center services for each group of ethnic students investigated (see Table 1). Specifically, the utilization of counseling services by White/Caucasian students was predicted by the percentage of White/Caucasian therapists on the counseling center staff. Similarly, the utilization rates of Black/African American, Asian American, and Latino(a)/Hispanic students were predicted by the percentage of staff of these particular ethnicities in the counseling centers. However, a second series of multiple regression analyses, in which service utilization was examined for clients of each ethnic group, showed that overall ethnic composition of the general student body was a much stronger predictor of service utilization than was the ethnic composition of counseling center staff, such that the latter was not a significant predictor when considered in conjunction with the former.

[FIGURE 1 OMITTED]

In addition to the ethnic composition of counseling center staff, we investigated other factors that might predict service utilization among racial/ethnic minority students. As reflected in Table 2, racial/ethnic minority students who sought help from their university counseling centers had significantly higher scores than did racial/ethnic minority non-help seekers on the Depression, Eating Concerns, Generalized Anxiety, Hostility, Social Anxiety, Family Distress, and Academic Distress subscales of the Counseling Center Assessment of Psychological Symptoms (CCAPS). However, the group members' scores did not differ significantly on the Substance Use subscale. As shown in Table 3, help seekers significantly differed from non-help seekers on several other aspects of mental health that were investigated, as measured by the Standardized Data Set (SDS). Of particular note, among students of color, help seekers were more than 3 times as likely than were non-help seekers to have been hospitalized for mental health concerns; more than one third of the help seekers engaged in nonsuicidal self-injurious behavior, which was more

than twice the rate of non-help seekers; 36% of the help seekers had seriously contemplated suicide, as compared with 17% of students who did not seek help; and one sixth had actually attempted suicide, whereas approximately 6% of students who did not seek help had previously attempted suicide. Help seekers also perceived that they received less family support than did students who did not seek help from the university counseling center. However, the two groups did not differ significantly on other issues pertaining to peer support, campus involvement, and other variables (see Table 3).

Discussion

College students experience considerable distress along a variety of dimensions, and a great many turn to their campus counseling centers for help. Although the services that counseling centers provide are effective at alleviating distress and improving functioning, to date, researchers have not been able to provide sufficient evidence about the extent to which counseling services are utilized by students of color. Thus, one goal of the present study was to examine counseling center utilization patterns among students of various ethnicities, particularly to determine whether services are underutilized by ethnic minority students. A second goal was to identify specific predictors of service utilization among students of color, most notably the ethnic composition of counseling center staff and students' current and previous mental health, social support, and campus involvement.

Implications for Practice

Findings from the study revealed good news in three areas. First, contrary to popular perception and previous research (Davidson et al., 2004), utilization of campus counseling services for African American, Asian American, European American, Latino(a)/Hispanic, and American Indian students was consistent with overall enrollments across 66 colleges. Despite sound theoretical reasons that students of color might hesitate to seek university counseling services (Barksdale & Molock, 2009; Braithwaite et al., 2009; Whaley, 2001), data from the present study indicated that counseling services were not significantly underutilized by racial/ethnic minority students. One reason for the discrepancy between findings from the present study and previous research is that this study was comprehensive, gathering data from more than five dozen institutions rather than relying on data from a single counseling center. Whereas counseling services may be underutilized by students of a particular ethnic group at any one school, on the basis of the current study, the general perception that campus counseling services are underutilized by students of color appears to be unfounded.

Second, not only was counseling service utilization for students of various ethnicities consistent with the ethnic composition of the general student body, it also was predicted by the ethnic composition of the professional staff at counseling centers. That is, the higher the percentage of African American therapists at a university counseling center, the greater the percentage of African American students who sought services. Similarly, higher percentages of Latino(a)/Hispanic therapists were associated with greater numbers of Latino(a)/Hispanic clients. Likewise, direct relationships were detected between help seeking among Asian American therapists and Asian American clients and between European American therapists and European American clients. Thus, on the surface, it appears that counseling centers arc responding to the service demands of the students they are intended to help. Larger numbers of clients of a particular ethnicity at a university counseling center tend to have more ethnically similar therapists with whom they might work. At the same time, it must be kept in mind that students of color generally experience greater distress related to depression, hostility, family concerns, social anxiety, and academic issues than European American students do (sec Hayes, Chun-Kennedy, Edens, & Locke, 2011; this issue). Therefore, it could be argued that, whereas students of color are utilizing counseling services at rates consistent with overall campus enrollments, they are underutilizing services relative to their psychological needs. Although causality cannot be inferred from the quasi-experimental data in this study, the data do suggest the possibility that if one increases the number of therapists of color on a counseling center staff, then more ethnically similar students will utilize counseling services.

