Help Seeking Attitudes and Behavior in India, the United States, and China

EMPORIA STATE RESEARCH STUDIES

Vol. 53, no. 1, p. 1 – 14 (2022)

_____________________________________________________________________________________ Help Seeking Attitudes and Behavior in India, the United States, and China

GEORGE B. YANCEYa , JAYASHREE GEORGEb , CHRISTINE K. JOOc, AND WEIWEI LIUd

a Southeast Missouri State University, b Southern Illinois University – Edwardsville, c Private Practice, d Korn Ferry; Corresponding Author: gyancey@semo.edu

Across cultures, there are differences in attitudes towards seeking help. This also corresponds with differences in the number of mental health care workers between countries. We inquired into the attitudes towards seeking help among participants in the United States, India, and China, gender differences in help seeking attitudes, and interactions between gender and country in help seeking attitudes and behavior. In a convenience sample of 1,412 participants (728 from India, 479 from the USA, and 205 from China), we found that participants from the United States sought help the most, followed by the Indians, and then the Chinese. The North Indians had the most positive help seeking attitudes, followed by the participants from the United States, China, and South India. While American women were more likely to have sought help than American men, in India and China, the men were more likely to have sought out help compared to their female counterparts. This study was done before the COVID-19 pandemic. Such a study is useful in providing comparison data with those done during the pandemic and in the years thereafter. Keywords: help seeking attitudes, mental health, cross-cultural, gender, help seeking behavior

INTRODUCTION

What makes someone seek help as a way to find lifeenhancing change while another shuns help because they see it as a personal weakness or moral failure? What shapes such attitudes? These were some of the questions Fischer and Turner (1970) and Fischer and Cohen (1972) sought to answer in the early nineteen seventies. Fischer and Cohen (1972) debunked the common notion of the times that one’s socioeconomic status correlated with seeking help, the assumption that upper class persons would be more open to seeking help than lower class persons. These early ponderings formed the impetus for the current inquiry, with the idea that understanding people’s views toward mental health and seeking help from both the United States and non-Western cultures, such as India and China, might provide useful information to mental health providers in the United States and elsewhere. Cultural attitudes are important to reckon with in psychotherapy as they have an impact on alliance. Attitudes towards help seeking impact whether clients access help, and having accessed help, whether they continue without prematurely dropping out. College students were the majority of the participants in the early articles, similar to our current inquiry. The research for this article was based on pre-COVID-19 experiences. Within the current context of the pandemic, rates of depression and anxiety and other correlated symptoms are on the rise globally (Zaidi et al., 2020). Many countries have responded by creating avenues for seeking help. What attitudes in the pre-pandemic context shape our understanding of help seeking behavior among participants in India, China, and the United States? This is the purpose of our inquiry.

EAST VERSUS WEST

According to the World Health Organization’s Global Health Workforce Statistics (2018), for every 100,000 people in the population, the United States had 10.5 psychiatrists, 4.3 nurses, 60.3 social workers, and 29.9 psychologists working in the mental health sector in 2016. In 2016, India had had .3 psychiatrists, .8 nurses, .1 social workers, and .1 psychologists per 100,000 citizens. In 2015, China had 2.2 psychiatrists, 5.4 nurses, and no numbers reported for social workers or psychologists for the number of people working in the mental health sector per 100,000 citizens.

The relatively small number of mental health care workers in China and India, per capita, does not indicate that Chinese and Indian citizens have less need of mental health care. Fong and Li (2014) estimate that “in China, 173 million adults have a mental disorder, 91.3% of whom have never received professional help” (p. 868). In India, the Central

Bureau of Health Intelligence (2011) estimated that in 2002 over 61 million people were suffering from mental and behavioral disorders. A year-long epidemiological study by the World Health Organization World Mental Health Survey Initiative, found the treatment gap in India to be 95% (Sagar et al., 2017).

While there is a great need for mental health care in China and India, compared to the United States, fewer Chinese and Indians seek help from mental health care providers. In a study of 747 undergraduate students (191 European Americans, 194 Chinese Americans, 170 Hong Kong Chinese, and 192 Mainland Chinese), Chen and Mak (2008) found that the European Americans were much more likely to actually seek help than the other three groups. While Asians in North America make less use of mental health services (Bui & Takeuchi, 1992; Zhang et al., 1998) than their European American counterparts, a study of Indian Americans and Asian Indians found no difference in their attitudes about seeking help from a mental health care professional. Both groups evinced negative attitudes towards seeking help (Shah, 2010).

