The Impact of Prior Counseling on Predictors of College Counseling Center Use

The Impact of Prior Counseling on Predictors of College Counseling Center Use

Jeffrey H. Kahn and Mona N.Williams

Path analyses revealed that one’s tendency to conceal distressing information, social support, psychological distress, and attitudes toward seeking help predicted intended use of counseling services for college students who had and had not previously been in counseling. Prospective analyses revealed that attitudes toward seeking help predicted actual use of the campus counseling center. These findings have implications for campus outreach programs and in-session work with clients.

ounselors working in university settings have long been aware that only a minority of students who experience psychological distress C actually seek professional help (Clary & Fristad, 1987; Kushner &

Sher, 1989). The literature suggests that the students most likely to use counseling services are the ones who are experiencing some degree of psychological distress (Halgin, Weaver, Edell, & Spencer, 1987), lack adequate social support (Rickwood & Braithwaite, 1994), and hold positive attitudes toward seeking help (Clary & Fristad, 1987; Deane & Todd, 1996).

There are individual difference variables that represent barriers to seeking help. Individuals who tend to conceal distressing information from others may be reluctant to seek professional help because they anticipate the level of disclosure required in counseling to be aversive (Kelly & Achter, 1995). Among college students, a willingness to self-disclose to a counselor has been found in some studies to be positively associated with a willingness to actually go to a counselor (Hinson & Swanson, 1993). However, not all research has found this link between low concealment and help seeking. Using a self-report measure of concealment, Kelly and Achter (1995, Study 1) found that college students who tended to conceal personal information reported being more likely to seek counseling than students who did not regularly conceal information, and Cepeda-Benito and Short (1998) did not detect any difference in the intended likelihood of seeking counseling between those who tended to conceal personal information and those who did not.

The relationship between a student’s tendency to conceal distressing personal information and tendency to seek help is not necessarily straightfor- ward. Cramer (1999) suggested that concealment tendencies have an indi- rect effect on help seeking through social support, psychological distress, and attitudes toward seeking help. Specifically, individuals who typically conceal distressing information do not develop strong social support networks, and this

jemey H. Kohn ond Mono N. Willioms, Deportment of Psychology. Illinois Store University. Mono N. Willioms is now ot Chestnut Health Systems, Bloorningron, Illinois. The outhors wish to thonk john Achter ond Morgoret Nouto for their cornrnentr on on eorlier droft ofthis article. Correspondence concerning this orticle should be addressed tolefrey H. Kohn, Deportment ofPsychology, Cornpus Box 4620, Illinois Stote University, Normal, IL 6 I 790-4620 (ernoil: [email protected]).

I44 Journal of College Counseling . Fall 2003 . Volume 6

combination of concealment tendencies and low social support leads them to experience higher levels of distress. Higher levels of distress, in tiirn, lead to a greater likelihood of seeking counseling. Concealment tendencies also influence help seeking through one’s attitudes toward seeking help. In particular, individuals who tend to conceal personal information have more negative attitudes toward seeking help, and these negative attitudes inhibit help seeking. Thus, students who conceal distressing information are drawn to counseling because of their weak social support and high levels of distress, but they are also repelled by counseling because of their negative attihides toward seeking help. Cramer’s model fits Kelly and Achter’s (1995) and Cepeda-Benito and Short’s (1998) data, suggesting that the relationship between concealment tendencies and help seeking is too complex to examine without accounting for students’ levels of social support, psychological distress, and attitudes toward seeking help.

Cranier’s (1999) model may help practitioners understand processes that lead individuals to seek counseling, but two questions remain. First, students who have been in counseling at some time in the past would likely have different expectations about counseling than do students who have never been in counseling, and the process of deciding to seek professional help may therefore be based on different factors for these two groups of students. Similarly, students who have had prior counseling typically have more positive attitudes toward seeking help than students who have not had prior counseling (e.g., Komiya & Eells, 2001), and it is reasonable to suspect that these different attitudes may also alter the process of deciding to seek help. Cramer’s analyses did not distinguish between these two groups of students. I t is important to establish that Cramer’s model is appropriate for both groups of students so that appropriate interventions can be developed to help bring counseling services to all students who need them.

Second, Cramer’s ( 1 999) analyses predicted students’ intentions to use counseling for a series of hypothetical problems, but perhaps a more important criterion is their actual use of campus counseling services. The intention to seek help represents a stage in the help-seeking process that is distinct from actual help-seeking behavior (Fischer, Winer, & Abramowitz, 1983), leading to questions about whether the variables in Cranier’s model would apply to actual help seeking. A prospective research design is required to examine how concealment tendencies, social support, psychological distress, and attitudes toward seeking help, as assessed at one point in time, influence actual use of counseling services at some point in the future. This prospective test would add predictive validity to the variables in Cranier’s model.

