A qualitative study of the perceived attitudes toward counseling and effective counseling practices in working with clients of Iranian origin
Table of Contents
Acknowledgments i Dedication ii Abstract iii Chapter One: Introduction 1 Statement of the Problem 2 Importance of studying the Iranian population in the United States 3 Research Questions 5 Chapter Two: Literature Review 6 Development of the “Attitudes Toward Seeking Professional Psychological Help” Scale 6 Help-Seeking Attitudes and Demographic Variables 7 Help-Seeking Attitudes and Personal Characteristics 15 Help-Seeking Attitudes and Nationality 24 Help-Seeking Attitudes in the Middle-Eastern Population 33 Help-Seeking Attitudes in the Iranian Population 36 Chapter Three: Methods 40 Participants 40 Design 41 Procedures 41 Data Collection 42 Data Analysis 42
v Coding 42 Chapter Four: Results 44 Introduction 44 Domain 1: Clients’ Expectations/Preferences in Therapy 45 Domain 2: Therapists’ Approach to Therapy 49 Domain 3: Relationship/Rapport Building 55 Domain 4: Boundary Setting 58 Domain 5: Gender Roles 59 Domain 6: Help-Seeking Barriers 60 Chapter Five: Summary, Discussion, Conclusion, Implications, and Limitations 65 Summary 65 Discussion 66 Conclusion 76 Implications 77 Limitations 82 References 84 Appendix A: Demographic Information of Participants 89 Appendix B: Interview Questions 90 Appendix C: Consent Form 92 Appendix D: Summary of Domains and Themes 94
1 Chapter One Introduction Leong, Wagner, and Tata (1995) noted that Hollingshead and Redlich’s (1958) study about social class and mental illness recognized that understanding the help- seeking process was a complicated enterprise. Additionally, Leong, Wagner, and Tata noted that individuals’ help-seeking attitudes determined whether they sought professional psychological help when they needed it. Other studies observed that members of certain groups such as some ethnic minorities, lower income or undereducated individuals, and those differentially acculturated to U.S. culture were at equal or greater risk for psychological problems than other members of society (Padilla, Ruiz, & Alvarez, 1975; Ruiz & Padilla, 1973). As such, it was important to try to understand the attitudes these individuals had toward seeking professional help in order to provide better access and more effective delivery of helping services to them. More than 30 years ago, Fisher and Turner (1970) operationalized the study of help-seeking attitudes when they developed the Attitude Toward Seeking Professional Psychological Help Scale (ATSPPHS). The ATSPPHS is a 29-item Likert scale with four subscales: Recognition, Tolerance, Interpersonal, and Confidence. In a follow-up study published several years later, Fischer and Farina (1995) developed a shortened, 10-item unidimensional version of the ATSPPHS. The authors concluded that the shorter form could be substituted for the original, though only for use in research and not as a clinical device.
2 Initial studies on help-seeking attitudes using the ATSPPHS tended to focus on demographic variables such as gender, race, and previous experience with counseling (Terrell & Terrell 1984; Blazina 1996; Leong 1999). More recent analyses concerning attitudes toward seeking help have focused on a variety of psychological and personal characteristics (Cepeda-Benito & Short, 1998). Authors, such as Komiya, Good, and Sherrod (2000) have also reported that lack of emotional openness, greater perception of stigma associated with counseling, and lower psychological symptom severity contribute to individuals’ reluctance to seek psychological help. Another major variable explored in studies of general help-seeking attitudes and behaviors is client nationality. A handful of studies have examined groups from a variety of cultural and ethnic backgrounds, and the majority of studies in this area have predominantly focused on the Asian and Asian- American college population. Statement of the Problem The ATSPPHS has been used by researchers in a variety of settings to study factors influencing attitudes toward seeking psychological help. Variables such as gender, level of self-disclosure, nationality, and race have been included in such studies. Although each of these studies has contributed to the body of knowledge regarding attitudes toward seeking help, there has been little systematic review of the research findings in this area. While a handful of studies have examined attitudes toward professional psychological help seeking in groups from a variety of cultural and ethnic backgrounds, the majority of studies in this area have predominantly focused on the Asian and Asian- American college population. In fact, it is notable how few studies have examined the
3 help-seeking attitudes of other cultures and nationalities residing in the United States. It is also notable how few of the studies to date have examined non-college populations. Accordingly, results should be interpreted and generalized with a high degree of caution, at least until more research about different cultural and ethnic groups is available. With the ever-changing population of the United States and current multicultural issues in present society, there is a definite need for investigation of the willingness to seek professional psychological help in other cultural and demographic groups. The purpose of this study is to explore the attitudes of Iranian population residing in the United States toward seeking professional psychological help. More specifically, we would like to see what has been working well with the Iranian population as it pertains to mental health, what mental health professionals working with this population have been experiencing, and what should be done to educate and encourage the Iranian population to seek mental health services during times of stress and despair. Importance of studying the Iranian population in the United States According to Price (2005), Iranian culture is a traditional, patriarchal, and class- based culture. For most, tradition is rooted in the religion of Islam. Additionally, class and patriarchy have been constant features of Iranian society since ancient times. Class, in its simplest form, is mainly based on socioeconomic status or family genealogy, though modernity (westernization) and traditionalism might also be used to set apart classes. In Iran different classes have different cultures and are bound together through different processes. For example, relationship is a primary source of security and financial support for low-income families; in contrast, connection is a source of emotional and psychological support for the affluent. Division of labor for the poor