Are Easterners less likely to seek the help of mental health professionals because of negative attitudes about the mental health field? In Chen and Mak’s (2008) study of European American, Chinese American, Hong Kong Chinese, and Mainland Chinese undergraduate students, the European American students had the most positive help seeking attitudes, followed by the Chinese Americans, the Mainland Chinese, and the Hong Kong Chinese, in that order. While they did uncover statistically significant differences in help seeking attitudes, the effect sizes were not large. The differences in actually seeking help were much larger.

If Asians need help as much as Europeans and their help seeking attitudes are, perhaps, only slightly less positive, why are they less inclined to actually seek help? Previous research (Cheung & Snowden, 1990; Kung, 2003; Mak & Chen, 2006; Leaf et al., 1986; Pearson, 1993; Sue, 1988; Takeuchi et al., 1993) suggests that people from East Asian cultures may view receiving help from outsiders as shameful, not only for themselves, but also for their families (Snider, 2003). Wong (2007) found that in China family and friends are frequently part of the process of seeking counseling services. While stigma may be universal, the particular experience and construction of stigma is highly textured, specific to cultures, and is, at its essence, a moral process (see Yang et al. (2007) for a further expansion of stigma as a moral process). For instance, Kleinman and Kleinman (1999) and Yang et al. (2007) discuss the nature of stigma in Chinese culture as shaped by sociopolitical forces, where mental illness may be seen as polluting the family and social network, and seeking help for it may be seen as dangerous to the family. Kleinman and Kleinman (1999) talk about those individuals who sought help after the Cultural Revolution and found their symptoms unabated as many deep-seated feelings could not be worked through. The authors say:

Most of our research subjects continued to live in the very same work-units (danwei) where they had been victimized by co-workers, neighbors, friends and even family members. They could not express their deeply negative feelings for fear they would recreate the greatly feared turmoil of the past. (p. 17)

According to Wang and Hernandez (2020), “In the Mao era, mental illness was declared a bourgeois delusion and the country’s psychiatric system was dismantled. Even today, discrimination persists, and many people with mental illnesses are shunned, hidden at home or confined in institutions” (para 4). Also, Tracey et al.’s (1986) research suggests that the Chinese cultural values of self-restraint and control, and sometimes suppression of emotional problems, are held in high esteem. These run counter to the central idea of “talk” therapy where open expression of feelings in an atmosphere of trust is highly valued.

Turning to India, in addition to both the lack of services and the poor quality of existing services, attitudinal and knowledge barriers to help seeking exist. A study of psychiatric patients from South India found fear of stigma and discrimination and a lack of knowledge about mental illness reduced help seeking (Raguram et al., 1996). A study of medical students in North India found that only 13% sought help from mental health professionals, although close to 75% felt that their studies were taking a toll on their physical and mental health. When asked why they did not seek help, the main reasons were the stigma of being labeled as mentally ill, being labeled as weak by peers, and a lack of time (Grover et al., 2019). In a study 521 people from across India, Gaiha et al. (2014, p. 150) found that “a significant proportion of respondents reported perilously low

mental health literacy; unaware of basic information vis-à-vis what constitutes mental illness, where mental health care is available and that medical treatment for mental health concerns exists and may prove efficacious.”

While differences in help seeking behavior and attitudes have been found in studies comparing participants from the United States and members of far Eastern cultures, we were curious about Indian help seeking behaviors and attitudes relative to the United States and China. Geographically, India rests in South Asia. Culturally, because of its long history as a British colony, perhaps India resides somewhere in the middle on the East-West cultural continuum.

These thoughts led us to our first two hypotheses:

H1: The US participants will be the most likely to seek help from mental health providers, followed by the Indian participants, followed by the Chinese participants.

H2: The US participants will have the most positive attitudes towards seeking help from a mental health provider, followed by the Indian participants, followed by the Chinese participants.

While we do not have much evidence about differences in help seeking attitudes and behavior between North and South India, we do want to investigate to see if differences emerge. Given Soman et al.’s (2009) report that South India, specifically the states of Kerala and Tamil Nadu, had the world’s highest suicide rates, perhaps South Indians have more negative attitudes and are less likely to seek help, but this is more of an exploratory research question than a hypothesis.

