The relationship between traditionality-modernity and help-seeking

This section describes the five main rationales for hypothesizing this relationship.

These rationales are based on the culture-bound values in counseling, the relationship between traditionality and indigenous healing, the relationship between societal modernization and the growth of counseling, the revised psychological convergence hypothesis, and finally the six hypothesized mediating variables.

2.3.1 Rationale one: Traditionality-modernity and culture-bound values in counseling

As discussed earlier in this chapter, the culture-bound values of counseling appear to be a key barrier to counseling service utilization in people from diverse cultural backgrounds (e.g. Sue & Sue, 2012). These culture-bound values include

individualism, mind-body dualism, emotional expressiveness, self-disclosure, and direct, assertive communication. Examining Table 2-2 reveals that some categories of Chinese modernity seem to correspond to these culture-bound values, while some categories of Chinese traditionality seem to be in opposition to these values. Modernity includes individualistic orientation, independent orientation, and self-expressive orientation, which correspond with the culture-bound values of individualism, emotional expressiveness, and self-disclosure. Traditionality includes opposing characteristics such as collectivistic orientation, familistic orientation, and self-suppressive orientation.

From this evidence, we hypothesize an inverse relationship between traditionality and

Figure 2-1

Representation of the rationales for hypothesizing relationships between traditionality-modernity and help-seeking attitudes.

Note. Solid lines indicate a direct relationship, and dashed line indicates an inverse relationship. a = rationale one; b = rationale two, c = rationale three, d = rationale four, e

= rationale five.

counseling attitudes and a direct relationship between modernity and counseling attitudes.

2.3.2 Rationale two: Traditionality and indigenous healing

We further hypothesize a direct relationship between traditionality and attitudes towards indigenous healing. Earlier in this chapter, we discussed theoretical

perspectives which argue that the popularity and effectiveness of indigenous healing is largely due to the degree to which it is integrated into local cultural worlds (e.g.

Kleinman, 1980), suggesting that there may be a relationship between an individual’s level of adherence to traditional cultural values and psychological orientation towards indigenous healing services. Yang (2005) proposed a conceptual structure to understand how characteristics of individual traditionality arise from, and exert influence on, traditional Chinese cultural characteristics. Yang hypothesized a process in which great

a, e

a, c, d, e Traditionality

Modernity

Indigenous healing attitudes

Counseling attitudes b

core philosophical ideas proposed and advocated for by prominent philosophers and scholars. Little traditions are the diverse ways in which great traditions appear in the cultural traditions and daily life of the people, such as in art, literature, rituals, social norms, values, and belief systems. Individual members of the society adopt certain psychological and behavioral characteristics (essentially, individual traditionality) appropriate for adjusting to the little traditions of the society. The ideas and worldviews on which Taiwanese indigenous healing systems are based (e.g., Taiwanese folk

religion, traditional Chinese philosophies, etc.) correspond with great traditions, while the specific healing interventions and beliefs correspond with little traditions. Positive attitudes towards indigenous healing may be a characteristic of traditionality that is connected with the relevant little traditions (including beliefs and values) and great traditions (including worldviews).

2.3.3 Rationale three: The relationship between societal modernization and the growth of counseling

Taiwan experienced rapid economic development from approximately the 1960s to the 1990s, earning a place among the four “Asian tiger” economies (Page, 1994).

Taiwan’s decades-long martial law was lifted in 1987, resulting in a democratic government and freedoms of press and speech (Ko, 2007). The growth of Taiwan’s medical care system in recent decades (see Table 2-3) and the implementation of the National Health Insurance system in 1995 (Chang et al., 2008) may represent the modernization of the health care system in Taiwan. Thus, the growth of the field of counseling in Taiwan over the last two decades or so (Chen, 2003) has occurred in the context of rapid societal modernization in the domains of economy, society, politics, and medical care.

Table 2-3

Practicing licensed medical personnel in Taiwan.

1971 1981 1991 2001 2012

Western medicine doctors 6,375 11,957 21,115 30,562 40,938

TCM doctors 1,466 1,682 2,514 3,979 5,740

Counseling psychologists - - - - 1,000

Clinical psychologists - - - - 832

Total licensed medical

personnel 18,227 45,696 96,921 165,855 258,283

Note. 2005 was the first year Taiwan had licensed psychologists. Adapted from Executive Yuan, R.O.C. (2012b) and Ministry of Health and Welfare, R.O.C. (2012).

It also appears that some of the specific characteristics of societal modernization described by Yang (2005) are connected to the certain core characteristics of the

counseling profession. The legal establishment of counseling reflects effective operation of the legal system, graduate training, licensure requirements, and ethical codes for counselors reflects high formal education and occupational specialization, and

counselors’ reliance on non-religious healing methods reflects secularization of religion.

