cross-cultural examination of depression expression and help-seeking behavior: a comparative study...

Cross-Cultural Examination of Depression Expression and Help-Seelung Behavior:

A Comparative Study of American and Korean College Students

Sung-KyungYoo and Thomas M. Skovholt

This study examined cross-cultural differences in depression expression and help-seeking behavior among college students in the United States and Korea. Results indicated that the Korean students showed more somatization tendency, negative affect, and negative help-seeking behavior. Negative help-seeking behavior of Korean students w a s shown to relate to somatization. Counseling implications are discussed.

epression has been a major focus of cross-cultural studies about emotion and psychological distress. Depression is a broad term that is used D for several kinds of emotional states. Depression can be a transitory

mood or emotion experienced at various times by all individuals. It can be a clinical symptom associated with a variety of psychiatric disorders. Depression can also be a commonly diagnosed mental illness (Kleinman & Good, 1985).

Early studies that looked a t depression across cultures indicated that the cluster of symptoms characterizing depression in the West seemed to be rare or absent in non-Western cultures (Chang, 1985). However, cross-cultural and anthropological studies (Kleinman, 1982; Marsella, 1981; Noh, Kasper, & Chen, 1998) revealed that people in non-Western cultures have their own way, in keeping with their culture, of formulating and expressing depressive affect. Sandhu (1997) said, “there are wide cultural differences in emotional scripts, social bonding practices, and psychological mechanisms to defend against intrapsychic and interpsychic threats among Asian and mainstream American cultures” (p. 14). Thus, investigation of depression, using the con- cepts and diagnosis criteria from the West, may overlook the unique phenomenon manifested in non-Western cultures and may result in the under diagnosis of depression in non-Western cultures.

The concept of depression in Western terms primarily emphasizes affective complaints, with somatic symptoms as secondary concomitants. However, the core symptoms of depression identified in East Asian cultures are mostly in the form of physical disabilities that tend toward the vegetative level of expression (Draguns, 1986; Kleinman, 1982; Kleinman & Good, 1985; Marsella, Kinzie, & Gordon, 1973). In East Asian cultures, there is no con-

Sung-Kyung Yo0 is on assistant professor at the Korea Youth Counseling Institute in Seoul, Korea. Thomas &. Skovholt is o professor in the College of Education ond Human Development at the University of Minnesota in Minneapolis. Correspondence regarding this article should be sent to Sung-Kyung Yoo, KYCI, Shindang &dong, Choong-Ku, Seoul 100-456, KOREA (e-mail: [email protected]).

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ceptually equivalent word or concept for depression that assumes the dichoto- mous mind-body relationship of the West. A study conducted by Tanaka- Matsumi and Marsella (1976) revealed that Americans mostly associate depression with ‘internal referent words such as sadness, despair, and loneliness. However, East Asians associate depression with external referent words such as rainy, cloudy, and dark. This study pointed to a possible bias among many Western-oriented investigations that overemphasize psychological meaning for the experience of depression.

East Asians’ somatization tendency is considered to have an impact on their underutilization of professional mental health help. Kawanishi (1992) defined somatzzation as presenting bodily complaints as explanations for one’s psycho- social problems, thus distinguishing it from psychosomatic disease that, even though the causes often include psychological factors, can be detected as a physiological problem. In the case of somatization, little or no physiological evidence for the patient’s complaint is discovered, yet the patient continues to claim somatic illness. White (1982), on the basis of a comprehensive review of the literature on depression in East Asian culture, suggested that somatization and the consequent underutilization of professional help are two of the most important issues in East Asian depression research. Research literature has suggested that somatization of depressive affect and underuse of professional help are culturally conditioned ways of managiiig underlying psychoiogical processes among East Asian cultures. “Stoicism is one of the significant hall- marks of Asian values. Due to this stoicism, emotional expressions are generally inhibited” (Sandhu, 1997, p. 16).