THE IMPACT OF EXPERIENCE ON ATTITUDES

Fischer and Turner (1970) found that participants who had sought mental health treatment had significantly more positive attitudes towards help seeking than those with no experience. While some people’s attitudes towards mental health care may become worse after a bad experience, this does not seem to be the case for the typical person who has sought help.

Carson et al. (2009) reported that many of India’s training programs are not accredited and Azar (2009) reported that licensing is not mandated to practice clinical psychology in India. However, today you can obtain a clinical psychologist or rehabilitation psychologist license in India from the Rehabilitation Council of India (RCI). Nonetheless, the regulation of mental health fields in India appears to be a work in progress (Agrawal, 2015).

Mental health counseling is still relatively new in post Mao China, although there has been much growth since 1987 (Chang et al., 2005). Qian et al. (2012) report that since the early 2000s China has experienced tremendous growth in counseling services. Nonetheless, Song et al. (2019) conclude that “Despite the rapid development of professional mental health services and increased demands for counseling in the contemporary China, the use of counseling services is minimal” (p. 1027). This changed dramatically at the height of the COVID-19 pandemic in Wuhan. Wang and Hernandez (2020) report psychologist Du Mingjun’s observation that “Because of the pandemic, they are braver in coming to ask for help … More and more people are accepting this. That is new” (para 11). Du Mingjun was one of many psychologists who helped launch a government authorized 24-hour hotline to deal with the uptick in depression, anxiety, insomnia, and acute stress. While more help may be available during the pandemic, a remaining barrier to seeking help may be the poor quality of service. In an earlier survey of mental health practitioners across China, Gao et al. (2010) found the quality of training to be not very good. This led us to our third hypothesis:

H3: The relationship between experience (those who have sought help from a mental health professional versus those who have not) and attitudes towards seeking help from a mental health provider will be moderated by country. The relationship will be stronger for Western participants than it will be for Eastern participants.

MEN VERSUS WOMEN

Previous research indicates that women have more positive attitudes about help seeking than men (Atkinson et al., 1990; Cook, 1984; Fischer & Turner, 1970; Garland & Zigler, 1994; Kuhl et al., 1997). One explanation for this difference is based on gender roles. For example, in Mendoza and Cummings’ (2001) study, men who saw themselves as similar to all men had more negative attitudes

towards help seeking, compared to men who saw themselves as similar to men and women. Research also shows that men who believe that men should strive for success and power and that men should be emotionality restrictive had more negative attitudes toward help seeking (Blazina & Watkins, 1996; Good & Wood, 1995).

While the research findings above suggest that men might be less likely to seek help, they are based on Western samples. Gender stereotypes are not universal. For example, Ward and Sethi (1986) administered the Bem Sex Role Inventory (BSRI) to 237 South Indian and 210 Malaysian university students and found that the masculine and feminine sex roles in the BSRI might not be applicable to South Asia. More to the point, in a study comparing men of Indian and Pakistani ancestry with men of United Kingdom ancestry in seeking treatment for cardiac chest pain found that:

Displaying a high threshold for pain and discomfort was a masculine attribute valued by white men in the study but not by the Indian and Pakistani men. White men's fears of being seen to be weak contributed to delays in seeking medical treatment and led to reluctance to disclose symptoms to others. Indian and Pakistani men emphasized wisdom, education and responsibility for the family and their own health as more valued masculine attributes, and this contributed to a greater willingness to seek medical help (Galdas et al., 2007, p. 223).

Not only are South Asian men less “macho” about seeking help compared to their Western counterparts, South Asian women may be less likely to seek help than their Western counterparts. A study by Dasgupta and Warrier (1996, p. 238) of Indian American women experiencing domestic abuse found that they were reluctant to seek help because their ideal of the “good” wife and mother made them feel “responsible for the reputation of their families.” For the Indian woman, an important dimension of femininity is the concept of personal sacrifice for the sake of the family’s honor.

Assuming that Chinese gender stereotypes follow more closely to the South Asian model than the Western model, our last two hypotheses were:

H4: There will be an interaction between country and gender such that Western women will be more likely to seek help from mental health providers than Western men, but Eastern men will be more likely to seek help from mental health providers than Eastern women.

H5: There will be an interaction between country and gender such that Western women will have more positive attitudes towards seeking help from a mental health provider than Western men, but Eastern men will have more positive attitudes towards seeking help from a mental health provider than Eastern women.