The correspondence between these core features of the counseling profession and certain aspects of Taiwan’s societal modernization suggests that they may be related in some way.

We further hypothesize that a similar relationship exists on the individual level, in which higher individual modernity results in more positive counseling attitudes. As previously mentioned, Yang (2005) proposed that societal modernization, individual modernization, and individual modernity are three distinct yet interrelated levels of a dynamic change process. In the current context, we propose that increasing availability of counseling as a help-seeking resource is a specific aspect of Taiwan’s societal modernization, increasing awareness of counseling is a specific aspect of individual modernization, and more positive counseling attitudes is a specific characteristic of individual modernity.

Research on the changing psychological characteristics of Taiwanese people during the process of modernization (Yang 1986, 1996) supports this hypothesis.

Taiwanese have an increasing number of psychological characteristics that are consistent with the culture-bound values of counseling, including increasing need for autonomy and change, decreasing need for endurance, increasing emphasis on present and future time perspectives, individualism, internal control, and decreasing emphasis on perseverance and fatalistic-helpless attitudes. Similar findings were reported by Allen et al. (2007), who found that between 1982 and 2002, Taiwanese university students’ values became more egalitarian and less hierarchical.

2.3.4 Rationale four: Revised psychological convergence hypothesis

Yang (1988, 1994) developed the revised psychological convergence hypothesis to explain which types of psychological characteristics tend to change and which tend to persist in the process of societal modernization. This hypothesis expects that individuals in all modernizing societies are becoming more similar in the degree to which they possess specific-functional psychological characteristics. This is because modernizing societies are increasing in the degree to which they resemble industrialized societies, so individuals in these societies develop similar psychological characteristics (such as attitudes, beliefs, values, and behaviors) of the specific-functional type in order to adjust to life in these societies.

The set of psychological characteristics (including attitudes, beliefs, and

behaviors) related to seeking help from a counselor can be understood as of the specific-functional type. They are specific-functional in that psychological help aims to help individuals reduce psychological distress and function more effectively in their social roles. They are also specific: in many highly industrialized societies, counseling is the main source

of psychological help, so we can expect that most individuals in these societies share a coherent set of psychological characteristics that includes beliefs and attitudes about counseling and relevant behaviors in times of need for psychological help. According to the revised hypothesis of psychological convergence, characteristics of the specific-functional type will converge between societies during the process of societal modernization. Members of mainstream cultural groups in highly industrialized societies such as those in Europe and North America tend to use counseling frequently and have positive perceptions of professional mental health services (e.g., Sue & Sue, 2012), so in the process of Taiwan’s societal modernization, individuals should converge towards the higher degree of possessing this set of characteristics such as in more highly industrialized societies. Therefore, we expect to find a relationship between modernity and counseling attitudes.

2.3.5 Rationale five: Hypothesized mediating variables

Finally, we expect that the six variables described below (social stigma, self-stigma, anticipated utility, anticipated risk, self-disclosure, and subjective norm) mediate the relationship between traditionality-modernity and counseling attitudes.

Previous research has found these six variables to be related to counseling attitudes and/or counseling utilization. To date, there has been no research investigating the relationship between modernity and these variables, there are various theoretical and conceptual rationales for expecting these relationships, which will be described below.

We expect that modernity is related to counseling attitudes because of the partial or full mediating effects of one or more of these variables. Due to the exploratory nature of this study, we have insufficient basis for formulating a more precise hypothesis. However, in a meta-analysis of studies investigating the psychological variables related to

American university students’ counseling attitudes, Nam et al. (2013) found significant correlations between counseling attitudes and five of our hypothesized mediating variables, including stigma (r = -.63), anticipated utility (weighted r =.52), self-disclosure (r = .34), anticipated risk (r = -.26), social stigma (r = -.24). From these results, it seems likely that the variables with stronger correlations may be more likely to have significant mediating effects on the relationships between traditionality-modernity and counseling attitudes.

Social stigma and self-stigma as mediating variables.

Two distinct types of stigma are relevant to the process of help-seeking:

stigmatization of having a mental illness, and stigmatization of seeking psychological help (Tucker et al., 2013). This study will focus on the latter form, because the stigma of seeking help is the focus of the most frequently-used research instruments on stigma in counseling research. Additionally, Tucker et al. found that self-stigma of seeking help, but not self-stigma of having mental illness, independently predicted help-seeking attitudes and intentions to seek help.