The underutilization of mental health services by East Asian college students is a well-documented phenomenon despite evidence that they may have a higher-than-average need for services (Leong, 1986; Sue & Sue, 1972). Asian Americans are highly represented on college campuses today, and there is evidence that they, too, are underrepresented in the utilization of psychological services for personal problems (Leong, Wagner, & Tata, 1995). Cross- cultural studies that compared help-seeking behaviors between Asian Ameri- can and White American students revealed that Asian American students were less likely to admit personal or emotional concerns (Sue & Kirk, 1975; Tracey, Leong, & Glidden, 1986), even though they reported higher levels of emo- tionaI distress than did White American students (Okazaki, 1997). Chang ( 1985) explored cultural differences in the configuration of depressive symptomatology between American and Asian college students and found that Asian students reported more bodily symptoms than affective symptoms.

Previous studies that examined within-group differences in help-seeking behavior among Asian American students (e.g., Atkinson & Gim, 1989; Solberg, Choi, Ritsma, & Jolly, 1994) found acculturation to be an important variable when addressing within-culture difference in help-seeking behavior. These authors found that the most acculturated students were most likely to have positive attitudes toward seeking professional help. Asian international students also were found to indicate a significant relationship between levels of

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acculturation and attitudes toward seeking professional psychological help (Yang & Clum, 1995; Zhang & Dixon, 1999). In summary, findings from previous cross-cultural studies, comparing Asian students living in America with American students, suggested that Asian students in American culture were more likely than their American counterparts to have high levels of depression and to express their depression somatically. Asian students’ somatization tendency and underuse of psychological help were found to be significantly related to their level of acculturation.

Several of hypotheses, most ofwhich assume a conflict between the psychotherapy process and the values of traditional East Asian culture, are offered to explain this pattern of underutilization. For example, attitudes and beliefs about mental illness among Asians have been identified as influencing Asians’ underuse of psychotherapy. Examples of these attitudes and beliefs include the belief that seeking outside help for psychological problems will bring shame upon one’s family, that psychological problems are the result of bad thoughts and a lack of willpower, and that one must resolve problems of this type on one’s own.

This comparative study is an attempt to better understand cross-cultural differences between American and Korean cultures regarding the expression of depression and help-seeking behavior. The specific problems investigated in this study are concerned with (a) ethnic differences in depression symptomatology and attitudes toward seeking professional psychological help and (b) the relationship between somatization tendency and attitudes toward seelung professional help among American and Korean college students in American and Korean universities.

Method

Participants

Research participants were 88 (27 men, 61 women) American undergraduate students enrolled at the University of California at Santa Barbara (UCSB) and the University of Minnesota (UM) in the United States (52 and 36 students from each school, respectively) and 95 (41 men, 53 women) Korean undergraduate students enrolled at Seoul National University (SNU) in Ko- rea. Participants were recruited during the winter quarter of 1996 from the classes of Human Values and Education at SNU, Introduction to Counseling Psychology and Career Decision Making at UCSB, and Introduction to Psy- chology at UM.

Participants ranged in age from 20 to 29 years ( M = 22.03, SD = 2.03) in the Korean sample and from 19 to 43 years ( M = 22.33, SD = 4.56) in the American sample. Notable differences between the two samples were found in participants’ majors and school years. There was a high percentage of social science majors (76.1%) and seniors (44.3%) in the American sample, whereas there was a relatively even distribution of majors in the Korean sample. The Korean

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sample included more arts majors (34.7%) than social science majors and a pre- dominance of freshman and sophomore students (65.3%). Another notable difference between the two groups was in participants’ previous counseling experience. Of the Korean sample, 8% had experienced counseling previously, whereas more than 45% of the American sample had engaged in counseling.

Procedure

Class instructors introduced the purpose and procedure of the study to the students and invited them to become participants. The American students who participated in the study were awarded either money ($10) or academic credit, whereas Korean participants received neither money nor academic credit. In the recruitment phase American students of all ethnic backgrounds were encouraged to participate in the study. However, to maintain cultural ho- mogeneity in the sample, 15 participants who were not White were ex- cluded from the data analysis. Therefore, in the final analysis, one group of student participants was entirely White and the other group was entirely Korean. Students who agreed to participate in the study were given a questionnaire that included a consent form, a demographic information form, the Korean version of the Center for Epidemiologic Studies-Depression Scale (CES-D-K, Radloff, 1977), and the Attitudes Toward Seeking Professional Help Scale (ATSPHS; Fischer & Turner, 1970). Instructors distributed questionnaires in class, and the Korean participants completed them there. However, for practical reasons, American participants completed the questionnaires at home and returned them at the next class meeting. Completion of the questionnaires required about 20 to 30 minutes. One questionnaire from each group was returned incomplete; therefore, these were not included in the analyses.