METHODS

Participants: There were 1,412 participants in our study: 728 from India, 479 from the USA, and 205 from China. The Indian participants came from a variety of locations. One researcher collected data from South India (Kerala, Karnataka and Chennai). Another researcher collected data from North India (New Delhi). Because we had two Indian samples, we decided to analyze the data separately for the two Indian groups. The American participants were all students from a single university in the American Midwest. The Chinese participants were all students from a single university in South China. The universities were chosen because the researchers had connections with them, which helped with access. Thus, they were convenience samples.

There were more female participants than male participants from each country. Sixty-one percent of the Indian participants were women, 65% of the American participants were women, and 62% of the Chinese participants were women. Most of the participants were young adults. The median age of the participants from America and India was in the 18-21 category. The median age of the Chinese participants was in the 22-25 category.

Measures: Help seeking attitudes. We used Fischer and Turner’s (1970) Attitudes toward Seeking Professional Psychological Help scale. The scale has 29 items and uses a four-point Likert scale from 0 (disagree) to 3 (agree) with slightly disagree or slightly agree in between. Their instrument produces an overall score and scores for four dimensions: (1) recognition of the need for psychotherapeutic help, (2) interpersonal openness, (3) stigma tolerance, and (4) confidence in mental health practitioners.

In their initial study, Fischer and Turner used Tryon’s (1957) method for determining internal consistency. With a sample of 406 participants, the internal consistency was .67 for the need help dimension, .62 for the openness dimension, .70 for the stigma tolerance dimension, and .74 for the confidence dimension. For the overall scale, the internal consistency was .83 and the test-retest reliabilities were consistently over .80 for four out of five groups.

Regarding validity, the overall scale correlated -0.04 with Crowne and Marlowe’s 1964 social desirability scale for women and .20 for men. Thus, social desirability did not have a great impact. As predicted, participants with high scores on authoritarianism and participants with an external locus of control had negative attitudes towards seeking help.

Help seeking behavior. A single question was used to measure this variable, “Have you ever sought help from a mental health professional (e.g., psychiatrist/psychologist/counselor /social worker/etc.)?” The participant simply answered yes or no.

Demographics. Gender and age were the only demographic variables measured.

PROCEDURES

The American data were collected from university students in large Introduction to Psychology and Introduction to Sociology classes. The students received an informed consent form, a survey, and an envelope at the beginning of class. First, they signed the informed consent form and passed them down to the end of the row so the researchers could collect them. Then they completed their surveys and put them in the envelope. They were instructed to not put their name on their survey. After 15-20 minutes, the researchers collected the envelopes.

Similar to the American data, the researcher who collected data in South India first distributed the informed consent form. However, many of the students took a long time to fill out the form and many said that they were hesitant to sign a form. Many lost the motivation to fill out the survey and, therefore, did not participate. The researcher realized that in the particular contexts within South India there was hesitation about signing something that looked official. The rest of the surveys were administered to groups of students with a verbal administration of informed consent. The researcher emphasized that participation was voluntary and that there would be no negative consequences to not participating.

The North Indian data were collected from university students at a university in Uttar Pradesh. The students were from many departments, such as education, psychology, communications, and home science. The researcher met with the students in their classrooms to inform them about the purpose of the study, the confidentiality of their responses, and how to fill out the survey. Then the students signed the informed consent form and put it inside a covered box with a slit on top. Next the students completed the survey. The survey was prepared in both English and Hindi. The translation was checked by two Indians whose first language is Hindi but who also speak fluent English. After completing the survey, the students put the survey in a blank envelope, which was provided with the survey, and then placed the envelope inside the covered box.

The Chinese data were collected from university students in large Learning English as a Second Language classes. The students received an informed consent form, a survey, and an envelope towards the end of a class. For those who wished to take the survey, they signed the informed consent form and passed it down to the end of the row so the researchers could collect them. The students who did not wish to participate left early from the class. After handing in their informed consent form, the students completed their surveys. They were instructed not to put their name on their survey. After they completed the survey, the students sealed their survey in the envelope provided and then they put their envelope in a mail box at the center of the classroom rostrum. This box was then sent to the researcher.

