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Article 58

Help-Seeking Attitudes and Behaviors of English-Speaking Caribbean College Students

A Review of the Literature and Implications for Clinical Practice

Wendy-lou L. Greenidge

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English-speaking Caribbeans continue to migrate to the United States with increasing frequency, with many migrating to pursue academic programs (Hernandez, 2012; Thomas, 2012). International student populations in the United States present with unique challenges, incompatible cultures, and a general distrust of professional mental health services (Baysden, 2002; Greenidge & Daire, 2010; Pottinger & Williams-Brown, 2006). Although there has been much emphasis on many minority cultures (Kim & Omizo, 2003; Lau & Takeuchi, 2001; Leong & Lau, 2001), the Caribbean population has only received scant attention in the counseling literature. Increasing the amount of information available to practitioners can only serve to further enhance the ongoing process of multicultural competence. This article will present key research on Caribbean mental health in an effort to establish the framework for conceptualizing our work with Caribbean college students. Clinical recommendations will also be proffered.

Although international students may be in need of professional counseling, most do not seek out these services due to the stigma attached to mental illness in their home countries (Edge & Rogers, 2005; Peluso & Blay, 2004). Apart from the common challenges that all students face, international students also grapple with issues such as a loss of support network, unfamiliarity, financial hardships due to visa restrictions, competing cultures, and differing educational systems. Unsuccessful resolution of these can potentially lead to depression, anxiety, an increase in the use and abuse of substances, and academic failure, to name a few (Baysden, 2002).

Professional counselors are charged with the responsibility of being multiculturally competent. Obtaining and maintaining multicultural competence is a continual pursuit that requires constant work, mindfulness, and development (Shallcross, 2013). However, the dearth of literature and outdated information on the Caribbean culture makes it difficult for one to be knowledgeable and skilled in this area. Further, whereas other cultures are often emphasized in graduate programs, the Caribbean culture, despite the increasing population in the United States, is not included in graduate courses.

Much of the research on Caribbean mental health focuses on Caribbean populations in the United Kingdom. The implications of this lack of information about the Caribbean population in the United States are dire. English-speaking Caribbeans are often incorrectly labeled as African Americans and, as a result, are provided with services that are culturally incompatible (Waters, 2004; Winer, 2006). This article seeks to bridge this gap in the literature by providing professional counselors with an overview of the Caribbean culture as well as cultural aspects that affect help-seeking attitudes and behaviors. The Caribbean is by no means a homogenous group as each island presents with racial and cultural differences. However, there are several factors that are common among the islands and assist in conceptualizing our initial work with this population.

The English-Speaking Caribbean

The Caribbean community consists of several countries that stretch from the Bahamas in the north to the coast of South America, and lies in the Caribbean Sea (Hall, 2001; Waters, 2004). The terms West Indies and Caribbean are commonly used interchangeably; however, the West Indies refers to the archipelago of islands between North and South America and the Caribbean represents the region where these islands are located. The West Indies consists of the Greater Antilles in the north, the Lesser Antilles to the east and the Bahamas in the northeast (Hall, Lopez & Bansal, 2001; Waters, 2004).

The Greater Antilles consists of the larger islands such as Hispaniola (Haiti and the Dominican Republic), Cuba, Jamaica, and Puerto Rico. The Lesser Antilles contains the smaller islands to the east of the Caribbean Sea and includes Saint Lucia, Barbados, Trinidad and Tobago, Grenada, Saint Vincent, Saint Kitts and Nevis, Antigua, Guadeloupe, Dominica, and Martinique. This article focuses on the English-Speaking Caribbean islands (Hall, Lopez, & Bansal, 2001; Waters, 2004).