Instruments

Depression expression. The expression of depression was measured by the Cen- ter for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977). This is a self-report instrument intended to identify symptoms associated with depression. It contains 20 items in four symptom clusters: Negative Affect (7 items), Positive Affect (4 items), Interpersonal Problems (2 items), and Somatic Activity ( 7 items). Participants were asked to rate how many days they had experienced an item during the past 2 weeks. Items were rated on a 4-point scale, with 1 = rarely or none of the time (less than 1 day per week) and 4 = most or all of the tame (5 to 7 days per week).

Noh, Avison, and Kaspar (1992) assessed the utility of the CES-D for identifying symptoms of depression among a sample of Korean immigrants in Canada and presented evidence that supports the content, construct, and concurrent validity of the Korean version (the CES-D-K) of the CES-D. The factor analysis of the CES-D-K also generated four dimensions with an

Journal ofcollege Counseling Spring 2001 . Volume 4 13

eigenvalue greater than 1 .O. From the comparisons of response patterns with individual items in the American sample and the Korean sample, it was noted that the ratio of Koreans’ scores to Americans’ scores in the Positive Affect dimension is about 3 times higher than those on other dimensions. The tendency was also reported with Japanese and Chinese samples (Iwata, Saito, & Roberts, 1993; Lin, 1989). This result was interpreted as a reflection of a cultural tendency not to express positive feelings or to be hopeful about the future. Based on these findings, it was recommended that the positive affect items be revised or deleted when computing the CES-D-K score to avoid overestimating the number of Koreans manifesting high levels of psychological distress (Noh et al., 1992; Noh et al., 1998). On the basis of this recom- mendation, four positive affect items were deleted from the CES-D in the present study.

The internal consistency reliability of the scale and the subscales achieved a satisfactory level with two current samples (For the CES-D-K, American .86 and Korean .87; for the Negative Affect subscale, American .87 and Korean 3 6 ; for the Interpersonal Problem subscale, American .66 and Korean .72; for the So- matic Activity subscale, American .63 and Korean .57).

Help-seeking behavior. Help-seeking behavior was measured by the ATSPHS (Fischer & Turner, 1970), whch has 29 items. Each item is a statement that is scored on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). A h g h total score on the scale indicates a positive attitude toward seeking professional help for psychological problems. The total score is obtained by summing the item scores. Atlunson and Gim (1989) adapted the ATSPHS by substituting the words psychologist-counselor and counseling center for psychiatrists and mental health center to make the scale more relevant to today’s college students. We used the modified version of the ATSPHS in this study. The ATSPHS has a satisfactory internal consistency coefficient with current two samples (American .92 and Korean 3 2 ) . The first author translated the ATSPHS into Korean, and two individuals who

are bilingual in English and Korean cross-validated the translated instruments. Their back-translation focused on whether the items of each scale were accurate in a clear way within a cross-cultural context. One of the translators was a doc- toral student in educational linguistics, and the other translator has a doctorate in engineering. The translated ATSPHS was given to the translators without any information about the original ATSPHS, and the back-translation was completed separately by the two individuals. The first author and the translators together compared the original items with the translated items and made minor revisions in the Korean version until it matched closely with the original English version.

Analysis of Data

To examine differences in depression expression between the Korean and American samples, a multivariate analysis of covariance (MANCOVA) was performed using each item of the CES-D-K as a dependent variable, with

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ethnicity as an independent variable. Because there were marked differences between the two samples in participants’ majors, school years, and previous counseling experiences, those variables were included as covariates. Also, because data were collected from two different American schools, the school variable was included as a covariate. To examine the difference in help-seeking behavior, an analysis of covari-

ance (ANCOVA) was performed using a total score of the ATSPHS as a dependent variable and using the same demographic variables included in the previous MANCOVA as covariates. To examine the relationship between somatization tendency and help-seeking behavior, a correlation coefficient between a CES-D-K subscale score measuring somatic depression and a total score of the ATSPHS was calculated for each sample.

