Assignment 3: Research Manuscript Critique Part 1

Psychological distress and help-seeking among Taiwanese college students: role of gender and student status

HSIAOWEN CHANG Nan Hua University, Student Counseling Center, 32, Chung Keng Li, Dalin, Chiayi,

62248 Taiwan, Republic of China; email: [email protected]

ABSTRACT This study investigated the relationship between psychological distress and attitudes

toward seeking professional help and whether the relationship was moderated by gender and student

status (traditional vs. non-traditional) among Chinese college students in Taiwan. 961 first-year

university students completed standardised measures of depression, anxiety, attitudes toward seeking

professional psychological help, and a demographic questionnaire. Results from the multiple regression

analysis found that while higher levels of depression were adversely correlated with help-seeking

attitudes, gender was positively correlated with help-seeking attitudes. Chinese female students held

more favourable attitudes toward seeking psychological help than their male counterparts.

Additionally, gender interacted with depression and anxiety in affecting attitudes toward help-

seeking. These results were discussed within the Chinese cultural context and recommendations were

given for student outreach programme aimed at increasing utilisation of mental health services on

campus.

Depression and anxiety are the most widespread mental health problems frequently

cited as indicators of mental health in college populations (Oliver et al ., 1999).

Several recently conducted surveys suggest that college students in general present a

noteworthy degree of depressive and anxiety symptoms, posing a significant

challenge for student adjustments on college campuses (e.g. Adlaf et al ., 2001;

Chen et al ., 2002; Rosenthal & Schreiner, 2000). However, few students suffering

from psychological difficulties seek professional help. Previous studies conducted in

Taiwan, Hong Kong, and China indicate that Chinese college students usually try to

resolve psychological problems on their own before seeking help from others (Boey,

1999; Chen, 1987; Cheung, 1984; Guo, 1986; Jiang & Wang, 2003). Even when

outside help is sought, there is a great reluctance to use mental health services. For

example, a study conducted in Taiwan showed that only 0.2% to 2.2% of Taiwanese

British Journal of Guidance & Counselling, Vol. 35, No. 3, August 2007

ISSN 0306-9885/print/ISSN 1469-3534/online/07/030347-09 # 2007 Careers Research and Advisory Centre

DOI: 10.1080/03069880701418789

college students indicated that they would seek psychological assistance for

emotional distress and severe psychological problems (Chen, 1987).

Many researchers believe that attitudes toward help-seeking, transmitted by

family and social network, are the major enabling factor in the utilisation of mental

health services (Deane & Chamberlain, 1994; Fischer & Farina, 1995). Negative

attitudes toward help-seeking have been found to contribute to the avoidance of

mental health services. It is, therefore, important to examine students’ attitudes

toward help-seeking in planning outreach programme aimed at increasing utilisation

of psychological services on campus. As studies that investigated the help-seeking

among Chinese students have been scarce, two search strategies were used in

identifying relevant literature. First, I searched PSYINFO using keywords such as

‘Asian’, ‘help-seeking’, ‘college students’, and ‘adolescents’. I also searched articles

quoted in reference lists that provided relevant information.

Numerous investigators concur that psychological distress is a major player in

the help-seeking process; however, contradictory evidence exists regarding the

direction of effect between distress and help-seeking (Amato & Saunders, 1985;

Bristow & Patten, 2002; Rickwood & Braithwaite, 1994; Yoo et al ., 2005). A number

of studies in the West found that higher psychological discomfort predicted greater

likelihood of professional help-seeking (Rickwood & Braithwaite, 1994). Their

results suggest that psychological distress is important in problem recognition and

this in turn facilitates the help-seeking process. However, previous studies with Asian

students found that students with elevated depressive symptoms tended to hold

negative attitudes toward help-seeking (Chang, 2005; Yoo et al ., 2005). These results

suggested that Asian students with psychological distress were likely to distance

themselves from professional psychological services, as psychological distress is

commonly viewed as resulting from personality flaws, lack of will power, and

immaturity in Asian cultures, and disclosing personal distress to outsiders may be

perceived as bringing shame to the family (Kung, 2003; Sue & Morishima, 1982).