Waters (2004) suggested that although the Caribbean islands vary in size, geography, demographics, and histories, they all enjoy three commonalities: legacies of European colonialism, legacies of slavery, and the domination of the island economies and cultures more recently by the United States. These commonalities shape the West Indian culture and identity that immigrants to the United States share (Waters, 2004). Although the Caribbean represents very diverse cultures, with each island sharing unique cultural aspects, there are still many broad commonalities among islands. For instance, Caribbean cultures espouse collectivist values as opposed to individualistic ones (Henry, 1994). There is also a very strong emphasis on religion and spirituality, a sense of community, strong family bonds, and a high value placed on education (Waters, 2004). It is not surprising then that many Caribbeans migrate to other countries for educational and occupational advancement.

Researchers have long argued that there is a strong stigma attached to mental illness and mental health services in the Caribbean (Edge & Rogers, 2005; Marwaha & Livingston, 2002; Peluso & Blay, 2004). People who seek mental health services are often shunned and viewed as weak and lacking the ability to care for themselves. Self- disclosing to others outside the family is also perceived as a form of betrayal and is frowned upon by many Caribbean societies (Marwaha & Livingston, 2002). It is more acceptable to seek professional help from clergymen, as there is less of a stigma attached to religious institutions (Greenidge & Daire, 2010).

This cultural stereotyping of mental health services contributes to the aversive experiences and subsequent avoidance of mental health services by Caribbeans (Callan & Littlewood, 1998; Campbell, Cornish, & McLean, 2004). A general mistrust of mental health services has also been associated with their reluctance to seek professional counseling (Campbell & McLean, 2002). These cultural values, which are transmitted from one generation to the other through socialization practices, help shape the attitudes of Caribbean people towards seeking professional counseling.

Help-Seeking Attitudes and Behaviors of Caribbeans

The Caribbean culture places great emphasis on emotional control, and the expression of emotions is often an undesirable personality trait where individuals are perceived as being weak. When faced with problems, many are socialized to “be strong,” “to pray about it,” and to “move on instead of dwelling on it.” Resiliency, self-reliance and self-silencing are strongly valued in Caribbean cultures (Ali & Toner, 2001; Schreiber, Stern, & Wilson, 2000). Women, in particular, silence certain thoughts and beliefs leading to self-devaluation and the onset of depressive symptoms (Ali & Toner, 2001; Penza, Reiss, & Scott, 1997). Equally important is the notion that unmasking personal, private, and family matters to strangers is frowned upon in Caribbean cultures. These values all conflict with the core concept of professional counseling where expression of emotions is encouraged and are usually expressed to strangers (Lin, 2002).

Fatimilehin and Coleman (1999) conducted focus groups with 24 Afro-Caribbean parents in the United Kingdom. The researchers sought to unveil the parents’ perceptions about and preferences for mental health services. These researchers discovered that, generally, participants knew very little about mental health services and about the distinctions between psychiatry and psychology. It was evident that participants were also extremely distrustful of mental health services, with confidentiality of records being their number one concern. Several fears associated with receiving mental health treatment emerged, including having their children taken away by “authorities,” becoming institutionalized, and losing control over their personal affairs (Fatimilehin & Coleman, 1999). There was also a strong stigma attached to receiving mental health services, and participants feared being labeled negatively. Focus group discussions also revealed that participants preferred to keep personal and family problems within the family. To cope with the challenges that accompanied migration, many turned to friends and family members for support rather than seek professional counseling.

Halcon, Blum, Beuhring, Campbell-Forrester, and Venema (2003) examined adolescent health in 15,695 students representing 19 Caribbean countries. These students were between 10 and 18 years old with 78.5% being of African heritage. The results of this study revealed that one in six described themselves as terribly sad, angry, or irritable. Half of participants reported feelings of depression, and one in six felt isolated and uncared for by friends; 15.9% of participants had been physically abused, and 9.9% sexually abused. One in five males had carried weapons to school within the last 30 days and one in ten males had been knocked unconscious in a fight and/or had been stabbed or shot. One in five reported having homicidal ideation, and 12.1% had attempted suicide; 14.8% of respondents in the English-speaking Caribbean did not believe they will live to be 25 years old. Consistent with other research on ethnic minorities, only 11.5% of respondents had received mental health services, whilst 36.2% sought medical services (Halcon et al., 2003).