Our research, therefore, had two purposes. First, we tested the fit of Cramer’s (1999) model of help seeking with students who had sought counseling in the past and with students who had not. IfCramer’s model could be applied equally well to both groups, then n o differences in the strength of the path coefficients would be detected. If, however, the processes of help seeking were to differ for these two groups of students, then the strength of the path coefficients would differ. The second purpose was to examine whether the predic-

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tors in the model could explain future indices of help seelung based on a subsample of respondents assessed 2 years after the initial data collection. Specifically, on the basis of counseling center records, we predicted whether or not students would use the campus counseling center during this 2-year period.

Method

Participants

A sample of 320 college students (270 women, 50 men) a t a large midwestern university participated in this study. The majority of students (84%) reported being Caucasian, and the sample included smaller percentages of African American (8%), Latino/Latina (2%), and Asian (2%) students, with 3% iden- tifying themselves as members of other ethnic groups. Of these students, 35% were freshmen, 23% were sophomores, 28% were juniors, 12% were seniors, and 2% were graduate students. The average age among the students was 19.97 years (SD = 4.00).

Follow-up data collection 2 years later involved 53 students (50 women, 3 men) from the initial sample. Most of these (89%) were students who had been freshmen and sophomores at the time of the initial data collection because these were the students who were available on campus 2 years later. The 53 students who participated in the follow-up did not differ on any of the study measures from those who did not participate, ps > .05.

Measures

Concealment tendencies. We used the 12-item Distress Disclosure Index (DDI; Kahn & Hessling, 2001) to measure students’ tendencies to conceal personally distressing information. A sample item is “I prefer not to talk about my problems.” Students responded to each statement on a 5-point scale ranging fiom 1 (itrondb disaBree) to 5 (i-tro&y aJree). In this study, the DDI was scored by sum- ming responses in such a way that higher scores reflect greater concealment. Test- retest reliability (2-month interval) of DDI scores has been reported as 30, and internal consistency has been reported to range from .92 to .95 (Kahn & Hessling, 2001); the coefficient alpha was -94 in this study. Confirmatory factor analyses of the DDI suggest it reflects a bipolar and unidimensional construct representing concealment versus disclosure tendencies (Kahn & Hessling, 2001).

Perceived social support. The 24-item Social Provisions Scale (SPS; Cutrona & Russell, 1987) was used to measure students’ perceptions of the adequacy of their support network. A sample item is “There are people I can depend on to help me if I really need it.” Students rated each item on a 4-point scale ranging from 1 (stron~ly disagree) to 4 (strongly agree), and responses were summed to yield a total social support score. Internal consistency of SPS scores has been reported as .92 (Cutrona & Russell, 1987); in the current study, the total score alpha was 39. Construct validity of the SPS total score has been supported by

I46 Journal of College Counseling . Fa11 2003 . Volume 6

correlations betwecn .35 and .46 with other self-report measures of social support (Cutrona & Russell, 1987).

Psychological distress. The Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977) was used to measure students’ levels of psychological distress. Although psychological distress is not assessed exclusively in terms of depressive symptoms, measures of depression are strongly correlated with other measures of psychological distress (Watson & Clark, 1984). The CES-D consists of 20 statements that assess symptoms experienced during the last 2 weeks. An example item is “In the past two weeks I was bothered by things that don’t usually bother me.” Each item was rated on a 4-point scale, with 1 = rarely or none of the time, 2 = some of the time, 3 = much of the time, and 4 = most of the tiwe. Possible total scores range from 20 to 80, with higher numbers indicating more depressive symptoms. Internal consistency has been estimated at .90 and above for nonpatient samples (Shaver & Brennan, 1991); internal consistency was also .90 in this study. Radloff reported a test-retest reliability coefficient of .67 over a 4-week interval. The CES-D correlates between .80 and .90 with other self- report depression tests among the general population (Shaver & Brennan, 1991).

Attitudes toward seeking help. Students’ attitudes toward seeking help were assessed with Fischer and Farina’s (1995) shortened form of the Attitudes Toward Seeking Professional Psychologicat Help Scale (ATSPPHS-S). The 10 items on this scale, designed to assess the positivity of one’s attitudes toward using psychological services, were rated on a 4-point scale ranging from 0 (disagree) to 3 (agree). Total scores can range from 0 to 30, with higher scores indicating more positive attitudes toward seeking help. A sample item is “If I believed I was having a mental breakdown, my first inclination would be to get professional attention.” Test-retest reliability ( 1-month interval) was reported as .80 (Fischer & Farina, 1995); the coefficient alpha was .82 in the current study. Validity was supported by a significant difference between the ATSPPHS-S scores of college students who had a serious emotional or personal problem and sought help for it and students with a comparable problem who did not seek help (Fischer 81 Farina, 1995).