RESULTS

The first hypothesis was supported. The Americans did seek help the most (31%), followed by the Indians (21%), and then the Chinese (12%) (χ2 (2) = 34.89, p < .001). In the Indian sample, 22% of the South Indians had sought help and 20% of the North Indians had sought help.

For the second hypothesis, it was difficult to make blanket statements about which country has the most positive attitudes about mental health care because of the different attitudes between Indians from South India and Indians from North India. The North

Indians had the most positive help seeking attitudes (M = 1.70, SD = 1.49), followed by the Americans (M = 1.68, SD = 1.56), then the Chinese (M = 1.60, SD = 1.51), with the South Indians having the lowest help seeking attitudes (M = 1.57, SD = 1.42). The differences were statistically significant (F (3, 1187) = 7.40, p < .001) with the North Indians and Americans having significantly more positive attitudes towards help seeking than the Chinese and South Indians.

These four groups did not follow the same pattern for the four dimensions of help seeking: recognizing the need for psychotherapeutic help, interpersonal openness, stigma tolerance, and confidence in mental health professionals. On recognizing the need for psychotherapeutic help (F (3, 1306) = 3.99, p < .01) and on interpersonal openness (F (3, 1298) = 22.11, p < .001), the Americans had the highest scores and the Indians, North and South, had the lowest scores. The descriptive statistics appear in Table 1.

On the other hand, on stigma tolerance (F (3, 1326) = 43.09, p < .001) and on confidence in mental health professionals (F (3, 1324) = 10.48, p < .001), the North Indians had the highest scores, followed by the Americans, the South Indians, and then the Chinese. The descriptive statistics appear in Table 2.

Our third hypothesis was supported. Country and experience with mental health care interacted in predicting attitudes towards seeking help from a mental health provider (F (3, 1137) = 9.87, p < .001). Specifically, of those who have sought help from a mental health professional, it was the Americans who demonstrated more positive attitudes towards seeking help from a mental health provider. In India and China, having experienced mental health care did not improve one’s attitudes towards seeking help. The interaction is depicted in Figure 1.

Recognition of Need for Psychotherapeutic Help

Country N M SD

USA 476 1.56a 0.63

North India 431 1.49 0.42

South India 201 1.42b 0.40

China 202 1.51 0.43

Interpersonal Openness

Country N M SD

USA 478 1.70a 0.57

North India 424 1.43b 0.49

South India 201 1.51b 0.50

China 199 1.52b 0.46

Note: A four-point Likert scale was used (0=disagree to 3=agree). Thus, an average score of 1.5 would be half way between slightly disagree and slightly agree.

Alphabetic subscripts designate which means are significantly different using a Tukey post hoc test with p < .05.

Table 1. Need for Help and Interpersonal Openness by Country

Table 2. Stigma Tolerance and Confidence in Mental health Practitioners by Country Stigma Tolerance

Country N M SD

USA 474 1.77b 0.64

North India 458 2.10a 0.64

South India 199 1.64c 0.63

China 199 1.63c 0.52

Confidence in Mental Health Practitioners

Country N M SD

USA 472 1.73b 0.56

North India 449 1.88a 0.46

South India 207 1.71b 0.45

China 200 1.69b 0.47

Note: A four-point Likert scale was used (0=disagree to 3=agree). Thus, an average score of 1.5 would be half way between slightly disagree and slightly agree.

Alphabetic subscripts designate which means are significantly different using a Tukey post hoc test with p < .05. Our fourth hypothesis was supported. Country and gender interacted in predicting who had sought help and who had not (F (3, 1251) = 4.87, p < .01). While American women were more likely to have sought help than American men, in India and China, the men were more likely to have sought out help compared to their female counterparts. This was especially true of the Chinese men and women. The results are depicted in Table 3.

Our fifth hypothesis was partially supported. Country and gender interacted in predicting attitudes towards seeking help from a mental health provider (F (3, 1103) = 11.84, p < .001). The American women did have significantly more positive attitudes towards help seeking than the American men. However, in India and China, our expectation that the men would have more positive attitudes than the women was not as clear cut. While the Chinese women were the least likely group to have sought out the help of a mental health provider, as shown in the third hypothesis, they held slightly more positive attitudes towards seeking help than the Chinese men. In North India the men had slightly more positive attitudes than the women, and in South India the men and women held similar attitudes. These differences are depicted in Figure 2.