4 and/or uneducated could be a relatively simple division between the public (men’s work) and domestic (women’s work). Generally the lower and uneducated classes may regard females as inferior or different, and entitled to a lesser position in society. On the other hand, the modern classes normally make every effort to guarantee the equality of sexes and eliminate gender inequity (Price, 2005). As stated by Jalali (1982), it is important to understand the cultural characteristics of Iranian clients in order to deal with psychological issues associated with this population. The family is considered the most significant element of Iranian culture. Most physical illnesses and mental disorders are usually managed by the family. The family acts as the decision maker and is considered an important source of support for the patient (Langsley et al., 1983). To this date, there have been only two published articles studying the attitudes of Iranian population toward seeking mental health. Both studies, conducted by female Iranian doctoral students in Counseling Psychology (Rahimi, 1989 & Khoie, 2002), have used the ATSPPHS for measuring the attitudes of Iranian population toward help-seeking with relatively small samples, and have either focused on a college population or only one gender (male). According to an extensive search of the published and unpublished research data- base, there does not exist a recent study conducted on the Iranian population residing in the U.S. regarding their help-seeking attitudes that has attempted to investigate these attitudes in depth, to learn about therapy experiences, or to find out what works and does not work with this group of people. Research Questions
5 In the present study, the questions to be explored are: What is the Iranian attitude toward seeking professional psychological help? What is most helpful to Iranians? What are some of the barriers in working with Iranian clientele? What does a therapist need to know when working with this population? What are certain therapist/therapy characteristics that help or hinder the therapeutic process with this population? The goal of this study is to explore the general view of Iranians toward psychological services and to learn what is unique about presenting such services to this community.
Chapter Two Literature Review Development of the “Attitudes Toward Seeking Professional Psychological Help” Scale Edward Fischer and John Turner were the first researchers to develop and standardize a scale to measure the attitude toward seeking professional help for psychological disturbances (Fischer & Turner, 1970). The scale was written in collaboration with several other psychologists familiar with a variety of mental health settings such as state hospitals, private clinics, and school counseling centers. Out of a pool of many suggested items for the scale, 31 items were considered to be highly relevant by the 14 clinical and counseling psychologists and psychiatrists who acted as judges on the panel. These 31 items were tested with a variety of subjects such as high school students and summer college students, along with the Marlowe-Crowne Social Desirability Scale (Marlowe & Crowne, 1960) to measure the correlation of the attitude scale with the social desirability scale. The eventual Attitude Toward Seeking Professional Psychological Help Scale (ATSPPHS) was formed with 29 items, from which eleven are positively stated and eighteen are negatively stated. The higher score on the scale indicates a more positive attitude toward help seeking (Fischer & Turner, 1970). A factor analysis of the attitude scale conducted on 424 college and nursing students (249 females, 175 males) resulted in four defined and interpretable factors: 1) Recognition of personal need for professional psychological help; 2) Tolerance of stigma associated with psychiatric help; 3) Interpersonal openness regarding one’s problem; and
7 4) Confidence in the mental health professional. Furthermore, the authors hypothesized that certain personality variables would have a significant relationship with attitudes toward help seeking such as masculinity, authoritarianism, trust, and social desirability. By administering the scale to different groups of subjects, along with other scales such as Marlowe-Crowne Social Desirability Scale (Marlowe & Crowne, 1960), Rotter’s scale of Interpersonal Trust (Rotter, 1967), and Rotter’s Internal-External control scale (Rotter, 1966), Fischer and Turner (1970) concluded that a great variability is evident in the attitudes expressed toward seeking professional psychological help. There was especially a strong sex difference with males holding a less positive attitude than females, though it was unrelated to masculinity. In a follow up study, Fischer and Farina (1995) developed a 10-item unidimensional version of ATSPPHS, aimed at devising a measure with adequate test characteristics to produce a single score representing the subject’s attitude toward seeking help (Fischer & Farina, 1995). By testing their abbreviated scale on university students similar to those studied by Fischer and Turner, the authors concluded that the shorter form can be substituted for the total-scale original version. Fischer and Farina believed that the shorter version of ATSPPHS would be easier to use and less obtrusive. Similar to Fischer and Turner (1970), Fischer and Farina cautioned that the ATSPPHS is intended only for use in research and is not an appropriate clinical device. The ATSPPHS has been the instrument of choice for a range of studies that will be presented in the next sections. Help-Seeking Attitudes and Demographic Variables Initial studies on help-seeking attitudes using the ATSPPHS tended to focus on demographic variables such as gender, race, and previous experience with counseling