The British Fourth National Survey of Ethnic Minorities revealed that rates of depression were significantly higher for Caribbeans than for Whites (Nazroo, 1998). Alarmingly, none of those who were clinically depressed were receiving anti-depressants or mental health services to manage their depressive symptoms (Nazroo, 1998). The annual prevalence of psychosis for Caribbeans in the United Kingdom was estimated at 75% higher than that of Whites, with comparable rates for those who were educated in Britain and migrant counterparts (Nazroo, 1998).

Marwaha and Livingston (2002) examined the help-seeking attitudes and behaviors of ethnic elders who were clinically depressed. Semi-structured qualitative interviews, which included vignettes and open questions, were used with 19 (10 clinically depressed) Caribbean and 21 (10 clinically depressed) White United Kingdom residents. Participants were provided with a description of someone suffering from a mental illness and then asked their opinions on what they believed had happened. With the depression vignette, the Caribbean sample was more likely to describe the problem in spirituality terms or as a result of a lack of contact with the family or community. Three of the depressed Caribbeans felt that the depressed individual could not be helped at all and nine of the non-depressed Caribbeans felt that returning to the West Indies would alleviate the depression. Caribbeans also viewed mental illness as a moral failure and extremely stigmatizing. Consulting with a general practitioner was seen as more acceptable than receiving mental health services from a counselor or psychiatrist (Marwaha & Livingston, 2002).

Day et al. (2004) explored the risk behaviors and healthcare needs of homeless drug users in two Caribbean islands (St. Lucia and Trinidad). Seventy-four homeless individuals participated in this study and results revealed that approximately 88% of respondents experienced symptoms that qualified them for at least one psychiatric disorder over the previous 2 years. Further, 18% reported symptoms of schizophrenia, 64% depressive symptoms, 54% anxiety symptoms, and 84% reported low self-esteem. Despite these self-reported symptoms, only 20% had been institutionalized for mental illness, and 88% of those with a mental health disorder were not currently taking prescribed medication; 65% of respondents admitted to self-medicating with crack cocaine and marijuana (Day et al., 2004).

McGovern and Hemmings (1994) examined the attitudes of Caribbeans and White British patients with schizophrenia towards mental illness and psychiatric services. Patients were interviewed 5 to 10 years after their first admission. Caribbean patients reported twice as many admissions than White patients. There was no statistically significant difference on measures of satisfaction, conceptualization, and attitudes towards mental illness and treatment services. Caribbeans were also more likely than Whites to associate the cause of mental illness with substance use.

Peluso and Blay (2004) systematically reviewed the perceptions of Latin Americans and Caribbeans towards mental health disorders. They revealed that the higher the socioeconomic status, the more positive the attitudes towards mental illness. In many cases, schizophrenia was the most identified mental illness, and behavioral disorders and alcoholism were less likely to be perceived as a mental health problem. In Dominica, the preferred source of treatment was from a General Practitioner (Peluso & Blay, 2004).

Edge and Rogers (2005) examined Caribbean women’s responses to adversity and psychological distress. Using a mixed-method design, 200 women completed surveys and 12 Caribbean women were selected for in-depth interviews. Results showed that Caribbean women were significantly less likely than White British women to report symptoms of depression. Both antenatally and postnatally, Caribbean women were also significantly less likely to receive mental health treatment for depression than white British women. A general reluctance to acknowledge and discuss depression was prevalent with the Caribbean women who were interviewed. One respondent shared, “I do think Black people get depression, but I don’t think we’re allowed to have depression” (Edge & Rogers, 2005, p. 19). Common reactions to dealing with stressors included: dealing with it, moving along, solving problems on their own, being strong, and drawing on spiritual sources for emotional support (Edge & Rogers, 2005).