Many Chinese are thus likely to obtain help from social networks rather than

professional helpers (Boey, 1999). As a result, despite its promise as a major

predictor of help-seeking among Western students, the impact of psychological

distress on Chinese students’ attitudes toward seeking professional psychological

remains to be empirically validated.

Another highly researched variable predicting attitudes toward help-seeking is

gender. Gender differences in help-seeking have been replicated across demographic

and geographic boundaries (Ang et al ., 2004; Morgan et al ., 2003; Yeh, 2002; Yoo

et al ., 2005). For example, previous help-seeking studies with college students have

consistently reported that gender made a significant contribution to the process of

help-seeking, with females holding more positive attitudes toward seeking help than

males (e.g. Deane & Chmaberlian, 1994; Oliver et al ., 1999; Rickwood &

Braithwaite, 1994). While the relationship between gender and help-seeking

attitudes has been extensively investigated, no study thus far has investigated

whether there are gender differences in the ability of psychological distress in

predicting help-seeking attitudes.

348 H. Chang

Furthermore, this study explored the effect of one student status as being a

traditional or non-traditional student on help-seeking attitudes. Traditional students

are those who typically enrol in college directly from high school. In contrast, non-

traditional students usually had at least 1 year between high school and college, and

most likely had multiple roles (e.g. employee, student, spouse, or parent). In the

research of college student mental health, non-traditional college students have been

noticeably under-researched and the majority of the studies have focused on

women. Among the few studies that examined non-traditional college students’

psychological functioning, the findings were inconclusive. Some studies reported

that non-traditional female students juggling multiple roles and demands showed

higher levels of stress, anxiety and depression (e.g. Backels & Meashey, 1997;

Mallinckrodt & Leong, 1992; Roehl & Okun, 1984), whereas other studies found

that multiple roles did not necessarily have negative impact on non-traditional

females’ psychological functioning (e.g. Dill & Henley, 1998; Home, 1997). These

researchers suggest that multiple roles may provide multiple opportunities to

experience success and thus an overall sense of well-being. None of the studies

conducted thus far has investigated the effect of student status on students’ attitudes

toward help-seeking in relation to psychological distress.

In response to the need for empirical knowledge that may explain under-

utilisation of mental health services among Chinese college students, the purpose of

this study was to examine the relationship between psychological distress (i.e.

depression and anxiety) and attitudes toward seeking professional psychological help

and whether the relationship was moderated by gender and student status. There-

fore, this study first aimed to determine the effects of gender and student status

(traditional vs. non-traditional) on emotional distress and then to test for the

moderating effects of gender and student status on the relationship between

psychological distress and attitudes toward seeking professional psychological help.

Given the importance of attitudes toward help-seeking in the help-seeking process,

the findings from the current study may assist the development of interventions

aimed at increasing the utilisation of mental health services for Chinese college

students experiencing psychological distress.

Method

Participants and procedures

The original sample consisted of 1,039 first-year Chinese college students who

participated in the mental health survey at a private university in Southern Taiwan.

The participants voluntarily completed a packet of psychological instruments in

the fall of 2004. Of those, 78 were excluded owing to missing data, resulting in the

current sample of 961 students. Among the 961 respondents, 403 (41.92%) were

male and 558 (58.08%) were female. Mean age for this sample was 19.29 (SD� 2.94) years, ranging from 17 to 50 years of age. A total of 818 (85.12%) students

were classified as traditional students as they entered university right after high

school while 143 (14.88%) students were classified as non-traditional students since

Taiwanese help-seeking 349

they attended the evening programmes and had at least one year between high school

and college. Only 13 (1.35%) of the participants reported being married.

Instruments

Beck Depression Inventory�II (BDI-II; Beck et al., 1996). The BDI-II is a 21-item self-report instrument that assesses the presence and severity of depressive

symptoms. The time frame for its assessment is for the past two weeks. Each BDI-

II item is rated on a 4-point scale, ranging from 0 to 3. A total score is calculated to

reflect severity of depressive symptoms, with summary scores ranging from 0 to 63.