Intentions t o seek counseling. Intentions to seek counseling were assessed by the Intentions of Seeking Counseling Inventory (ISCI; Cash, Begley, McCown, & Weise, 1975), as adapted by Robertson and Fitzgerald (1992). This form of rhe ISCI consists of 17 items to which respondents rate their “likelihood of seeking professional psychological help if they were experiencing the problem” on a 6-point scale ranging from 1 (very unlikely) to 6 (very likely). Total scores can range from 17 to 102; higher scores indicate a greater likelihood of seeking help. Sample issues include “choosing a major” and “relationship difficulties.” The coefficient alpha for the ISCI has been reported as 3 4 (Kelly & Achter, 1995); the coefficient alpha was .90 in the current study. Kelly and Achter reported a .36 correlation between ISCI and ATSPPHS scores.

Use of counseling services. Past use of counseling services was assessed through a single yes-no question: “In the past have you ever seen a counselor, psychologist,

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or psychiatrist for any personal problem?” Responses to this item were used to create the subsamples of students who had and who had not previously sought professional help. Use ofcampus counseling services was assessed among the 53 students in the follow-up study. These students signed a release-of-information form, allowing the university counseling center to indicate to the first author whether or not the student had been seen for an intake appointment for counseling at the counseling center during the 2-year period after the initial data collection.

Procedure

Initial data collection. The 320 students completed the aforementioned measures during a mass-testing session. This session was advertised to all students who were enrolled in a psychology course, and attendance was voluntary. After participants provided informed consent, questionnaires and computer- scored answer sheets were distributed. A supplemental consent form was provided on which participants could write their name and phone number if they wanted to be contacted for future research experiences. When students were finished with the questionnaire, they were read a debriefing statement. Extra- credit vouchers for use in the psychology class of their choice were provided.

Follow-up data collection. Starting 2 years after the initial data collection, we contacted as many students as possible from the initial sample, using the name and phone number provided at the initial testing session. Some students were reached through electronic mail. All students from the initial sample who were still on campus were contacted so that attrition would be minimized, but many students had graduated. Each student contacted was asked to participate in a follow-up study in exchange for $5 compensation and extra course credit. The follow-up participation consisted of completing the release of information form; all students in the follow-up sample agreed to sign this release. (The release of information form required a witness’s signature; therefore, we had been unable to have this form signed during the initial mass-testing session.)

Results

Correlations, means, and standard deviations for the variables are displayed in Table 1 . Students who had previously been in counseling had more positive attitudes toward seeking help, 4318) = 5.60, p < .001, and reported being more likely to seek help, 4318) = 4.35, p < .001, than students who had not previously sought counseling.

Path Analyses

We used a multiple-groups path analysis to compare the effectiveness of Cramer’s (1999) model for students who had sought counseling previous to the time of the initial data collection with the effectiveness for students who had not. In the equalpaths model, the six path coefficients ( i s . , beta weights) were constrained to

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TABLE 1

Correlations, Means, and Standard Deviations for All Groups of Students

Variable 1 2 3 4 5 M SD

Students Who Have Previously Sought Counseling (n = 114) 1. Concealment

tendencies - 27.98 2. Social support -.48* - 84.74 3. Psychological

4. Attitudes toward

5. Intentions to

distress .18 -.43 - 36.97

seeking help -.51* .34* -.19' - 20.80

seek counseling -.15 .I3 -.01 .28' - 55.70

Students Who Have Not Previously Sought Counseling ( n = 206) 1. Concealment

tendencies - 28.31 2. Social support -38' - 86.82 3. Psychological

distress .07 -.40* - 35.79 4. Attitudes toward

seeking help -.25* .12 .oo - 17.02 5. Intentions to

seek counseling -.lo -.06 .18* .42* - 46.84

11.64 10.44

10.97

5.91

18.1 6

11.17 8.10

9.46

5.71

17.05

All Students (N = 320)

tendencies - 28.19 11.32 86.08 9.05

36.21 10.02

18.37 6.05

seek counseling -.12* -.01 .1 l* .41 - 50.00 17.93

1. Concealment

2. Social support -.42" - 3. Psychological

4. Attitudes toward

5. Intentions to

distress .11* -.42' -

seeking help -.33' .17* -.06 -

be equal between the two groups. For example, the beta between concealment tendencies and social support was constrained to be the same in both groups of students. In the unequal-paths model, the six beta weights were allowed to differ between groups. If the beta weights are truly different between two groups, then the unequal-paths model will provide a better fit than the equal-paths model. For this study, the difference in fit between these two models was determined by the chi-square difference test. The comparative fit index (CFI), the root-mean-square error of approximation (RMSEA), and the standardized root-mean-square residual (SRMR) were reported as additional indices of model fit. Hu and Bentler (1999) suggested that values of .95 or higher for the CFI, .06 or lower for the RMSEA, and .08 or lower for the SRMR reflect good model fit.