In terms of help-seeking, spirituality was used as a means of coping rather than seeking professional counseling (Edge & Rogers, 2005). Still, many viewed psychological distress as an indicator of moral weakness or that enduring this distress enhances their spirituality (Edge & Rogers, 2005). Fear of being labeled as depressed and viewed as incompetent also hindered individuals from seeking professional counseling. Avoiding mental health services was also a means of preserving one’s self-concept and perception of being able to cope with problems on their own. Common barriers to help- seeking, as cited by respondents, were a lack of knowledge about accessibility and availability of mental health services, waiting lists, limited Caribbean counselors, and doubts about the professionalism of counselors (Edge & Rogers, 2005).

Greenidge and Daire (2010) evaluated factors that influence the attitudes towards seeking professional counseling of 500 English-speaking Caribbean college students in the United States and the Caribbean. More specifically, the role of outcome expectations, emotional openness, and social stigma in influencing the attitudes towards professional counseling was investigated. The results of this study indicated that stigma tolerance and anticipated risks of seeking counseling both had a significant inverse relationship with the attitudes towards seeking professional counseling of English-speaking Caribbean college students. Anticipated utility of seeking professional counseling has a statistically significant relationship with the attitudes towards seeking professional counseling (Greenidge & Daire, 2010).

Caribbean students with low levels of emotional openness also reported more negative attitudes towards seeking professional counseling (Greenidge & Daire, 2010). The results also indicated that students who live and attend college in the Caribbean reported higher mean scores for anticipated risk, anticipated utility, and attitudes towards seeking professional counseling than their counterparts who live and attend college in the United States. Length of stay in the United States was not a statistically significant predictor of one’s attitudes towards seeking professional counseling. Further analyses also revealed that although Caribbean students recognize the utility of seeking professional counseling, they would not readily seek professional counseling services. This is largely due to the strong stigma which is still attached to mental illness in their home countries (Greenidge & Daire, 2010).

Additional analyses by Greenidge and Daire (2010) revealed that of 500 Caribbean college students (both in the United States and the Caribbean), 68.7% reported academic problems, 37.6% had experienced depression in the past year, 35.4% struggled with adjustment to university life, and 27.1% experienced significant homesickness within the past year. Despite this, only 6.3% of respondents reported seeking individual professional counseling, while 13.5% sought academic counseling. Most participants (47.9%) chose to speak with a close friend about their concerns, while 37.8% discussed these with family members (Greenidge & Daire, 2010).

Implications for the Counseling Profession

The English-speaking Caribbean is not a heterogeneous group, and as such, general recommendations cannot be made. However, there are many commonalities among islands and the implications for clinical practice offered here are based on these commonalities. It is advisable that professional counselors account for individual differences, varying levels of acculturation, and the racial and cultural heterogeneity that exist among Caribbean college students.

The review of the literature indicates that although Caribbean college students may have positive attitudes towards seeking professional counseling, many will not seek these services due to the stigma attached, the anticipated risks, the low level of self- disclosure, and the fear of negative repercussions (Greenidge & Daire, 2010). Counseling programs need to account for these critical factors when designing, implementing, and evaluating their services. Implications of this research include development of program interventions that are aimed at increasing treatment utilization, and facilitating the better conceptualization of those factors that influence help-seeking behaviors and attitudes.

Marketing of counseling services, utility of counseling services, and available options are all integral parts of effectively working with Caribbean college students. To dispel many of the myths and suspicions associated with professional counseling services, practitioners need to collaborate with school officials, medical professionals, community partners, and others to educate and sensitize people on key issues such as mental health, what counseling entails, and what can be expected. On college campuses, counseling centers may partner with organizations such as the International Student Association or Caribbean Student Association to host varying educational programs. The International Student Office on campus also plays an integral part in the life of international students and can be tapped in as a method of reaching these students.

