Yonago Acta medica 2008;51:39–47

Factors Related to Attitudes toward Seeking Professional
Psychological Help among Japanese Junior High and HighSchool Students
Soichi Takamura, Iwao Oshima*, Koji Yoshida† and Takuro Motonaga‡
Department of Nursing Care Environment and Mental Health, School of Health Science, Tottori
University Faculty of Medicine, Yonago 683-8503, *Department of Clinical Social Work, Facultyof Social Welfare, Japan College of Social Work, Kiyose 204-8555, †Department of PsychiatricRehabilitation, National Institute of Mental Health National Center of Neurology and Psychiatry,Tokyo 272-0827 and ‡Department of Psychology, Faculty of Liberal Arts, Teikyo University, Hachioji 192-0395, JapanTo develop intervention methods of primary prevention for adolescents who are at highrisk for mental health disorders, we investigated help-seeking behavior (HSB) and factors related to HSB. We distributed questionnaires to 1222 junior high (age, 13.55 ± 0.5
years) (mean ± SD) and high school students (age, 16.56 ± 0.49 years) in Japan. A totalof 1168 questionnaires were answered and returned. Correlation analysis and multiple
linear regression analysis were conducted to determine HSB and related factors scales.
Among the sample students, 39% had previous knowledge of mental health consultation.
However, only 10% said they would seek out a mental health specialist. Friends or senior
students were frequently chosen (70%) as the initial consultant. Using multiple regression linear analysis, we found that image of and stigma towards psychiatry and psychological counseling and knowledge of mental health to be factors related to HSB. Highschool students were more likely than junior high students to display HSB. Initially, students tended to choose friends and family rather than specialized professional support
for their mental health concerns. The image of psychiatry, knowledge of services andstigma towards mental health problems and services were related factors. We conclude
that educational programs that include students, parents, family and friends are neededfor early intervention to change the general image and knowledge of specialized mental
health services to increase HSB.
Key words: adolescence; help seeking; mental healthDespite the high prevalence of mental health problems and disorders in adolescents (Rickwood etal., 2007), only a few receive appropriate help. For
young people, acceptance of early intervention
would greatly influence their future, yet preventive
support is not accepted (Jorm, 2001). Students

who have immediate mental needs require earlyintervention and specialized consultation. Developing access in educational settings would improvethe mental health status of the adolescent age group
before serious problems occur and thus impact themental health of subsequent generations.

Abbreviations: ASPH, Attitudes toward Seeking Professional Psychological Help scale; GHQ, General Health Questionnaire; HSB, help-seeking behavior[Correction added in May 2015, after online issue publication: Iwao Oshima’s affiliation has been corrected.]39

S. Takamura et al.

Previous studies regarding help-seeking
behavior (HSB) for consultation or treatment(Oshima, 1987; Mizuno and Ishikuma, 1999)
found some correlations between certain attributes such as, age (Leaf et al., 1987; Surgenor,
1985), sex (Fischer and Turner, 1970; Good et al.,
1989; Tijhus et al., 1990), race and culture (Tataand Leong, 1994; Razali and Najib, 2000), income and educational level (Surgenor, 1985), support network in the family (Goodman et al., 1984;
Sayal, 2006), individual mental health and symptoms (Dew et al., 1988; Garland and Zigler, 1994;
Bland et al., 1997), individual character traits(Garland and Zigler, 1994; Neighbors, 1985),
stigma (Phillips, 1963) and knowledge of mental
health (Robbins, 1981). However, no studies havereviewed the factors related to HSB among Japanese junior high and high school students.
In order to identify needs and develop effective intervention, there are several things to consider. Physical and mental development occurs
rapidly in adolescents and mental health varies
within different generations and within different
environments. Thus, it is necessary to monitor
trends in different age groups. The purpose ofthis study was to identify factors related to HSB
that are specific to age groups. We surveyed
the mental health status of junior high and highschool students and investigated their needs. We
also examined the content and timing of primaryprevention methods and discussed implications
for early intervention.