The BDI-II scale has been used extensively with college students (e.g. Beck et al .,

1996) and has demonstrated acceptable psychometric properties with Chinese

college students (Chang, 2005). The Chinese BDI-II has a satisfactory internal

consistency coefficient of 0.87 with the current sample.

Beck Anxiety Inventory (BAI; Beck & Steer, 1990). The BAI is a 21-item self-report

inventory for measuring the presence and severity of anxiety (Beck & Steer, 1990).

The time frame for its assessment is for the ‘past week, including today’.

Each BAI item is rated on a 4-point scale: 0 (not at all) to 3 (severely, I could

barely stand it). A total score is calculated to reflect the severity of anxiety symptoms,

with summary scores ranging from 0 to 63. The Chinese BAI shows a high internal

consistency coefficient of 0.91 for the current sample.

Attitudes Toward Seeking Professional Psychological Help Scale�Short Form (ATSPPH- SF; Fischer & Farina, 1995). The ATSPPH-S is a 10-item version of Fischer and

Turner’s 29-item scale for measuring attitudes toward seeking psychological help.

Each item is a statement that is scored on a 4-point scale, ranging from 1 (strongly

disagree) to 4 (strongly agree). The total score is obtained by summing the item

scores. High scores on this scale indicate a positive attitude toward seeking

professional help for psychological problems. The ATSPPH-S has an adequate

internal consistency coefficient of 0.73 with the current sample.

Results

Table 1 presents the means and standard deviations of the BDI-II, BAI, and

ATSPPH-SF. In order to investigate the relationship between psychological distress

and Chinese students’ help-seeking attitudes and whether the relationship was

moderated by gender and student status, the researcher conducted a series of

analyses. Prior to conducting the main analyses, a gender�student status (tradi- tional vs. non-traditional) multivariate analysis of covariance (MANCOVA) with age

as covariate and depression and anxiety as dependent variables was performed to

determine whether the participants differed by gender and student status in relation

to depression and anxiety scores. The MANCOVA which examined the influence of

gender and student status on depression and anxiety produced significant main

effects for both gender (Wilks’ lambda�0.99), F (6, 955)�5.68, p�0.004, and

350 H. Chang

student status (Wilks’ lambda�0.99), F (6, 955)�6.03, p�0.002. The analysis also produced a significant interaction effect between gender and student

status (Wilks’ lambda�0.99), F (6, 955)�5.55, p�0.004. Follow-up univariate analysis of covariance (ANCOVAs) for the BDI-II scores yielded significant main

effects for both gender, F (1, 956)�11.24, p�0.001, and student status, F (1, 956)�10.83, p�0.001. Examination of the BDI-II mean scores indicated female participants (M�9.74, SD�7.74) reported significantly higher ratings of depres- sion than males (M�9.16, SD�7.49), while non-traditional students (M�10.78, SD�9.53) reported significantly higher levels of depression than their traditional counterparts (M�9.26, SD�7.21) (see Table 1). Additionally, the ANCOVA for the BDI-II scores also yielded a significant interaction effect between gender and

student status, F (1, 956)�10.85, p�0.001, with non-traditional female students reporting highest levels of depression, followed by traditional female students,

traditional male students and non-traditional male students, respectively. With

regard to the BAI scores, the follow-up ANCOVA showed that non-traditional

students (M�8.25, SD�9.42) reported significantly higher levels of anxiety than traditional students (M�6.94, SD�7.17).

