Abstract: The main objective of this study is to identify the state of international students’ mental health in a university setting. As the second objective, the study investigates students’ attitudes toward seeking help from counseling centers located in their university. A sample of 150 international postgraduate students with mental health problems was selected from a population of 412. For the purpose of data collection a questionnaire was administered. The questionnaire was a researcher-made questionnaire concerning students’ attitude toward seeking counseling help. The findings indicated that from the total of 150 international students with mental health problems only 49 had visited the university counseling center. The main reasons behind the reluctance of students to seek counseling help were students’ negative culture and beliefs, lack of information regarding the location of the counseling center or places that offer related services, lack of necessity to visit counselors and lack of safety when visiting a counselor.
INTRODUCTION
According to the World Health Organization in 1993, almost 500 million people were suffering from some kind of mental disorder (Rickwood et al., 2005). Periods of adolescence and young adulthood are the two most important life stages that affect mental health and wellbeing. Psychological problems and mental disorders such as depression, anxiety, substance use and eating disorders are increasingly prevalent between the ages of 12-26 (NAYH, 2012; Rickwood et al., 2005). It seems that mental disorders and mental problems affect more young people these days than ever before (Rickwood et al., 2005). Therefore, the help seeking behavior of young people plays an important role in their mental health and wellbeing. As Hinson and Swanson (1993) declared, help seeking behavior of individuals is affected by his or her attitude towards counseling. Language barriers, financial problems, different educational systems, acculturation and racial discrimination are the usual obstacles that international students encounter while studying in a foreign country (Parr et al., 1992; Yi et al., 2003).
Although, seeking help is one of the initial choices available to assist someone in coping with their mental health problem (Alavi et al., 2012; Garvey et al., 2008), counseling assistance is the last attempt of international students to seek help when they are in need. Seeking help means communicating with others to obtain help in terms of understanding, advice, information, treatment and general support in response to a problem or distressing experience (Garvey et al., 2008; Rickwood et al., 2005). Informal help seeking involves informal social relationships, such as friends and family. Formal help seeking should be sought from professional sources of help; that is, professionals who have authority and are appropriately trained to provide help and advice such as mental health and health professionals, teachers and youth workers. Increasingly, however, individuals tend to seek help from unofficial sources or sources that do not involve direct contact with people such as the Internet (Rickwood et al., 2005). According to Garvey et al. (2008), in formal terms it is defined as a ‘coping response’. There are other types of ‘coping response’, some are positive, some are negative. These include denial, escape, disengagement, behavioral change, self-medication, procrastination and active problem solving among others.
International students themselves have their own excuses and reasons for not using counseling services. For example, students from non-western cultural background may not be familiar with this kind of service at university (Mori, 2000). They may feel uncomfortable receiving one-on-one counseling from a stranger in a structured time and place (Arthur, 1997; Fouad, 1991; Siegel, 1991; Hayes and Lin, 1994). They may also see a stigma attached to counseling and be afraid of loss of status in the eyes of others (Arthur, 1997; Mori, 2000). Feeling too embarrassed to discuss the issue, feeling ambivalent about giving up control and perceiving an imbalance of power with the source of help are other reasons. Even when discussing problems with friends these issues can be seen (Alavi et al., 2012; Garvey et al., 2008; Wilson et al., 2002). Negative attitude is also considered to be one of the main obstacles for seeking psychological specialist help (Rickwood et al., 2005). Such negative judgments are the result of negative beliefs about the quality of professional help. Thus, international students from non-Western cultural backgrounds may be unwilling to confess to having a problem that needs professional help (Mau and Jepsen, 1990; Fernandez, 1988; Pedersen, 1991). Moreover, they may fear ruining their student status or the national reputation of their home country (Alexander et al., 1981). In addition, cultural differences with a counselor or language barriers may also deter them from asking for counseling (Leong and Chou, 2002; Mori, 2000; Pedersen, 1991). They may also prefer other sources of help such as family, friends, or academic advisors (Hayes and Lin, 1994; Pedersen, 1991), or they simply may not be familiar with the campus counseling resources (Mori, 2000).
Obviously, young people’s beliefs about seeking professional help will affect their willingness to ask help from others. There is a significant relationship between seeking help and being hopeless (Rickwood et al., 2007; Wilson et al., 2002, 2003). Hopelessness is strongly associated with the belief that nothing will change the problem. So, people’s attitude plays an important role in determining help seeking behavior (Corrigan and Watson, 2002; Donald et al., 2000; Kabir et al., 2004; Rickwood et al., 2005, 2007; Segal et al., 2005; Wilson et al., 2003). Based on previous studies, there should be an important connection between a person’s attitude towards counseling and their utilization of counseling services (Leong and Zachar, 1999).