report questionnaires and the participants completed and returned the anonymous and unsigned
questionnaires within 1 class hour. Students were
informed that cooperation was voluntary andprotection of anonymity would be ensured. This
study was authorized and supported in 2002 by
the executive board of the National Federation of
Families with Mentally Ill Members in trust of
the Ministry of Health, Labor and Welfare of Japan.
We conducted a pretest with several students
from the same age group for the content of thequestionnaire. We created an investigation manual to define technical terms and to give guidelines
for consistent administration, of which a single
copy was distributed to each participating school.
The teachers were considered investigators, andwere asked to explain the procedure and distributeand collect the questionnaires. After the investigation, we distributed a pamphlet and a video toeach school in order to avoid any negative impression or image, and that impaired cognitive functioning was related to the investigation.
Measurements
HSB: Fischer and Farina (1995) and Fischer andTurner (1970) developed the Attitudes toward
Seeking Professional Psychological Help Scale(ASPH), creating a 1-dimensional scale consisting of 10 items (Fischer and Farina, 1995). With
the authors’ permission, we translated this revised
scale into Japanese, and then it was back-translated and checked by 2 native English speakers for
accuracy. Each item was measured on a 4-point
Likert scale (Nakagawa and Daibo, 1986). In
addition, we created a multiple answer type questionnaire to clarify knowledge of HSB and orientation to counseling resources. We included 2
items that were related to HSB: “Do you know ofa place for consultation or a person to talk to when
you experience psychological distress?” (knowledge) and “Have you consulted with a counseloror mental health specialist when you have been
mentally distressed?” (orientation). An affirma-

Subjects and Methods
Eight schools approved of and participated in thisstudy: 3 junior high schools and 2 high schools
from urban areas in Tokyo, Osaka and Saitama,and 2 junior high schools and 1 high school fromrural areas in Nagano. To control for possible
bias due to locality or type of school, we chose
public institutions in both urban and rural areas.
The investigation was conducted between September and November 2002. We distributed self40

ASPH-related factors in Japanese students

tive response yielded 1 point. In these items,
mental health specialists included psychiatrists,
school counselors and psychological counselors;
general specialists included school nurses, medical doctors (except psychiatrists), public education
counseling centers staff, public child consultation
centers staff and public health nurses. Others included school teachers, family members, friends,
priests and telephone counselors for comparison
with each specialist.

Analysis
We compared the participants’ knowledge andorientation of consultation resources and the valueof distribution between selective items to determine their HSB. In addition, we analyzed the
ASPH items after comparison (one-way analysis
of variance, t-test) by distribution of attributes to
HSB. We conducted a correlation analysis (Pearson correlation coefficient = r) of the ASPH withother scales which related factors of HSB that had
an effect on participants. A hierarchical multiple
linear regression analysis was conducted on dependent variables for the ASPH in each model.
Independent variables for scales other than the
ASPH were input in each model. In addition, we
considered the results of correlation analysis comparing both junior high and high school students.
SPSS for Windows (version 11.0) was used forstatistical analysis.

Measurement of factors related to HSB: We
measured participants’ image of mental healthspecialists, psychiatry and counseling, knowledgeof disorders, stigma towards disorders, mental
health status, self esteem, support network of individuals, individuals’ experiences of consultation
with mental health specialists and demographics
as factors related to HSB. To determine the variables, we discussed with specialists who engage
in mental health consultation. We then designed
an original scale of 10 items to evaluate image
towards psychiatric medicine and an 8-item scale
was used to evaluate image towards psychologicalcounseling. These items used a 4-point Likerttype scale. We developed an additional 6-item
scale on knowledge of disorders, which used a
3-point Likert-type scale. For accuracy, these
items were examined by a school counselor who
had experience in psychiatry and mental healthresearch. In addition, the stigma of impaired
cognitive function was assessed using a negative
attitude scale of 10 items concerning respect for
the autonomy of mentally handicapped persons
and their rights (12-point total score) (Okagami
and Ishihara, 1986). Mental health status was assessed using the 12 items of the General Health
Questionnaire (GHQ) and the GHQ scoring method (4-point cutoff) (Nakagawa and Daibo, 1985).
Rosenberg’s self-esteem scale (1 to 5 points) wasused to assess self-esteem (Rosenberg, 1965;
Yamamoto et al., 1982).