The stigma related to seeking psychological help includes social stigma and self-stigma (Corrigan, 2004; Corrigan & Kleinlein, 2005). Social self-stigma refers to the

perception of society’s negative evaluation of those suffering seeking psychological help, while self-stigma refers to an individual’s self-labeling as “someone who seeks help” and the subsequent internalization of negative attitudes and stereotypes towards themselves (Corrigan; Corrigan & Watson, 2002). Social and self-stigma are associated with a range of negative outcomes both in- and outside the context of psychological treatment (see Vogel, Bitman, Hammer, & Wade, 2013) such as impaired recognition of the need for help, seeking informal instead of professional help (Alvidrez, Snowden, &

Kaiser, 2008; Cooper, Corrigan, & Watson, 2003), and early termination of treatment (Sirey et al., 2001).

Past research has found that social stigma is related to negative counseling attitudes and reduced willingness and intentions to see a counselor (Barney, Griffiths, Jorm & Christiansen, 2006; Kessler et al., 2001; Komiya et al., 2000; Shea & Yeh, 2008;

Vogel, Wester, Wei, & Boysen, 2005). However, Golberstein, Gollust, and Eisenberg (2009) found no significant relationship between social stigma and subsequent use of counseling or psychopharmaceuticals in a two-year follow up period. Furthermore, other studies have found no relationship between social stigma and actual help-seeking in samples of Australian community members (Jorm et al., 2000) and US college students (Eisenberg, Down, Golberstein, & Zivin, 2009).

More consistent finding exist for self-stigma, which has been linked to negative attitudes and intentions towards counseling (Conner et al. 2010; Tucker et al., 2013), lower likelihood of help-seeking (Eisenberg et al., 2009), and reduced likelihood of returning for subsequent counseling after an initial visit (Wade, Post, Cornish, Vogel, &

Tucker, 2011). In a sample of Taiwanese university students, Wang (2010) found that both self-stigma of help seeking (r = -.47) was more strongly negatively correlated with counseling attitudes than social stigma of help seeking was (r = -.27).

We expect that modernity is associated with reduced social stigma and self-stigma, and traditionality is associated with stronger social stigma and self-stigma. Past research has found that Asian-Americans (Eisenberg, Downs, Golberstein, and Zivin, 2009) and Chinese (Fung, Tsang, Corrigan, Lam, & Cheung, 2007) have relatively high self-stigma. Among Asian-Americans, higher adherence to Asian values is related to higher stigma (Miville & Constantine, 2007; Shea & Yeh, 2008). The relatively strong help-seeking stigma found in Asian and Chinese cultural groups (e.g., Mellor, Carne,

Shen, McCabe, & Wang, 2012) has been ascribed to cultural elements such as

supernatural etiological beliefs, collectivism, cultural norms of inhibition of emotional expression, tendency to somaticize psychological distress, and desire to avoid shame and maintain face (Kleinman & Kleinman, 1993; Rao, Feinglass, & Corrigan, 2007;

Yang et al., 2007; Zane & Yeh, 2002). Therefore, higher traditionality may be associated with stronger stigma. However, it’s also possible that the collectivistic orientation associated with traditionality in Taiwan may lead to weaker self-stigma, because of lessened emphasis on the individual self (Angermeyer & Dietrich, 2006;

Vogel et al., 2013), while the stronger individualistic orientation associated with modernity may be associated with higher self-stigma.

Individualistic orientation, self orientation, independent orientations, and low integration with relatives are key traits of Chinese individual modernity (Yang et al., 1991; Yang, 1988). Lower integration with others and a stronger emphasis on the self may lead to a reduced perception or less concern about society’s stigmatizing attitudes towards help-seeking, and result in reduced internalizations of social stigma. On the other hand, Chinese individual traditionality is characterized by collectivistic orientation, familialistic orientation, other orientation, and relationship orientations. Closer

integration with one’s family and other social groups may result in greater concern about those people’s stigmatizing attitudes, and a stronger propensity to internalize these attitudes as self-stigma.

Anticipated utility and anticipated risk as mediating variables.

Anticipated risk and utility refer to individuals’ expectations of the potential personal benefits and risks associated with disclosing personal information to a counselor (Vogel & Wester, 2003). Anticipated risk is associated with more negative counseling attitudes (r = -.24 to -.30) and reduced intentions to seek counseling (r = -.10

to -.25). In contrast, anticipated utility is associated with more positive counseling

attitudes (r = .39 to .57) and greater intentions to seek counseling (r = .27 to .47; Shaffer, Vogel, & Wei, 2006; Vogel et al., 2005; Vogel & Wester). Similar results were found in a sample of Taiwanese university students, with anticipated utility positively correlated with counseling attitudes (r = .49) and anticipated risk negatively correlated with counseling attitudes (r = -.25; Wang, 2010).