1.95 1.90 1.85 1.80 1.75 1.70

1.65 1.60 1.55 1.50 Sought Help

Not Sought Help

Figure 1. Country by Mental Health Care Experiences Interaction in Predicting Overall Help Seeking Attitude.

Table 3. Country by Gender Interaction for Predicting Help Seeking Behavior

Country Percentage of Men Who Have Sought Help Percentage of Women Who Have Sought Help

USA 24% 36%

North India 21% 19%

South India 32% 19%

China 17% 08%

1.80 1.75 1.70 1.65 1.60 1.55 1.50

USA China North India South India Men Women

Figure 2. Country by Gender Interaction in Predicting Overall Help Seeking Attitude

DISCUSSION

Different Help Seeking Behaviors and Attitudes

across Countries: Our first hypothesis was supported. Participants from the United States did seek help the most, followed by the Indians, and then the Chinese. However, our second hypothesis was not fully supported. The North Indians and the Americans had more positive help seeking attitudes than the Chinese and the South Indians. Our first hypothesis was consistent with previous results in which Asians and people with Asian heritages were less likely to seek help from a mental health professional than Westerners (Bui & Takeuchi, 1992; Chen & Mak, 2008; Li & Browne, 2000; Zhang, et al., 1998). However, just because Asians do not seek out professional help does not mean they do not suffer from mental health issues (Li & Browne, 2000). It has been suggested that their reticence may be due to their cultural teachings that receiving help from outsiders is shameful (Cheung & Snowden, 1990; Kung, 2003; Mak & Chen, 2006; Leaf et al., 1986; Pearson, 1993; Sue, 1988; Takeuchi et al., 1993; Wang & Hernandez, 2020), not just for oneself but also for one’s family (Snider, 2003). For example, Lee et al., (2005), in a study of schizophrenia outpatients in Hong Kong, found that over 50% of the outpatients hid their mental illness from co-workers and friends to protect themselves. For example, almost 70% felt that promotion at work would be adversely affected and nearly 60% felt that their partner would leave him or her if their mental illness was made known. These fears are real as 44.5% of the outpatients who did disclose their mental illness were laid off as a result. In China, the individual who seeks help for a mental disorder must also consider the possible negative consequences of seeking help on his or her family. Yang and Pearson (2002) report that in Chinese society mental illness is often seen as a moral “defect” that is not only attached to the individual sufferer, but to his or her entire family. As Yang et al. put it:

Something crucial is missed when stigma is seen as affecting the individual only; in these examples from Chinese society, stigma is most grievously felt as its conditions reverberate across social networks, such that both the entire network is threatened or devalued and the individual sufferer is shunned, banned, or discriminated against within that network as a defensive response. The end result for individuals with mental illness and their families in China can be a kind of social death that threatens the very existence, value, and perpetuity of the family group (2007, p. 1529). In addition to the stigma attached to seeking help, the quality of care in China is also suspect. Mental health counseling is still relatively new in China, despite recent growth (Chang et al., 2005; Qian et al., 2012), and the quality of training is not very good (Gao et al., 2010; Wang & Hernandez, 2020). Thus, there are many good reasons why China trailed both India and the United States in help seeking attitudes and behavior in our study.

While the Indians and the Chinese in our study were less likely to actually seek out help from a mental

health provider compared to their American counterparts, the North Indians in our sample had high stigma tolerance and high confidence in mental health providers. On the other hand, they were also low in interpersonal openness and in recognizing a personal need for mental health services. It was the Americans who had consistently positive attitudes towards help seeking across all four dimensions. Nonetheless, we were somewhat puzzled by the North Indians’ positive attitudes. In recent years Indian schools and universities have been mandated to have a counselor on staff. This has increased access to mental health services and might explain why Indian students have more positive attitudes towards help seeking than Chinese students. However, anecdotally, some of the respondents in our study pointed out that barriers remain towards seeking help because of the lack of laws and ethical guidelines protecting client confidentiality. The regulation of the mental health fields in India appears to be a work in progress (Agrawal, 2015; Azar, 2009; Carson et al., 2009). What is also a work in progress is the idea of recontextualizing therapy, a Western enterprise, to suit the exigencies in the Indian cultural context. These explanations are cogent with our samples from India. In terms of the larger societal context, the role of stigma persists in being a barrier towards accessing mental health treatment.