Most young people do not like to be seen by their friends and others as having mental problems (Wisdom et al., 2006). Thus, the stigma of a mental problem is relevant to being less willing to ask for help. People who have a negative attitude toward counseling are unlikely to choose counseling as a treatment. However, teens with negative attitudes about treatment in general are likely to prefer medication (Hoagwood et al., 2008). Based on Dr. Mostafa Moein, 70% of patients in the world do not like to visit a psychiatrist due to fear of stigma and discrimination (Pourasl, 2011).
Mental health workers such as counselors who screen people should be sensitive to the desires of teens to feel good, connected and autonomous. Clients need to feel they are being listened to and their conversations will be kept confidential (Hoagwood et al., 2008). Fear of stigma is related to the fear of lack confidentiality in counseling centers and services (Rickwood et al., 2005). Previous studies indicated that the most common barriers in receiving professional help are secrecy and confidentiality of problems (Rickwood et al., 2005; "The World Health Organization"). Moreover, lack of knowledge about counseling centers and the services provided are other barriers to making contact with the authorities and accessing services; financial issues and client or counselor time constraints are also reported (Wilson et al., 2003).
Professor Hamid Ghods of the University of London St. George pointed out that 450 million people worldwide are suffering from some kind of mental disorder. He noted that 121 million people suffer from depression and this number is expected to increase in 2020 compared with 15% of these diseases in the world. Further, 28% of the world’s countries have no specific budget for mental health and 36% of the countries that allocate funds to this area, allocate only one percentage of their health budget to mental health (Pourasl, 2011).
Dr. Mostafa Moein, head of UNESCO Health Education, announced that 42% of patients with psychological problems do not inform their families about their problems. He added that 80% of people with mental disorders are living in Third-world countries and they impose great financial burden on society. The Head of Psychiatry and Psychology Research Centre, University of Medical Sciences, Tehran, Iran has announced that 80% of patients with psychiatric disorders in developing countries are deprived of essential services (Pourasl, 2011).
Since, curing mental health problems is significant, the current study aimed to identify barriers that hinder students from visiting counseling centers. In particular, international students who are pursuing further study in a foreign country are at a greater risk than students in general. Considering this matter, international students with mental health problems were asked to focus on the specific reasons why they are not interested and willing to use counseling services that their university (Universiti Teknologi Malaysia) provides. Investigating the students’ attitude toward visiting counseling centers is the second objective of this study. It is important to examine help-seeking attitudes because they are one of the strongest predictors of intention to seek help. Fischer and Turner shared the same opinion, reinforcing the belief that this would be an important factor to explore (Fischer and Turner, 1970).
MATERIALS AND METHODS
Sample preparation: The sample of this study consisted of international postgraduate students who were currently studying at the Universiti Teknologi Malaysia (UTM) main campus. A set of questionnaire was randomly distributed to 412 international students to identify their mental health status. After receiving the responses from these students, 150 students were identified with some kind of mental health problems and were selected as the sample of the study. From the sample, only 49 students have visited the counseling center at least once and the other 101 students have not visited the center at all.
Instrumentation: The questionnaire entailed a demographic section as well as a set of questions. This set (including 4 dimensions and 20 items) was constructed by the researchers in order to identify students’ attitude toward four domains: Necessity to visit a counseling center (5 items), safety and trust in counseling (5 items), Information about counseling services and the location of counseling center (5 items) and students’ culture regarding counseling (5 items). The dimensions were chosen based on the issues that previous studies highlighted and considered items which were related to students who were more likely to have mild psychological conflict rather than mental illness.
The participants were asked to assess their attitude toward a counseling center. In this study, each item's score has been calculated as the sum of scores obtained from 5 assigned questions related to item measuring. To do so, 5 relevant questions were considered for every item on a 1-5 answer scale for every item in each question.
Table 1 indicates that Cronbach’s alpha of each domain was higher than 0.7. Necessity to visit a counseling center was 0.76, Safety and trust in counseling was 0.82, Information about counseling services and the location of counseling center was 0.85 and Students’ culture regarding counseling was 0.74. Since, the domains of attitude toward counseling instrument showed alpha higher than 0.7 it has acceptable reliability (Jamshidi et al., 2012).
Moreover, the validity of items was also investigated with 2 members from the Counseling Department and 2 members from the Psychology Department of the Faculty of Education Universiti Teknologi Malaysia (UTM). As a result, different items of the questionnaire were reviewed and edited to enhance the validity of the questionnaire.