8 (Terrell & Terrell 1984; Blazina 1996; Leong 1999). Terrell and Terrell (1984) conducted a hierarchical regression analyses to examine the relation between counselor’s race, mistrust level, and clients’ sex and the premature termination from counseling. The subjects were selected from a community mental health center. They were originally referred to the clinic because of complaints of mild depression, anxiety attacks, sexual dysfunctions, or marital problems. Mostly lower-class outpatient subjects were assigned to the study. The subjects were native-born blacks, 72 males and 80 females. Counselors consisted of three white men and three black men working at the community health center as a part of their practicum requirements. The counselors held at least the equivalent of a master’s degree in clinical or counseling psychology and had a minimum of two years of clinical experience. The clients and counselors were assigned randomly. The clients were asked to complete all standard agency forms as well as the Cultural Mistrust Inventory (CMI; Terrell & Terrell, 1981). Each client was seen for an hour-long intake interview and was scheduled for a return appointment within one week. Premature termination was defined as clients not returning for the second or any subsequent counseling session. Terrell and Terrell (1984) concluded that there exists a significant relation between termination rates of the clients and the counselor’s race. The results of this study indicated that black clients are more likely to terminate from counseling prematurely when seen by a white counselor than when seen by a black counselor. The other significant finding of this study was the relation between the trust level of the clients and the termination rate. A lower level of trust related to a higher rate of premature termination of counseling. This effect might be due to a generalized mistrust of people, or
9 the clients might have perceived the counseling clinic as a white-oriented context. The results of this study confirmed the major hypothesis which was to examine whether combined variables of counselors’ race and cultural mistrust level are related to premature termination from counseling. Black clients with a high level of mistrust who were seen by white counselors had a higher rate of premature termination from counseling than those who were seen by black counselors. The results of this study failed to produce evidence for differences in termination rates between male and female clients, and male counselors. One possibility is that the clients of this study were solely black people and that gender differences was less important among black women than they were among white women. To enhance the results of this study, one could assign white and black female counselors to black clients and review the premature termination rates in those clients for studying gender differences. In a comparable study, Blazina and Watkins, Jr. (1996) investigated the effects of gender role conflict (GRC) on college men’s scores of psychological well-being, substance usage, and attitude toward psychological help-seeking. Blazina and Watkins, Jr. (1996) conducted a correlational study of 148 male undergraduate students at a southwestern university, ages ranging from 18 to 55 years old. The subjects were 80% white and 20% African-American, Hispanic, and Asian. Subjects were asked to complete six psychological scales: the Gender Role Conflict Scale (GRCS, O’Neil et al., 1986); Beck Depression Inventory (BDI; Beck & Steer, 1987); the State-Trait Anger Expression Inventory (STAEI; Spielberger, 1991); the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983); the Substance Abuse Subtle
10 Screening Inventory (SASSI; Substance Abuse Subtle Screening Inventory Manual, 1985); and the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; Fischer & Turner, 1970). The Gender Role Conflict Scale consisted of four subscales: (a) success, power, and competition; (b) restricted emotionality; (c) restricted affectionate behavior between men; and (d) conflict between work and family relations. The authors concluded that each of the four sub-scales for Gender Role Conflict was significantly related to at least one of the variables of interest (psychological well- being, substance use, & help-seeking attitude). With regards to psychological well-being, the Success, Power, and Competition variables of GRCS were strongly related to men defined as Angry Reaction type (disposition to express anger when criticized or treated unfairly by other individuals). Moreover, there was a significant relation between the Success, Power, and Competition variable and college men’s willingness to admit to increased alcohol usage. Men, who scored higher on GRCS, viewed seeking help more negatively than did men who scored lower. In addition, men who present as more traditional may believe that feelings are unnecessary and time-consuming baggage and view help seeking more negatively. The results of Balzina and Watkins, Jr. (1996) study have some limitations. The majority of the subjects studied identified as white for their race and the diversity of ethnicity among subjects was limited. Additionally, the results of this study are restricted to a sample of college students and might not generalize to a wider population. It would be beneficial to extend this study to a more diverse group of male subjects and randomize the administration of the self-report measures.