Results

Results of the MANCOVA on each item of the CES-D indicated that there was a significant group difference between the American and Korean samples in the way depression was expressed, 816, 156) = .16, p < .05. Univariate tests for each item of the CES-D indicated that Korean students reported more somatic symptoms than American students on three items in the CES-D-K that measure somatic activity: having poor appetite, q l , 171) = 5.42, p c .05; feeling that everything was an effort, F( 1, 171) = 6.75, p < .01; and talking less than usual, F( 1,171) = 6.78, p < .01. However, there were no significant differences between the two samples on the other four items: being bothered by things, having trouble focusing, restless sleep, and cannot “get going.”

Korean students also expressed more negative affects than American students on three items in the CES-D-K that measure negative affect: feeling depressed, F(1,171) = 5.98, p < .05; cannot shake off the blues, F( 1,171) = 6.75, p < .01; and feeling fearful, F(1, 171) = 4.34, p < .05. No significant differences were found between the two samples on the remaining four items: feeling failure, lonely, crying, and sadness. No significant differences were found between the two groups in interpersonal problems, nor was there a significant group difference found in the level of depression.

Results of the ANCOVA on the total score of the ATSPHS indicated that American students showed significantly more positive attitudes toward seelung professional help than did Korean students, F(1, 167) = 8.47, p < .01. This result is consistent with the previous findings of underutilization of mental health services by East Asians (Leong, 1986; Sue & Sue, 1972; Uomoto & Gorsuch, 1984).

There was a significant negative relationship between a score of somatic depression and a score of the ATSPHS for each sample (American, Y = -.27, p < .05; Korean, r = -.20, p < .05). This result indicates that the more the participants somatized their depression, the more negative they were about seeking professional help.

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Discussion

In this’study we examined cross-cultural differences in depression expression and help-seeking behaviors between American and Korean college students. We also examined the relationship between somatization tendency and help- seeking behaviors. On the basis of the results of a MANCOVA on the items of the CES-D, we found that Korean students express their depressive affect through somatic symptoms more than American students do. This result is consistent with the reported tendency of East Asians to somatize psychological problems.

Unexpectedly, in this study, Korean students also expressed more negative affect than did American students, although Korean students reported more somatic symptoms than American students reported. This result suggests that the “somatization hypothesis” in Asian culture-that Asians tend to somatize their emotional tendency-requires further examination. In fact, although there has been a prevalent assertion that Asian psychiatric patients tend to somatize their emotional distress (Kawanishi, 1992), previous research data have yielded conff icting results regarding this assertion. Methodological differences in research participants and instruments are probably responsible for these conflicting results. Most previous studies that supported the somatization tendency in Asian culture used community samples that may be less Westernized than student samples. This study used only college students, a group that may have been more exposed to Western cultural values than the community sample. This difference may have resulted in more depressive affect being reported in the Asian sample.

In addition to the characteristics of the participants, limitations of the study’s instruments should be considered. Because the CES-D was developed on the basis of American samples, it may be less sensitive and less adequate for the Korean sample than for the American sample. The lack of sensitivity and adequacy of the instrument, when used with the Korean sample, may have in- terfered with capturing an accurate picture of Korean culture regarding depression expression. Uncertainty about the sensitivity and adequacy of the CES-D in this situation calls for hture studies with large representative samples using culturally valid instruments to examine the somatization issue in Asian culture.

Concerning help-seeking behavior, results of the ANCOVA on a total score of the ATSPHS indicated that Korean students reported more negative attitudes toward seeking professional help than American students reported, which is consistent with the research findings with Asian American students living in the United States. This study did not include acculturation level, which has been found to significantly relate to help-seeking behaviors, because the research participants were Korean students living in the Korean culture. How- ever, the ambivalence toward seeking professional psychological help found in the present study may be related to participants’ low level of acculturation to Western culture. We recommend that future cross-cultural studies in help-

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seeking behaviors in the Asian culture include both Asian students and Asian American students to compare how acculturation level is related to help- seeking behaviors.

Korean students’ negative attitudes about seeking professional help partly explain the major difference in the counseling usage rate between the two samples (8% in the Korean sample vs. 45% in the American sample), although there is no way to determine causality. On the basis of this result, we suggest that Asian cultural meanings attached to seeking professional help from outside the family should be thoroughly understood to make counseling services more accessible to East Asians. In addition to negative attitudes toward seeking professional help, the unfamiliar nature of professional psychological help and the lack of counseling resources in East Asian cultures may be responsible for the low percentage of counseling usage among East Asians.