Similar to the Chinese experience, stigma also plays a role in India regarding help-seeking attitudes and behaviors. However, this phenomenon has to be seen in the context of low numbers of available mental health practitioners, somatization of symptoms and clients’ particular idioms of distress (Kleinman & Kleinman, 1999). In studies by Mishra et al. (2011) and Naik et al. (2012), faith healers were more commonly accessed by patients and their caregivers. In the study of caregivers of clients with schizophrenia at New Delhi and Bilaspur, Naik et al. (2012) found that despite the relatively greater accessibility of psychiatrists in New Delhi and the greater socioeconomic status of the caregivers, faith healers were more frequently accessed by the caregivers at both centers. The authors say:

It seems that the traditional methods of help seeking which have been passed across generations may be deeply ingrained in people. These socioculturally sanctioned methods of help seeking may not show an immediate and drastic change with an increasing affluence, socioeconomic progress, or exposure to a globalized culture of a metropolitan city. (p. 343) Naik et al. (2012) also cite that the awareness of mental health resources, higher education or economic resources may not be enough to stem the tide of stigma associated with mental illness and seeking help. and while efforts must be made to reduce misconceptions and stigma, the individual’s perceptions and attitudes about illness must be taken into account even as mental health treatment is offered as another item on the menu of care available for treating mental illness. In fact, Bhugra (2004) highlights the fact that understanding patients’ idioms of distress is important as such cognitive schemas modify the experience of stigma. Another factor mitigating stigma is the somatization of psychiatric symptoms (see Raghuram & Weiss, 2004), thereby normalizing the illness process and perhaps accentuating visits to non-psychiatric physicians. The apparent generational gap between urban college students’ attitudes towards help seeking in our study and the clinical samples cited in the literature, may indicate a changing landscape in mental health consumption due to structural changes already underway and measures taken by the psychiatric community in India.

Some light is shed on these cross-cultural differences by comparing participants who have seen a mental health provider with those who have not. As our third hypothesis revealed, in the United States, those who had experience with mental health counseling had much more positive attitudes about mental health care than those without experience. This seems to indicate that the mental health experience in America is positive, for the most part. In India and China, on the other hand, first-hand experience with mental health care is not related to dramatically higher attitudes and in North India there is no difference in help seeking attitudes between those with experience and those without experience. Thus, it seems that the positive attitudes of the North Indians towards help seeking may be based more on theory than on practical experience.

Different Help Seeking Behaviors and Attitudes

across Gender: Our fourth hypothesis explored the interaction of gender and country in predicting who had actually sought help. As expected, the American women were more likely to seek help than the American men. One possible explanation for this difference is based on gender roles. The masculine ideal is not consistent with asking for help (Blazina et al., 1995; Mendoza & Cummings, 2001).

Also as expected, the Asian men were more likely to seek help than the Asian women, especially in China, as Table 3 depicts. This is consistent with Dasgupta and Warrier’s (1996) finding that Indian women may be reluctant to seek help to protect their family’s reputation. The percentage of women who sought help was over four times higher in America than in China, with India in between.

We had expected Asian men to seek help more than American men. As Galdas et al. (2007) found in their study of cardiac chest pain, men of Indian and Pakistani ancestry were more likely to seek help than men of United Kingdom ancestry. However, the percentage of men who sought help was roughly the same across all three countries.

Our fifth hypothesis explored the interaction of gender and country in predicting who had positive attitudes towards help seeking. The American women had more positive attitudes about help seeking than the American men. This is consistent with previous research (Atkinson et al., 1990; Cook, 1984; Fischer & Turner, 1970; Garland & Zigler, 1994; Kuhl et al., 1997). Again, the masculine gender role of not asking for help may explain the difference.

We had expected the opposite results from the Asian participants. While the American men in our study did have the lowest help seeking attitudes, the Chinese men and the South Indian men also had relatively low help seeking attitudes, as can be seen in Figure 2. It was only the North Indian men from New Delhi who evinced significantly higher help seeking attitudes. We had also expected the Asian women to have lower help seeking attitudes than the American women, and they did, but their help seeking attitudes were not lower than the Asian men, except for the North Indian women, as can be seen in Figure 2.