A third piece of encouraging news from this study is that a number of variables were identified that predict service utilization among students of color. With the exception of Substance Use, all of the CCAPS subscales differentiated help seekers from non-help seekers. In other words, as shown in Table 2, students of color were more likely to seek help from the university counseling center when they had greater distress related to anxiety, depression, academic problems, hostility, social anxiety, family concerns, and eating concerns. In general, scores for students of color who sought help at university counseling centers were about half a standard deviation greater than for students of color who did not seek help at the university counseling center. In addition, students of color whose mental health histories were more severe also were more likely to seek help. Specifically, among students of color, those who had been hospitalized for psychological problems, had contemplated suicide, or had engaged in suicidal or other self-injurious behavior were more likely to seek help from their university counseling center. Perceived lack of support from family members also was associated with help-seeking behavior, although support from peers was not related to help seeking, nor were other variables related to support or campus involvement.

One way to understand this study's findings is through Andersen's (1995) theoretical model for predicting health service utilization. According to Andersen's model, help-seeking behavior for health problems is a function of three factors: predisposing characteristics, enabling variables, and need. Predisposing variables include one's cultural characteristics such as ethnicity, race, age, and gender. Enabling factors include the availability of services that are perceived to be helpful. Need pertains to health-related distress. Although utilization of university counseling center services does not seem to be a function of student ethnicity (a predisposing factor), the availability of an ethnically similar treatment provider (enabling factor) and students' psychological distress (need) do predict help-seeking behavior. Finer grained analyses may be required in future research to examine student ethnicity in conjunction with other predisposing factors, such as religiosity, gender, or socioeconomic status, to further test the applicability of Andersen's model to help-seeking behavior in relation to campus counseling services.

Limitations and Directions for Future Research

Another set of important questions that remain unanswered in convincing fashion pertains to the treatment benefits that students of color derive from services at university counseling centers. For instance, are dropout rates higher for students of color and are they ameliorated by seeing ethnically similar counselors? For students of color with particularly high levels of distress, both generally and in specific areas, is counseling effective, and if so, how much time in treatment is needed to decrease symptoms? Dose-response and treatment effectiveness studies may help counseling center directors plan proactively for the treatment needs of clients seen at their centers and provide an empirical basis to supplement their arguments about staffing needs.

One of the limitations to this study is that, although data were drawn from a large number and variety of institutions, most schools were predominantly White and few historically Black colleges and universities or urban colleges were included. Also, whereas the CCAPS and SDS are sound instruments that were developed specifically for college students, they do not capture every type of psychological problem with which college students may be dealing. Therefore, there are likely factors in addition to the ones identified in this study that predict service utilization patterns among students of color. Limitations notwithstanding, findings from this research suggest that ethnic minority students do not underutilize campus counseling services and that utilization of counseling center services for students of color is predicted by the ethnic composition of counseling center staff. Furthermore, among students of color, utilization of campus counseling services is predicted by greater psychological distress, less family support, and a history of previous psychological problems.

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Jeffrey A. Hayes, Counseling Psychology Program; Soo Jeong Youn, Louis G. Castonguay, Andrew A. McAleavey, and Sam Nordberg, Department of Psychology; and Benjamin D. Locke, Center for Counseling and Psychological Services, Pennsylvania State University. Correspondence concerning this article should be addressed to Jeffrey A. Hayes, Counseling Psychology Program, Pennsylvania State University, 307 CEDAR Building, University Park, PA 16802 (e-mail: jxh34@psu.edu).
TABLE 1
Hierarchical Multiple Regression Analyses for Counseling
Center Staff Ethnicity Predicting Service Use by Students of
the Same Ethnicity

Variable                  B    SE B   [beta]   [R.sup.2]      p

White/Caucasian          .56    .11      .56         .32   <.001
Black/African American   .62    .11      .58         .34   <.001
Asian American           .44    .06      .70         .48   <.001
Latino(a)/Hispanic       .50    .08      .64         .41   <.001

TABLE 2
Counseling Center Assessment of Psychological Symptoms
(CCAPS) Scores Among Racial/Ethnic Minority Students Who Did
and Did Not Seek Help From University Counseling Centers

                                      Non-Help
                      Help Seekers    Seekers

CCAPS Subscale         M      SD      M     SD      F        p

Depression            1.41   0.91   0.85   0.76   515.79   <.001
Eating Concerns       1.22   0.93   1.01   0.82    62.20   <.001
Substance Use         0.71   0.85   0.70   0.84     0.15    .702
Generalized Anxiety   1.53   0.90   1.03   0.76   403.74   <.001
Hostility             1.01   0.84   0.68   0.70   212.13   <.001
Social Anxiety        1.89   0.89   1.53   0.85   164.58   <.001
Family Distress       1.22   0.95   0.80   0.78   269.81   <.001
Academic Distress     1.65   0.97   1.24   0.85   210.84   <.001