Data analysis: The collected data was analyzed using Statistical Packages for Social Sciences (SPSS version 17). Based on the obtained result from questionnaire, the candidates were divided into two groups: Students who visit the counseling center (n = 49 students) and those who do not visit the counseling center (n = 101 students). In order to identify the problems students have in visiting the counseling center, independent t-test analysis was used. In this test the mean difference of the problems in different dimensions between the two mentioned groups of candidates was found. The chi-squared test was performed for the purpose of identifying the most influential factor that makes the students visit or not visit the counseling centers. The findings are shown in the Table 2 and 3.
RESULTS
The result of T-test (Table 2) shows there is a significant difference in the mean of all 4 dimensions; negative culture, lack of information, lack of necessity and lack of safety.
In order to identify the relationship of 4 dimensions with visit the center parameter or not visit the center parameter Chi-squared test was used. According to Pearson Chi-Square, phi and p-value in Table 3, there is a relationship among all dimensions including negative culture, lack of information, lack of necessity and lack of safety between two groups of students who were having mental health problems who did and did not visit counselors (sig.
| Table 1: | Reliability of domains in attitude toward counseling instrument |
| Table 2: | T-test for equality of means |
| Table 3: | Chi-square tests results |
| ** = p = 0.01 | |
DISCUSSION
The findings of this study showed that although mental health problems existed among students, International students have no desire to visit counselors and counseling centers. There are various reasons behind their reluctance (Garvey et al., 2008; Rickwood et al., 2005, 2007; Wilson et al., 2002, 2003). The results of this study indicated that different culture is the significant reason behind student’s nonchalance and visitation rate. Since international students are from different countries and different cultural backgrounds, they have a different perception of counseling too. Students from non-western countries are not very open to counseling services and this could be the result of not having faith in the whole process of counseling services and underestimating the value of using professional help to solve their mental illnesses and negative attitude towards counseling, which leads to low visiting rates. Obviously people’s attitude plays an important role in determining help seeking behaviour (Alavi and Mansor, 2011; Kim and Omizo, 2003; Kim and Park, 2009). In this study, cultural background of international students also plays an important role in the low number of clients in UTM counseling center. Based on Rickwood et al. (2005), people’s belief about counseling affect their willingness to meet counselors. The findings of this study show that the participants, based on their cultural background, were not interested in counseling.
Another factor that hinders international students from visiting counselors is lack of information such as being unaware that there was a counseling center on campus, not knowing the location of the counseling center and not having information about the facilities they have and the services they provide. Wilson et al. (2003) confirm that not having enough information about counseling services was a barrier to making contact with counseling centers.
The third factor that stops international students from visiting counselors is lack of necessity to visit counselors. As previous studies also show, students report necessity of seeking help from counseling centers only if they are not able to solve their problems on their own or do not get positive feedback from social support and others to help them solve problems (Gao and Lu, 2001). In studies about the U.S population, lack of need for counseling is the most common reason cited for keeping Americans from seeking professional mental health services (Kessler et al., 2001).
The last factor behind the respondents’ unwillingness to see a counselor was lack of trust. Previous studies showed that the most common reason behind an unwillingness to seek professional help relates to the assurance of counselors’ secrecy and the clients feel that their problems must remain confidential (Rickwood et al., 2005; The World Health Organization).
CONCLUSION
Students who have no desire to visit counselors and counseling centers face more psychological problems than those who are doing so regularly. Refusing to visit counselors can cause serious psychological problems and loss of function in personal, academic and other areas of life. Therefore, it is important that counseling centers reduce the barriers and work to prevent the aforementioned problems.
The results of this study are useful for university mental health professionals in terms of better promoting and providing counseling services to international students. In addition, counselors, students, teachers, coordinators, administrators and student affairs centers must cooperate to reshape students’ negative attitudes toward counseling. Lecturers, on the other hand, play an important role in this regard because they are in unique relationship with students and they can promote the students’ wellbeing and mental health. Professional mental health services need to change students’ mind-set and develop a feeling of trust and by using psycho-education, professional psychologists can educate and help students in need of mental health services. Counseling center takes step to increase awareness among international students about its existence, location and services that are offered. In order to increase the trust of international students, the students need to be aware of the credentials of their counselors. If these credentials are known, their trust will easily increase.
It is suggested that future researches address demographic information like age, gender and nationality. The length of their stay in the destination country can help researchers obtain a more in-depth understanding about a person’s attitude toward using counseling services. Furthermore, it is suggested that future researches use longitudinal studies with psycho-education to increase the willingness to seek counseling services. This type of study can show how effective an educational model is over time. In addition, experimental approaches can be effective in determining how changeable attitudes are towards professional psychology and counseling and what can be used to maintain them.