11 Leong and Zachar (1999), in an attempt to investigate the relationship between students’ opinion about mental illness and their attitudes toward seeking professional help, conducted a correlational study of 290 white undergraduate students at a large American university. The subjects were 53% male and 47% female, ages raging from 17 to 20 years old. The subjects were asked to complete two questionnaires: the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; Fischer & Turner, 1970); and the Opinions about Mental Illness scale (OMI; Cohen & Struening, 1962). The OMI scale has five orthogonal factors of Authoritarianism, Benevolence, Mental Hygiene Ideology, Social Restrictiveness, and Interpersonal Etiology. Leong and Zachar (1999) concluded that female college students had more positive attitudes toward seeking psychological help than male students did. In addition, with respect to opinions about mental illness, college men were more socially restrictive and less benevolent than college women. Subjects with a higher social restrictiveness and those who were more authoritarian had a more negative attitude toward seeking help. Finally, subjects that believed in a mental hygiene ideology carried a more positive attitude toward help seeking. These subjects believed that psychological intervention can work. The results of this study provide helpful information for psychologists and mental health practitioners. Clients’ expectations of counseling and willingness to cooperate at sessions are highly related to their opinions about mental illness and consequently their attitudes toward seeking help. The result of the study is limited since it can only indicate that certain opinions about mental illness are correlated with certain help-seeking
12 attitudes. In a future study, one could monitor the subjects’ opinions about mental illness and actual psychological services utilization. Comparable to the previous study, Halgin, Weaver, Edell, and Spencer (1987) conducted a multivariate analysis of variance (MANOVA) to investigate the relation of help-seeking history, sex, and depression to college students’ attitudes, beliefs, and intentions about obtaining professional psychological help. The authors conducted a pilot study to assess college students’ significant beliefs about advantages and disadvantages of seeking professional psychological help. The results of the pilot study were used to formulate the items of the attitude measure administered in the main study. For the main study, subjects were 429 undergraduate students from a large northeastern university. The sample was 51.7% female and the mean age of the participants was 19.1 years. About 14.8% of the students answered positively to the question whether they have sought professional psychological help in the past. The subjects were asked to complete two measures: Decision Measure, constructed by the authors, and Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The Decision Measure measured the intention to seek professional psychological help and a global attitude toward psychological help. The authors concluded that the experience of having sought professional psychological help in the past is significantly related to how one felt about seeking such help again. Among students who had never sought professional psychological help, there was no difference in beliefs between depressed and non-depressed students; therefore the experience of depression did not seem to be significantly related to one’s views toward help seeking. Depressed subjects evaluated the experience of seeing a competent mental
13 health professional very positively and predicted that seeking help would more likely lead them to confront painful feelings and issues. Finally, the depressed subjects saw help seeking as likely to involve a commitment of their time. Halgin, Weaver, Edell, and Spencer (1987) indicated that help-seeking history is positively related to perceived positive outcome of the help-seeking experience. For future studies, it is interesting to determine whether those beliefs are specific to the sample characteristics or are representative of college students’ beliefs about the outcome of seeking professional psychological help. Further research could gather information on the relationship between types of personal distress and the decision to seek help and attitudes about professional help. According to the studies by Terrell and Terrell (1984) and Leong and Zachar (1996), women and people with previous counseling experience tend to have more positive attitudes toward seeking professional help. Additionally, traditional attitudes about the male role, concerns about emotional expression, and concerns about expressing affection toward other men were significantly related to negative attitudes toward seeking professional psychological assistance (Good, Dell, & Mintz, 1989). In an attempt to study the relation between help-seeking attitudes and behaviors and adherence to traditional male gender role, Good, Dell, and Mintz (1989) conducted a canonical analysis and regression on 401 undergraduate male students with an average age of 19.3 years at a large Midwestern university. Subjects were asked to complete four psychological instruments: the Attitudes Toward Men Scale (AMS; Downs and Engleson, 1982); the Gender Role Conflict Scale-I (GRCS-I; O’Neil, 1986); the Attitudes Toward Seeking Professional Psychological Help scale (ATSPPHS; Fischer and Turner,