TABLE 3
Comparison on Select Standardized Data Set Items Between
Students of Color Who Did and Did Not Seek Help
From Campus Counseling Centers

                                   Non-Help Seekers

Variable                          %      M      SD

                                        Mental Health
Ever attended counseling for     23.2
mental health concerns

Ever been hospitalized for        3.2
mental health concerns

Ever purposely injured self
without suicidal intent (e.g.,   14.3
cutting, hitting, burning,
hair pulling)

Ever seriously considered        17.0
attempting suicide

Ever made a suicide attempt       5.9
Receiving emotional help and
support needed from families
                                          Support

                                        3.96   1.19

Receiving emotional help and
support needed from social              3.95    1.1
network (e.g., friends and
acquaintances)

Importance of religious or
spiritual preferences in the            2.70   1.13

student's life                          Stressors

Student's current level of              3.29   1.14
financial stress

Level of financial stress               2.72   1.26
experienced while growing up
                                     Campus Involvement

Member of at least one student   60.9
club or organization during
the current semester/quarter

Involved in at least one         28.1
intramural group, club sport,
or organized fitness activity
on campus during the current
semester/quarter

Member of an intercollegiate      5.5
athletic team

                                            Other
International student status     11.3

First in family to attend        22.8
college

Hours typically spent a week            4.29   2.16
studying

Hours during academic year              3.48   2.79

                                     Help Seekers

Variable                          %      M      SD      n

Ever attended counseling for     72.9                 4,027
mental health concerns

Ever been hospitalized for       11.4                 3,991
mental health concerns

Ever purposely injured self
without suicidal intent (e.g.,   36.7                 4,005
cutting, hitting, burning,
hair pulling)

Ever seriously considered        36.2                 4,018
attempting suicide

Ever made a suicide attempt      16.0                 4,013
Receiving emotional help and
support needed from families

                                        3.64   1.34   4,016

Receiving emotional help and
support needed from social              3.90   1.08   4,010
network (e.g., friends and
acquaintances)

Importance of religious or
spiritual preferences in the            2.76   1.08   3,992

student's life

Student's current level of              3.54   1.18   4,013
financial stress

Level of financial stress               2.92   1.32   4,009
experienced while growing up

Member of at least one student   62.7                 4,019
club or organization during
the current semester/quarter

Involved in at least one         25.8                 4,014
intramural group, club sport,
or organized fitness activity
on campus during the current
semester/quarter

Member of an intercollegiate      5.4                 4,010
athletic team

International student status     10.7                 4,009

First in family to attend        29.0                 4,012
college

Hours typically spent a week            4.11   2.16   4,022
studying

Hours during academic year              3.33   2.33   3,962

                                             Test

Variable                         [chi square]      t      df       p

Ever attended counseling for        273.25                  1   <.001
mental health concerns

Ever been hospitalized for          39.74                   1   <.001
mental health concerns

Ever purposely injured self
without suicidal intent (e.g.,      79.25                   1   <.001
cutting, hitting, burning,
hair pulling)

Ever seriously considered           52.65                   1   <.001
attempting suicide

Ever made a suicide attempt         35.67                   1   <.001
Receiving emotional help and
support needed from families

                                                 3.94   4,014   <.001

Receiving emotional help and
support needed from social                       0.63   4,008   0.530
network (e.g., friends and
acquaintances)

Importance of religious or
spiritual preferences in the                    -0.73   3,990   0.463

student's life

Student's current level of                      -3.17   4,011   0.002
financial stress

Level of financial stress                       -2.29   4,007   0.022
experienced while growing up

Member of at least one student       0.28                   1   0.600
club or organization during
the current semester/quarter

Involved in at least one             0.53                   1   0.467
intramural group, club sport,
or organized fitness activity
on campus during the current
semester/quarter

Member of an intercollegiate         0.01                   1   0.930
athletic team

International student status         0.08                   1   0.776

First in family to attend            4.63                   1   0.032
college

Hours typically spent a week                     1.18   4,020   0.240
studying

Hours during academic year                       0.80   3,960   0.423
spent working for pay

Note. A Bonferroni correction was applied, so effects are
considered significant at a .003 level.
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Title Annotation:Research
Author:Hayes, Jeffrey A.; Youn, Soo Jeong; Castonguay, Louis G.; Locke, Benjamin D.; McAleavey, Andrew A.;
Publication:Journal of College Counseling
Date:Sep 22, 2011
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