The equal-paths model provided a good fit to the data based on the CFI and the RMSEA, but the SRMR was high, xz( 14) = 13.78, CFI = 1 .OO, RMSEA =

Joornal of College Counseling Fall 2003 Volume 6 I49

.OO (90% confidence interval = .OO to .08), SRMR = .l 1. The unequal-paths model provided a n unequivocally good fit to the data, ~ ~ ( 8 ) = 4.00, CFI =

1.00, RMSEA = .OO (90% confidence interval = .OO to .05), SRMR = .04. However, the difference in chi-square values for the two models was not statistically significant, Ax2(6) = 9 . 7 8 , ~ > .05. Thus, Cramer's (1999) model was found to apply equally well to both groups of students.

Figure 1 illustrates the path coefficients for the model based on the combined sample. All hypothesized paths were significant and in the predicted direction, except for the path from concealment tendencies to psychological distress. Con- cealment tendencies significantly predicted social support (Rz = .15) and, to a lesser extent, attitudes toward seeking help (R2 = .06); students who tended to conceal personally distressing information reported less social support and more negative attitudes toward seeking professional psychological help. Social support was a significant predictor ofpsychological distress (R2 = .18) in that students with stronger support networks were less likely to experience symptoms of depression. Finally, intentions to seek counseling were directly predicted by psychological distress and by attitudes toward seeking help ( R2 = ,21), with the latter variable being a particularly strong predictor. College students who had more positive attitudes toward seeking help, as well as students who reported experiencing some distress, reported being more likely to seek counseling.

Prospective Analyses

Our second goal was to examine whether concealment tendencies, social support, psychological distress, and attitudes toward seeking help would predict the use of campus counseling services over a 2-year period. CounseIing center records revealed that 8 (15%) of the 53 students went to the counseling center

Concealment Attitudes Tendencies -.3P * Toward

Seeklng Help

i

Intentions to I C0:::lna I I -

Social -.44' P8ychologicr I Distress ' p c .05 SUPpofl

-

FIGURE 1 Beta Weights Expressing Relationships Among Concealment Tendencies, Social Support, Psychological Distress, Attitudes

Toward Seeking Help, and Intentions to Seek Counseling Note. Data are shown for combined sample of students who had and who had not previously sought counseling.

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during the 2 years after the initial data collection. A logistic regression analysis revealed that the block of four predictors had a significant predictive effect on use of the counseling center, ~ ~ ( 4 ) = 10.28, p < .05. However, an examination of the individual predictors revealed that only attitudes toward seeking help significantly predicted use of the campus counseling center, B = 0.28, Wald = 5.64, p < .05. The odds ratio suggested that each 1-point increase on the ATSPPHS-S was associated with a 36% increase in the likelihood of using the counseling center. The odds ratios for concealnient tendencies ( 1.04), social support ( 1.04), and distress ( 1.09) were not statistically significant.

Discussion

This research supported Cramer’s (1999) model of help seeking among both college students who have previously been in counseling and college students who have not. This was the case even though students who had sought counseling in the past had more positive attitudes toward seeking help and were more likely to seek counseling if they were experiencing a problem. Thus, based on this research, our conclusions about the relationship between concealment tendencies and intentions to seek counseling can be generalized to both groups of students.

Specifically, individuals who tended to conceal personally distressing information had weaker social support networks, and these weaker networks in turn were associated with higher levels ofdistress and greater use of counseling services. This model, therefore, specifies the process by which students who conceal personally distressing information come to require counseling. However, concealment tendencies were also a barrier to help seeking because of their relationship with attitudes toward seeking help. Consistent with past research (Cepeda-Benito &Short, 1998; Kelly & Achter, 1995), a tendency to conceal personally distressing information was associated with less favorable attitudes toward seeking help.