Negative attitudes about seeking professional help were shown to relate significantly to the somatization tendency for both Korean and American samples. This result indicates significant interrelatedness between ways of expressing emotions and managing problems.

ImDlications for Counselins

Several important implications can be drawn from the results of this study for cross-cultural counseling generally and specifically for college counseling centers with a large Korean population. First, in accordance with previous research, this study supports the premise that East Asians, more than Americans, tend to somatize their depression. Consequently, counselors and therapists should be aware of this tendency in order to make assessment and intervention more valid and useful.

Second, East Asians, at least the participants in this sample, express depressive affect in a manner similar to constructs of depression developed by researchers in the West. This unexpected result shows that clients should not be stereotyped on the basis of ethnicity. The younger generation of college students in East Asian cultures may differ from traditional East Asian culture because of their increased contact with modern Western values.

Third, consistent with prior research, the results of this study indicate that practitioners also should understand that many East Asians are highly am- bivalent about the use of professional mental health services. The individual’s acculturation level to Western culture may be a key point in understanding the level of ambivalence (Sandhu, Portes, & McPhee, 1996). Yamashiro and Matsuoka (1997) suggested that, “Western treatment approaches may have been successful to some Asian and Pacific American clients, but the success often depends on the degree to which the client is acculturated to Western norms” (p. 183). Pairing less acculturated clients with ethnically similar counselors is recommended to improve counseling success (Atkinson, Wampold, Lowe, Matthews, & Ahn, 1998). Also, counselors should note that client adherence to culture-of-origin values plays an important role in the provision

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of culturally relevant and sensitive psychological services (Kim, Atkinson, & Yang, 1999).

Last, in light of results of the current study, practitioners should be aware that the most distressed East Asian clients who express their depression physi- cally may also be the clients who are least likely to seek professional help. Practitioners are urged, therefore, to redouble their efforts to reach these individuals through the use of transcultural approaches and innovative alter- natives (Sandhu, 1997).

In addition to general implications for counseling, we make the following recommendations to college counselors. First, there is a need to provide broad- based, cross-cultural training to college counselors, health practitioners, and faculty and staff in institutions of higher education with a significant number ofAsian or Korean students. Such training can help to improve both counseling success and academic performance.

Second, the staff at college and university counseling centers with a large number of Asian or Korean students should receive specific training about the somatization of emotional distress and the ambivalence about seelung help.

Finally, colleges and university counseling centers could develop and offer community outreach workshops and seminars to communities with large Asian or Korea populations. These workshops could increase awareness of cross- cultural differences in the larger community.

References

Atkinson, D., & Gim, R (1989). Asian-American cultural identity and attitudes toward mental health services. Journal of Counseling Psycholog;, 36, 209-212.

Atkinson, D., Wampold, B. E., Lowe, S . M., Matthews, L., & Ahn, H. (1998). Asian Ameri- can preferences for counselor characteristics. The Counseling Psychologist, 26, 101-123.

Chang, W. ( 1985). A cross-cultural study of depressive symptomatology. Culture, Medicine, and Psychiatry, 9, 295-317.

Draguns, J. (1986). Culture and psychopathology: What is known about their relationship. Australian Journal of Psychology, 38, 329-338.

Fischer, E. H., & Turner, J. (1970). Orientation to seeking professional help: Development and research utility of an attitude scale. Journal of Counseling and Clinical Psycholofly, 35,

Iwata, N., Saito, K., & Roberts, R E. (1993). Responses of Self-Administered Depression Scale among young adolescents in Japan. Psychiatric Research, 53, 275-287.

Kawanishi, Y. (1992). Somatization ofhians: An artifact of Western medicalizationl Transcultural Psychiatric Research Review, 29, 5-36.

Kim, B. S. , Atkinson, D. R., & Yang, P. H. (1999). The Asian Value Scale: Development, factor anaylsis, validation, and reliability. Journal of Counseling Psychology, 46, 342-352.