A hierarchical multiple regression analysis was conducted to test the relationship

between psychological distress and attitudes toward help-seeking and whether the

relationship was moderated by gender and student status. The ATSPPH-SF served

as the criterion variable in the analysis. The predictor variables for the analysis were

the BDI-II scores, BAI scores, gender, student status and the interaction variables

(i.e. gender�BDI-II, gender�BAI, student status�BDI-II, and student status� BAI). In the hierarchical regression equation, the BDI-II scores and BAI scores were

entered first, followed by gender and student status, and then the interaction

variables. Results of the hierarchical regression analysis revealed that higher BDI-II

scores were significantly negatively related to the ATSPPH-SF scores (beta��0.13, p�0.001) (see Table 2). That is, participants with higher levels of depression were

TABLE 1. Means and standard deviations of the BDI-II, BAI, and ATSPPH-SF

BDI-II BAI ATSPPH-SF

M SD M SD M SD

Male 9.16 7.49 6.74 7.75 17.31 5.21

Traditional 9.22 7.48 6.63 7.24 17.49 5.10

Nontraditional 8.86 7.58 7.29 9.91 16.44 5.73

Female 9.74 7.74 7.14 7.57 18.53 4.73

Traditional 9.29 7.03 7.15 7.11 18.59 4.73

Nontraditional 12.45 10.72 9.08 8.96 18.18 4.71

Total 9.50 7.63 7.14 7.57 18.14 4.91

Traditional 9.26 7.21 6.94 7.17 17.37 5.26

Nontraditional 10.78 9.53 8.25 9.42 18.02 4.97

N�961.

Taiwanese help-seeking 351

less likely to hold favourable attitudes toward seeking professional psychological help.

After accounting for the variance in help-seeking attitudes contributed by the BDI-II

and the BAI scores, gender added increased variance to the ATSPPH-SF (beta� 0.13, p B0.001). In other words, female participants were more likely to hold more

positive attitudes toward seeking professional psychological help than males. After

accounting for the aforementioned predictor variables, the gender�BDI-II interac- tion term made a significant positive contribution to the prediction of help-seeking

attitudes (beta�0.35, p�0.02), while the gender�BAI interaction made a significant negative contribution to the prediction of help-seeking attitudes (beta� �0.31, p�0.02). However, it is noteworthy that together these variables explained less than 10% of the help-seeking variance, indicating that the majority of the

variance was not accounted for.

Discussion

The purpose of the current study was to explore the relationship between

psychological distress and attitudes toward help-seeking among Chinese college

students in Taiwan. Results from this study indicate that Chinese non-traditional

students reported significantly higher levels of anxiety and depression than

traditional students, and female non-traditional students reported the most

pronounced level of depressive symptoms. This finding supports previous studies

in the West. As previous research has suggested, although non-traditional students

TABLE 2. Multiple regressions predicting ATSPPH-SF using the BDI-II, BAI, gender, age and

student status

Predictor statistics

Model Variable Beta r t

Multiple R�0.11 BAI 0.05 �0.02 1.31 Adjusted R

2�0.01 BDI-II �0.13 �0.10 �3.21** F�5.39, p�0.005

Multiple R�0.17 BAI 0.05 �0.02 1.26 Adjusted R

2�0.03 BDI-II �0.13 �0.10 �3.25** F�6.05, p B0.001 Gender 0.13 0.13 3.98***

Student status �0.04 �0.05 �1.28

Multiple R�0.19 BAI 0.43 0.02 2.39* Adjusted R

2�0.03 BDI-II �0.50 0.10 �3.09** F�6.05, p B0.001 Gender 0.09 0.13 1.73

Student status �0.05 �0.05 �0.94 BAI�gender �0.31 0.01 �2.26* BDI-II�gender 0.35 �0.03 2.42* BAI�student status �0.12 �0.04 �0.96 BDI-II�student status 0.10 0.71 �0.09

N�961; *p B0.05, **p B0.01, ***p B0.001.

352 H. Chang

bring valuable experience, high motivation, and a pragmatic attitude to their study,

increases in roles, demands, and time conflicts may make them more vulnerable to

anxiety and depression (Backels & Meashey, 1997; Home, 1997; Mallinckrodt &

Leong, 1992). The results from the current study together with previous studies in

the West suggest that non-traditional college students across cultural boundaries

appear to be in high need of psychological assistance. Counselling services need

to attend to the mental health needs of non-traditional students and develop

appropriate intervention for these students.