14 1970); and the Help-Seeking Attitude and Behavior Scale (HABS), which was designed by the authors for this study. Good, Dell, and Mintz (1989) concluded that there is a significant relation between men’s attitudes and behaviors of help-seeking and the elements of the male role. Moreover, men with more traditional male roles in society, like having concern about expressing affection toward other men and concerns about expressing emotions, had a more negative attitude toward seeking professional psychological help. It is interesting to note that contrary to theoretical literature, the authors did not find that men’s need for success, power, and competition impacts their views on seeking help. The results of this study might only be generalized to men of a late adolescent age group who attend college. These relations need to be examined within groups of older male subjects and those who do not attend college to be able to draw a clearer conclusion. If the results of such a study are generalized for male clients, the relationship of the therapist and client might be moderated based on the therapist’s gender. Alternatively, Cash, Kehr, and Salzbach (1978) found that help-seeking attitudes provided a significant positive influence on counselors’ perceived expertise, trustworthiness, regard, and empathy, and on subjects’ willingness to return for a second counseling session and expectation to improve across a variety of personal problems. Cash et al. (1978) conducted an investigative study to examine the attitudes toward help- seeking in relation with clients’ perception of counselor’s behavior. The subjects were 219 female undergraduate students, ages ranging from 18 to 26 years old. The subjects were asked to indicate if they had any previous experience with counseling, to complete the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS Fischer
15 & Turner, 1970), to listen to a taped counseling session, and to complete an 8-point Counselor Rating Scale (Barak & LaCrosse, 1975). The Counselor Rating Scale measured the perceived expertness, attractiveness, trustworthiness of the taped counselor. Subsequently, the subjects completed the Relationship Inventory (Barrett-Lennard, 1962) to express their perceived empathy, regard, and genuineness of each counselor. Finally, subjects completed another 8-point Likert scale, designed by authors to determine the helpfulness of continuing counseling with the taped counselor. The results of this study indicated that subjects with prior counseling experience expressed a more favorable attitude toward seeking help. Subjects with a positive attitude toward seeking help described the taped counselors in regards to expertise, trustworthiness, regards, empathy, and genuineness. They also were more optimistic about the outcome of counseling and more favorable toward a need for commitment to future counseling. The authors pointed out that these results must be considered with caution, as factors such as need recognition, stigma tolerance, interpersonal openness, and generalized confidence might affect each subject’s perceived quality of counseling. An apparent limitation of this study is the restriction of the subjects to a non- clinical sample of female college students who evaluated counselors’ behaviors from a passive role, rather than an active and participant role. Help-Seeking Attitudes and Personal Characteristics More recent analyses concerning attitudes toward seeking help have focused on a variety of psychological and personal characteristics. For instance, Cepeda-Benito and Short (1998) indicated that self-concealment (i.e., the tendency to keep intimate information secret) was positively associated with self-reported distress and avoidance of
16 needed psychological treatment. Cepeda-Benito and Short (1998) conducted a correlational study to explore the likelihood of seeking professional help in relation to level of self-concealment, degree of psychological distress, and fear of psychotherapy. The subjects consisted of 732 Texas A&M University undergraduate students. The mean average age of participants was 19.5 years, and 65% were female. The majority of subjects (73%) identified themselves as European American, and the rest were Hispanic American, African American, Asian American, and Native American. The subjects were asked to complete five psychological inventories: The Hopkins Symptom Checklist-21 (HSCL-21; Green, Ealkey, McCormick, & Taylor, 1988); the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS; Fischer & Turner, 1970); the Thoughts about Psychotherapy Survey (TAPS; Kushner & Sher, 1989); the Wilcox Social Support Network Survey (WSSNS; Reis, 1988; Wilcox, 1981); the 10-item Self Concealment Scale (SCS; Larson & Chastain, 1990); and the Intention of Seeking Counseling Inventory (ISCI; Cash et al., 1975). The authors concluded that people with high self-concealment (those who are inclined to keep distressing intimate information secret) were more likely to avoid counseling. The subjects with high self-concealment reported an elevated level of psychological distress and need for counseling, but did not seek help. In addition, general feelings of psychological distress were predictive of the likelihood of seeking psychological help, but not the somatic symptoms. To the authors’ surprise, those with fear of psychotherapy were positively associated with the likelihood of individuals who would seek help for academic difficulties.