Kleinman, A. (1982). Neurasthenia and depression. Culture, Medicine, and Pycbiatry, 6,117-190. Kleinman, A., & Good, B. (1985). Culture and depression. Berkeley, CA: University of Cali-

fornia Press. Leong, F. T. L. (1986). Counseling and psychotherapy with Asian-Americans: Review of the

literature. journal of Counseling Psycholog;, 33, 196-206. Leong, F. T. L., Wagner, N. S., & Tata, S. P. (1995). Racial and ethnic variations in help-

seeking attitudes. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multictsltural counseling (pp. 415438) . Thousand Oaks, CA: Sage.

79-90.

18 Journal of College Counseling Spring 2001 Volume 4

Lin, N. ( 1989). Measuring depressive symptomatology in China. Journal of NervousandMental Disease, 177, 121-131.

Marsella, A. J. (1981). Depressive experience and disorder. In H. C. Triandis & J. W. Berry (Eds.), Handbook of crt)ss-cz~lturalp~chology (pp. 237-289). Boston: Allyn & Bacon.

Marsella, A. J . , Kinzie, D., & Gordon, P. (1973). Ethnic variations in the expression of depression. Journal of Cross-Cultural Psychology, 4, 435458.

Noh, S., Avison, W. R., & Kasper, V. (1992). Depressive symptoms among Korean immigrants: Assessment of a translation of the Center for Epidemiologic Studies-Depression Scale. Psychological Assessment, 4, 84-9 1 .

Noh, S., Kasper, V., & Chen, X. (1998). Measuring depression in Korean immigrants: Assess- ing validity of the translated Korean version of the CES-D scale. Cross-Cultural Research, 12,

Okazaki, S . (1997). Sources of ethnic differences between Asian American and White Ameri- can college students on measures of depression and social anxiety. journal ofAbnorma1 Psy-

Kadloff, L. S . (1977). The CES-D Scale: A self-report depression scale of research in the general population, Applied Psychological Measurement, 1, 385-401.

Sandhu, D. S. (1997). Psychocultural profiles of Asian and Pacific Islander Americans: Impli- cations for counseling and psychotherapy. Journal of Multicultural Counseling and Develop- ment, 25, 7-22.

Sandhu, D. S., Portes, P. R., & McPhee, S. A. (1996). Assessing cultural adaption: Psycho- metric properties of the Cultural Adaptation Pain Scale. Journal of Multicultural Counseling and Development, 24, 15-2 5 .

Solberg, V. S. , Choi, K., Ritsma, S . , & Jolly, A. (1994). Asian-American college students: It is time to reach out. Journal of College Student Development, 35, 296-301.

Sue, D. W., & Kirk, B. A. (1975). Asian-Americans: Use of counseling and psychiatric services on a college campus. Journal of Counseling Pychofom, 22, 84-86.

Sue, D. W., & Sue, S. (1972). Counseling Chinese-Americans. Personnel and Guidance Jour- nal, 50, 637-644.

Tanaka-Matsumi, J., & Marsella, A. J. (1976). Cross-cultural variations in the phenomeno- logical experience of depression: Word association studies. Journal of Cross-Cultural Psychol-

Tracey, T., Leong, F., & Glidden, C. (1986). Help seeking and problem perception among Asian Americans. Journal of Counseling Psychology, 33, 33 1-336.

Uomoto, J., & Gorsuch, R. (1984). Japanese American response to psychological disorder: Referral patterns, attitudes, and subjective norms. American Journal of Community Psychol-

White, G. ( 1982). The role of cultural explanations in ‘somatization’ and ‘psychologization.’ Social Science and Medicine, 16, 1519-1530.

Yamashiro, G., & Matsuoka, J . K. (1997). Help-seeking among Asian and Pacific Americans: A multiperspective analysis. Social Work, 42, 176-1 86.

Yang, B., & Clum, G. A. (1995). Measures of life stress and social support specific to an Asian student population. Journal of Psychopathology and Behavioral Assessment, 17, 5 1-67.

Zhang, N., & Dixon, D. N. (1999, August). Acculturation and attituder of Asian intema- tional students tovard seekingpsychological help. Paper presented at the meeting of the Ameri- can Psychological Association, Boston.

35 8-377

chology, 106, 52-60.

ogy, 7, 379-397.

om, 12, 537-550.

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cross-cultural examination of depression expression and help-seeking behavior: a comparative study...

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