Because students who typically conceal distressing information experience greater distress but hold more negative attitudes toward seeking help, they most likely experience ambivalence about seeking counseling. Specifically, these students may recognize that they need help but have negative attitudes about receiving the very help they need. One implication of this approach-avoidance conflict might be that to overcome their negative attitudes, students who conceal distressing information need to experience a greater degree of distress than students who disclose distressing information before making the decision to enter counseling. However, Kahn, Achter, and Shambaugh (2001) did not detect any difference in the symptomatology o r perceived stress of counseling center clients they studied who tended to disclose distress versus clients who concealed distress. Thus, attitudes toward seeking help is probably the more important predictor of entering counseling, and our prospective analysis cer- tainly confirmed this. Even a student who tends to conceal personally distressing information may decide to seek counseling if he or she holds favorable attitudes toward seeking help. This case may be illustrated by a first-semester student who has positive attitudes toward seeking help but does not know

Journal of College Counseling . Fall 2003 Volume 6 15 I

anyone on campus to talk to; for such a person, counseling may be very ap- pealing because it would provide a much-needed opportunity for disclosure.

Limitations and Suggestions for Future Research

Our conclusions about the importance of these variables i n the decision to seek counseling must be considered in light of two limitations. First, the composition of the sample was predominantly Caucasian and female. Because there are known gender and ethnic differences in help seeking (e.g., Robertson & Fitzgerald, 1992; Yo0 & Skovholt, 2001), this research may not generalize to all college students. Additional research with other populations would be valuable.

Second, our conclusions are based on the presupposition that the model tested in this research was correctly specified. Although Cramer (1999) based his model on a theoretical and empirical foundation, it is possible that the hypothesized direction of influence is incorrect. For example, the model specifies that concealment tendencies “cause” one to experience less social support, but might a lack of a support network, instead, necessarily lead one to keep information to oneself? Experimental research and time-series designs would help to untangle the direction of causation among these variables.

Third, we were not able to determine whether students in the follow-up sample sought counseling at an agency other than the university counseling center. Our release-of-information form gave the university counseling center permission to release client information; it did not give other agencies that permission. There- fore, our results are limited to whether or not students sought help from the university counseling center, not whether or not students sought professional help in general.

Implications for Practice

Preventative outreach programs are recommended to increase the likelihood that students will seek counseling when they need it. These programs, led by counselors, peer counselors, or resident assistants, may occur in residence halls. Alternatively, outreach programs may be held in freshman orientation courses required by many colleges and universities. Programs that reach out to all students may help students who experience early signs of distress to use the counseling center rather than waiting until more extensive services are needed.

Counseling center use may be most effectively increased if attitudes toward seeking help are targeted. One specific way attitudes may be changed is by promoting personal involvement through an analytical argument (Petty & Cacioppo, 1981). For example, an outreach program could encourage students to list aloud the benefits of using counseling services when in need. The program leader can then add to the list and challenge students to support their ideas. This rational, high-involvement method will help students form their own opinions about the benefits of counseling and possibly change negative attitudes, ideally resulting in a long-lasting attitude change that can influence

I52 Journal of College Counseling Fall 2003 ’ Volume 6

behavior. Moreover, because we did not detect any difference in how the model fit for students who had and who had not experienced prior counseling, this ty-pe of intervention should apply equally well to both groups of students. This research, therefore, suggests that practitioners need not be concerned with students' prior counseling experiences when delivering preventative interventions; thus, services can be delivered more economically.

If the goal of an outreach program is to minimize the need for counseling, then our results suggest that the program should focus on increasing social support. As found in prior research (e.g., Cutrona & Russell, 1987), students in our sample who perceived more social support reported being less distressed. We therefore recommend interventions that provide students with practice ask- ing for assistance from peers. In such an outreach program, students could ask each other for help with small, trivial problems, and the program leader could facilitate positive responses to these requests. For some students, it may be necessary for program leaders to model ways in which one can ask for support. Ideally, students will then start to believe that help is available when needed, and they will be able to seek social support for more involved personal problems in the future. Theoretically, such a progression would reduce their level of distress.

These findings may also help counselors understand more about the motivation of their clients who do seek counseling. The client who is reticent to discuss problems in counseling may be exhibiting concealment behaviors that are typical for that client outside of counseling. In such a case, it is perhaps important for the clinician to understand that the client who conceals distressing information and who does seek counseling most likely has unusually positive attitudes toward seeking help. These positive attitudes should be viewed as a client strength. A useful goal for such a client may be to build o n this positive attitude toward seeking help by encouraging the individual to disclose problems to informal sources of support, such as family and friends. Moreover, when working with a client who conceals distressing information, clinicians may find imparting the ideas represented in this model to be of psychoeducational value. If the client understands how concealing personally distressing information may erode a support network, then that client may find the motivation to start disclosing information to others, ideally paving the road toward well-being.

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Documents

The Impact of Prior Counseling on Predictors of College Counseling Center Use