We expect that traditionality will be associated with higher anticipated risk and lower anticipated utility. Familialistic orientation may lead to stronger possible feelings of shame from seeking help, due to the traditional Chinese emphasis on not bringing shame to one’s family. Past orientation, other orientation, and self-suppressive

orientation may result in lower tendency to consider the future benefits of counseling to oneself. The Filial piety and ancestor worship factor of MS-CIT includes the desire to avoid harming one’s parents’ reputations and causing them to worry (possible outcomes of seeking help), so it should show a direct relationship with anticipated risk. The Conservatism and endurance factor of MS-CIT, which includes the attitude of accepting and not working to change difficulties, should show the strongest inverse relationship with anticipated utility. However, the Submission to authority factor of MS-CIT may show an inverse relationship with anticipated utility, since a higher degree of respect for and trust in counselors may lead to stronger beliefs that counseling is helpful.

We also hypothesize that modernity will be associated with higher anticipated utility and lower anticipated risk. A number of psychological characteristics of

individual modernity (Yang, 1988) may be associated with more positive expectations of counseling. Sense of personal efficacy may result in the expectation that one’s participation in the counseling process would bring about desired changes, and cognitive and behavioral flexibility may be related to the ability to imagine and enact

counseling-related changes. The Optimism and assertiveness factor of MS-CIM may have a direct relationship with anticipated utility. An optimistic attitude about the possibility of improving one’s life could be closely related to an expectation that counseling has the ability to assist in that improvement.

Self-disclosure as a mediating variable.

Self-disclosure refers to the degree to which an individual tends to conceal or reveal personal problems and psychological distress (Kahn & Hessling, 2001). Higher tendencies to self-disclose are associated with more positive counseling attitudes, with correlations ranging from .30 to .42 in American university students (Pederson & Vogel, 2007; Vogel & Wester, 2003; Vogel et al., 2005), while self-concealment is a barrier to help-seeking (Benito & Short, 1998; Masuda, Anderson, & Edmonds, 2012).

Modernity may be associated with stronger self-disclosure tendencies, and traditionality with weaker self-disclosure tendencies. Taiwanese are socialized not to disclose personal feelings, especially negative ones, since doing so risks bringing shame to oneself or one’s family and harming important relationships (Kleinman, 1980). An emphasis on relationships (guanxi) is a core feature of Taiwanese and other Chinese cultures (Fei, 1992). An individuals’ network of guanxi extends from closer

relationships such as family to more distant relationship such as co-workers, and is important for individuals’ assess to social capital and other resources (Yang &

Kleinman, 2008). Self-disclosure of personal problems or psychological distress may threaten this key social system. Chen, Lai, and Yang (2013) found that for ethnic Chinese, decisions to conceal mental illness were motivated by concerns over losing face, burdening others, harming relationships, and negative social consequences, while decisions to reveal mental illness were motivated by expectations of supportive

responses from important others.

Similarly, Yang’s (2003) conceptual categories of Chinese traditionality includes Self-suppressive orientation, which may correspond to self-concealment of problems and distress, and Relationship orientation, which may correspond to greater concern for the possible implications of self-disclosure of distress on one’s relationships.

In contrast, modernity includes Self-expressive orientation and Individualistic orientation.

Subjective norm as a mediating variable.

Subjective norm has been defined as “perceived social pressure from important others to perform or not perform a behavior” (Hammer & Vogel, 2013; p. 83). More specifically, subjective norm for help-seeking refers to an individual’s perception that important others (e.g., friends and family) view help-seeking for psychological distress as an acceptable behavior. Subjective norm has been found to be correlated with counseling attitudes (r = .31 to .42, Kim & Park, 2009; Vogel et al., 2005), willingness to see a counselor (r = .38, Kim & Park) and intention to seek counseling (Bayer &

Peay, 1997). In a sample of adult Hong Kong Chinese, Mo and Mak (2009) found that subjective norm is correlated with counseling attitudes (r = .56) and intention to seek counseling (r = .58).

Modernity may be related to a stronger subjective norm for help-seeking, and tradtionality to a weaker subjective norm. Subjective norm for help-seeking varies as a function of cultural background (e.g.,Ying & Miller, 1992). Individuals’ involvements in their social worlds influence the degree to which they manifest the culture

characteristics of those social worlds (Kleinman, 1980). Therefore, high-modernity individuals may tend to exist in high-modernity social contexts, and high-traditionality individuals tend to exist in high-traditionality social contexts. In this study, we

hypothesize that traditionality is associated with more negative counseling attitudes and

modernity with more positive attitudes. Therefore, high-modernity individuals may perceive their friends and family members’ positive counseling attitudes and develop a strong subjective norm for counseling, while high-traditionality individual may perceive their important others’ more negative counseling attitudes and have a weak subjective norm for counseling.

2.3.6 Summary

This section described the five rationales for hypothesizing a relationship between traditionality-modernity and help-seeking attitudes. These rationales are derived from past empirical findings and theoretical concepts related to modernity. There appears to be sufficient evidence to expect that traditionality-modernity and help-seeking attitudes are related.