By incorporating psychological distress as well as gender and student status in

the analytical model, this study found that depressive symptoms were important

predictors to help-seeking attitudes among Chinese university students. Chinese

students with higher levels of depressive symptoms tended to exhibit greater

resistance toward help-seeking. Despite an increased need for mental health services,

there was no corresponding increase in help-seeking. These results run counter to

previous findings in the West, which have suggested that psychological distress is the

primary prompt to seek help (Amato & Saunders, 1985; Bristow & Patten, 2002;

O’Neil et al ., 1984; Rickwood & Braithwaite, 1994). These findings are under-

standable within the Chinese cultural context, as psychological problems are often

viewed as signs of personality flaws and moral defects and seeking help is stigmatised

(Sue & Morishima, 1982). There are cultural preferences in the ways distress is

expressed and communicated, with physical complaints judged as more socially

acceptable than psychological complaints (Parker et al ., 2001). Indeed, the focus on

affective and cognitive complaints in depression may be seen as evidence of weakness

of character and a cause for family shame and would not justify seeking help from

mental health professionals. Social stigma and cultural reluctance to endorse

psychological symptoms may be responsible for negative attitudes toward help-

seeking among depressed Chinese students.

One interesting finding from the current study is the gender effect on

psychological distress and help-seeking attitudes among Chinese college students.

Gender made significant contribution to the prediction of help-seeking attitudes

when considered in conjunction with depressive and anxiety symptoms. Consistent

with previous studies across cultural boundaries (e.g. Ang et al ., 2004; Fischer &

Farina, 1995; Yeh, 2002), Chinese males in the present sample displayed less

favourable help-seeking attitudes than females. Moreover, results from this study

suggest that gender interacted with depression and anxiety scores in affecting help-

seeking attitudes among Chinese students. Closer examination of the data indicates

that female students with lower levels of depression were more likely to hold

favourable attitudes toward help-seeking; however, males with higher levels of

anxiety were more likely to hold favourable attitudes toward help-seeking. These

results further amplify the important role that gender plays in the relationship

between psychological distress and help-seeking among Chinese college students.

The current study’s findings are certainly curious and warrant more deliberate

attention in future investigations.

Based on the current findings, outreach efforts in the form of mental health

education may be needed to improve Chinese college students’ attitudes toward

Taiwanese help-seeking 353

seeking professional help. A study with American college students found that a

psychoeducation intervention that aimed to normalise the type of individuals that

might seek help, and the reasons they might seek help, significantly improved the

students’ attitudes toward help-seeking (Gonzalez et al ., 2002). Such psychoeduca-

tion programmes may be useful with Chinese students given the social stigma

traditionally attached to psychological problems and mental health services in

Chinese societies. Additionally, this and previous studies with Asian students suggest

that although many students troubled by depression may not initiate counselling,

those who do may hold less positive attitudes toward counselling (Chang, 2005; Yoo

et al ., 2005). As a result, an outreach programme that emphasises the warning signs

of depression while highlighting the importance of knowing when and where to seek

help may be especially important for Chinese students with depression. Further-

more, as Chinese students tend to seek help from family and friends rather than

professional helpers (Boey, 1999), informed peers may enhance referrals to

counselling services. Further research is needed to ensure the effectiveness of these

outreach interventions with Chinese college students.

The findings from the current study need to be interpreted within the limitations

of the study’s design. It is important to note that in the correlational nature of this

study’s design, causality cannot be assumed regarding the significant relations found

between gender, depression and attitudes toward help-seeking. In addition, the

factors explored in this study accounted for less than 10% of variance of help-seeking

attitudes among Chinese students. Other variables that were not addressed in this

study may play a role in the determination of Chinese students’ attitudes toward

help-seeking. Further investigation into the factors that influence help-seeking

attitudes are needed. Furthermore, attitudes toward help-seeking, important

precursors to help-seeking behaviour, do not necessarily translate into actual

behaviour. Future studies are needed to establish the empirical relationship between

attitudes toward help-seeking and help-seeking behaviour.

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(Accepted 10 December 2006)

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