Many Caribbean college students (especially those who recently migrated to the United States) are unaware of the counseling options available to them and the utility of seeking out these services (Greenidge, Daire, & Lewis, 2011). Advertisement of services needs to be delivered using strategies that would appeal to this population and should be delivered in a friendly, simple, and non-threatening manner (Karim, 1996). Educating the population on the benefits of professional counseling, confidentiality and the limits, normalizing their experiences, increasing knowledge, and debunking myths that perpetuate the negative stigma associated with seeking professional counseling are also critical.

On college campuses, the use of peer counseling can also be used as an adjunctive approach to providing support to Caribbean students. Formal and informal mentoring programs are effective ways of reducing the isolation and gradual decline in psychological well-being of Caribbean college students. Online counseling should be explored as an option for reaching Caribbeans and other international students who shy away from traditional face-to-face counseling due to the cultural stigmas attached to mental health services. Future research should explore the utility of this as an option as well as the limitations associated with online counseling.

Counselors should also devote specific attention to their screening and diagnosis procedures, case management, and interventions and techniques used in counseling. Although Caribbean college students face many of the problems which their American counterparts encounter, it is vital that counselors ensure that diagnosis of these clients be done within the cultural framework that is native to the client. What may be considered pathological in the American culture may be conceptualized differently in the Caribbean culture. For example, religions differ from island to island with some known for engaging in mysticism and spiritual practices that include spirits and supernatural powers. Not fully understanding these cultural practices may lead a counselor to believe that the client is experiencing psychosis.

Baptiste, Hardy, and Lewis (1997) stated that many Caribbeans object to being identified as a “minority,” and this objection has led to negative labeling of Caribbean clients by American counselors. Further, many Caribbeans identify themselves by their national origin (e.g., St. Lucian or Jamaican) rather than race and may refrain from answering questions about minority group membership on an intake form. Counselors who do not understand this express frustration, and these behaviors may be “labeled as a rejection of their black identity and thus explicit exploitation of their pathology” (Baptiste et al., 1997, p. 353).

Counselors must also examine their attitudes, beliefs, and feelings about Caribbean clients. Misinformation, lack of information, cultural differences, xenophobia, and racism should be explored and processed so that they do not impede the counseling relationship. Through mindfulness, counselors can remain congruent about their feelings and how these are translated in therapy (Baptiste et al., 1997). As with all cultures, an awareness, appreciation of, and sensitivity to differences will serve to enhance the therapeutic relationship with Caribbean college students.

Once the client agrees to return for services after the intake session, it is important to continue to articulate an understanding and acceptance of the client and his/her culture. Counselors need to pay special attention to session dynamics. The “goal setting process, verbal and nonverbal communication, client’s value systems and worldview. . . treatment planning and intervention selection” should be formulated and interpreted within the client’s cultural framework (Karim, 1996, p. 89). Taking a tutorial stance and gaining a thorough understanding of the client’s culture and individual differences will provide counselors with the information needed to develop culturally appropriate services. Body gestures, eye contact, silence, and interpersonal physical distance all have different meaning in the Caribbean culture. Having this knowledge will affect the conceptualization of the case.

Resistance also needs to be re-conceptualized when working with Caribbean college students. As previous researchers argue, resistance is not primarily due to negative attitudes towards seeking professional counseling, but rather it can be as a result of an ingrained fear of negative repercussions associated with self-disclosure (Komiya et al., 2000). These negative repercussions include being perceived and judged negatively by others, being viewed as weak and having a lack of self-control, and betraying themselves and their family by disclosing to a complete stranger (Komiya, Good, & Sherrod, 2000). As emphasized previously, it is impossible to know everything about the Caribbean culture, especially as there are also variations unique to each Caribbean island. Each island presents with different dialects, differing cultural heritage, and different histories. For this reason, it is imperative that counselors take a tutorial stance with clients.