In America, the women had positive attitudes towards help seeking and they were comfortable seeking help. However, in China the women had more positive attitudes towards help seeking than the Chinese men, but they were less likely than the Chinese men to actually seek help. While the poor quality of mental health care in China combined with cultural messages of not seeking help from outsiders or bringing shame to the family may explain why men and women in China are reluctant to seek help, they do not explain why Chinese women are the least likely group to actually seek help. To gain additional insight into the Chinese women, we examined differences in help seeking attitudes for the women by country. The Chinese women were more likely to perceive a need for help and they were higher on interpersonal openness than the Indian women, but they were the lowest on stigma tolerance and confidence in mental health providers. Perhaps the costs and benefits of receiving mental health care are different for women in different countries. For example, it might be a liability for a Chinese woman to receive mental health care if she is then perceived by potential suitors as “damaged goods.” Thus, while a woman in China might feel the need for mental health care and feel that mental health care might be beneficial on a personal level, these benefits might be outweighed by potential social costs. As Yang et al. (2007, p. 1529) observed about seeking help for mental health in China, “Especially threatened are the material and social opportunities for the patient to marry, have children, and perpetuate the family structure.” In addition, societal discrimination against women may also play a role. Pearson (1995, p. 1159) notes that in China “women occupy fewer psychiatric hospital beds and generally receive fewer resources (e.g., health insurance) than men.” Not only can many Chinese women simply not afford good quality mental health care, but the various patriarchal barriers preclude women from accessing services, which are scant to begin with. More research is needed to uncover why Chinese women do not seek out the help they need compared to the men.

LIMITATIONS AND FUTURE RESEARCH

Regarding the internal validity of this study, the primary limitation was that survey research did not allow us to make any causal inferences. For example, we cannot say what caused the American women to be more likely to seek help and the Chinese women to be less likely to seek help. In future studies, it would be useful to examine the effectiveness of different interventions aimed at improving help seeking attitudes and/or behaviors. Another internal validity limitation of this study is the questionable cross-cultural validity of Fischer and Turner’s (1970) Attitudes toward Seeking Professional Psychological Help scale. Their scale was developed by US psychologists using US participants. Developing help seeking scales that fit different cultural contexts might be a worthy psychometric pursuit.

Regarding the external validity of this study, the primary limitation was that we used convenience

samples, not random samples. Thus, we cannot generalize our findings to the US, Indian, or Chinese populations. Replications of this study will need to collect data from more heterogeneous groups. For example, Dubow et al. (1990) found in a study of American adolescents that young people value selfreliance and are slow to share personal problems with others. If this study were replicated with an older sample, perhaps the help seeking attitudes and behaviors might be different.

Another question that future researchers might address is the gender of the mental health providers. Duffy et al. (2002) found that 68% of mental health providers in America are women (65% of psychiatrists, 49% of clinical psychologists, 79% of social workers, 92% of psychiatric nurses, 72% of counselors, 67% of marriage and family therapists, 66% of rehabilitation counselors, 70% of school psychologists, and 32% of pastoral counselors). In a study of American undergraduates, Snell et al. (1992) found that both men and women were more likely to disclose personal information to a female counselor. Gao et al. (2010) surveyed the professional training of 1,391 mental health practitioners across China (i.e., psychiatrists, psychiatric nurses, clinical psychologists, and the counselors working in industry, prisons, and schools). Sixty-two percent of the respondents were women and 38% were men. While they used a convenience sample, the results suggest that the profession appears to be mostly female, as it is in America. We were unable to discover the percentage breakdown of men and women in the mental health fields in India. While American men and women prefer disclosing personal information to a female counselor, we do not know if this is true in India or China. To examine this, it would be useful to ask people about their therapeutic preferences regarding therapist gender and approach.

PRACTICAL APPLICATIONS

Although one cannot generalize the findings to all Chinese women or all women of Chinese origin in the US, or even all Asian women, the data do suggest, in step with other research, that while Asians, in general, are hesitant to seek help, Chinese women may need to surmount more barriers to getting the help they need. Perhaps the difficulty might be a question of “cultural fit” between talk therapy, that is essentially a Western invention, and the requirement of restraint and emotional control among the Chinese. Perhaps the idea of individual therapy might be a more uncomfortable fit compared with family therapy that might help garner more help for the family without individuals having to give up their familiar and familial roles.

Perhaps the current pandemic might offer data regarding mental health usage. As global needs rise, countries have to individually and collectively respond to the crisis both at the height of the pandemic and in the duration thereafter. These data might offer ideas related to the mitigation of barriers to seeking mental health help and people’s help seeking behaviors.

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