Counselors should strive to be nonjudgmental and, initially, questioning should be kept at a minimum. Open-ended questions that will allow the client to share his/her story will be useful, as clients may perceive multiple questions as an invasion of privacy. Being extremely attentive to the client is also critical at this stage. As the level of trust heightens and the counselor establishes a relationship with the client, more questioning can be incorporated. Creative techniques should be used in sessions as well. Because many Caribbean college students may find it difficult to verbally self-disclose in sessions, the use of art and play therapy and other expressive techniques may be more effective with these clients. The use of music and poetry may also be effective techniques as these forms of expression are highly valued in the Caribbean culture.

Professional counselors may also assess for any discrepancies between pre- and post-immigration expectations and the realities of living in the United States. According to Baptiste et al. (1997), many Caribbeans arrive in the United States and are unaware that adjustment to a new culture can be potentially stressful. The authors argued that many Caribbeans experience anger and frustration as a result of this discrepancy. This can further lead to feelings of depression as well as externalizing behaviors. Often this discrepancy between pre- and post-immigration experiences are central issues in therapy. Issues of loss, which may be associated with migrating to attend college, may also be a significant contributor to presenting problems. When these issues are unresolved, they run the risk of negatively affecting the academic performance of these college students (Baptiste et al., 1997; Greenidge & Daire, 2010). Students who are experiencing these issues may benefit from acquiring coping skills to manage these changes as well as issues of discrimination.

Caribbean college students in the United States may also struggle to deal with their new minority status. In the Caribbean, many are part of the majority culture and do not experience racism. Although they are generally aware of the minority status assigned to African Americans, they may be ill-prepared to manage the sudden change in their status once they migrate to the United States. Many may perceive it as a “social demotion” and this may complicate the acculturation process and negatively impact their overall well-being, self-worth, and sense of belonging (Baptiste et al., 1997, p. 352). Many Caribbeans assert that acceptance of this new minority status is equivalent to acceptance of negative beliefs about themselves and object to being identified as a minority.

College counselors may also facilitate educational programs about the Caribbean culture for faculty and other employees on college campuses. These educational sessions may highlight commonalities among Caribbean and U.S. cultures as well as key differences between the two cultures. They may also provide faculty with strategies for working successfully with this student population. Hosting various cultural celebrations on campus may also demonstrate a willingness to learn and embrace the culture, which can translate to a greater sense of belonging among Caribbean college students.

Counselors should also account for the transitory nature of Caribbean college students when developing interventions and goals for treatment. The implications of treatment on clients when they return home need to be considered and explored with Caribbean college students (Karim & Gnaw, 1993). Counselors should provide the coping and stress management skills needed to adapt to the competing culture they are now immersed in. Counselors should do so without attempting to change their original core values and beliefs, which especially will be needed when they return to their home islands.

Conclusion

An analysis of the literature revealed that Caribbean college students encounter many stressors that are associated with college life, migration, and acculturation (Baysden, 2002). Failure to successfully resolve these stressors can threaten one’s academic achievement, psychological health, and interpersonal relationships (Lafromboise, Coleman, & Gerton, 1993; Marsh, 1990; Roysircar, 2002).

Despite these major challenges, however, researchers argue that Caribbeans hold more negative attitudes towards professional counseling than Caucasians, White Canadians, and White British subjects (Edge & Rogers, 2005). Some of the salient factors that impact Caribbeans college students’ attitudes towards seeking counseling include stigma tolerance, perceived social support, anticipated risks and anticipated utility of seeking professional counseling, and one’s level of emotional openness. The use of creative techniques in counseling, as opposed to a reliance on traditional talk therapy, may prove to be effective when working with English-speaking Caribbean college students.

A review of the literature highlights the paucity of mental health research on the Caribbean population. More specifically, identifying those factors that influence the attitudes of Caribbean college students towards seeking professional counseling is lacking in the counseling literature and multicultural research. Future research should expand on existing research while providing empirical evidence of counseling techniques and interventions that work well with Caribbean college students.