Results
Response rate and attributes of participants
We distributed 1222 questionnaires to students(age, 15.7 ± 1.49 years) (mean ± SD) and received
1168 (collection rate, 95.6%). Respondents included 508 junior high school students (43.5%) and
660 high school students (56.5%). The urban/rural
living area ratio was 72.3% for urban areas and27.7% for rural. Percentage of participating males
was 48.8% and 51.2% for females. Family constitution was 62.3% for nuclear families, 29.4% formulti-generational families and 8.3% for others(Table 1).
Knowledge of support resources and tendencies to select consultation
We asked about psychiatric services and psychological counseling awareness. Two items
measured knowledge: “I know very well because
my friend(s) and/or I have sought help” and “I
41

S. Takamura et al.

Table 1. Attributes of participants
Attribute

have some idea of or I know what it is”. Results
showed 24.6% knew about psychiatry and 30.9%
knew about psychological counseling in juniorhigh school students. 42.4% knew about psychiatry and 48.6% knew about psychological counseling in high school students (Table 1). In addition,
we compared the selection regarding types ofcounselors among those with knowledge about
consultation resources. Although 39% knew
about psychiatrists, school counselors and psychological counselors, only 10% chose or would
choose them for consultation. For 107 participants (9.4%) who had gone to school nurses for
consultation when they were distressed, the orientation towards counseling services was generally
low. In addition, persons who were chosen for
consultation were family members or friends.

Number* Percentage

District
Urban area
Rural area
Grade
Junior high school (5 schools)
High school (3 schools)
GenderMale
FemaleComposition of a family
ParentParent and brother/sister
Grandparent and parent
Grandparent and parent andbrother/sister
Grandparent
Other
Type of living place
Residential area
Busines area
Industrial area
Rural area
Other

845
323

72.3
27.7

508
660

43.5
56.5

550
578

47.1
49.5

96
609
42

8.5
53.8
3.7

291
5
89

25.7
0.4
7.9

888
24
9
189
12

76.0
2.1
0.8
16.2
1.0

Comparison by attributes with the ASPH
A higher score meant that a respondent had apositive attitude toward HSB. We developed aJapanese version of 10 items of the ASPH andcalculated the correlation coefficient between theitems. We omitted 1 item because of low correlation, and then reconstituted the scale (points werereversed in 4 items). As a result, Cronbach’s coefficient for all 9 items was 0.65 (junior high school,
0.64; high school, 0.66). Fundamental attributes
were compared with the average scores from the
ASPH (Table 2) and using the one-way analysis
of variance (2 groups, t-test), and high school students (13.4 ± 4.45) (mean ± SD) had significantly
higher scores (P < 0.001) compared to junior highschool students (12.1 ± 4.34). Females (13.2 ±4.14) also scored higher than males (12.4 ± 4.71)(P < 0.01). No significant differences were foundbetween urban and rural regions.

*Total number of participants, 1168.

Table 2. Comparison by attributes with ASPH
		RateAttribute(%)
District
Urban area
Rural area
Grade
Junior high school
High school
GenderMale
FemaleRelation to family
Very good
Good
Bad
Very bad
Number of friends
0–4
5–10
over 10

Mean

ASPH
F(t)

P
NS

72.3
27.7

12.8
13.0

–0.8

43.5
56.5

12.1
13.4

–4.8 < 0.001

47.1
49.5

12.4
13.2

–2.9

< 0.01

38.7
40.0
11.8
6.6

13.2
12.8
12.3
12.1

2.2

NS

77.9
14.6
4.3

12.9
12.7
12.0

1.0

NS

Qualitative analysis of the ASPH
Items from the ASPH were divided into 2 categories according to participants’ viewpoints of HSB.
Items were first categorized according to how aparticipant would personally act, and secondly

One-way analysis of variance.
ASPH, Attitudes toward Seeking Professional Psychological Help scale; NS, not significant.

42

ASPH-related factors in Japanese students

Table 3. Multiple linear regression analysis of ASPH and related factors					Model 1
FactorP

Model 2P

ASPH
Model 3District (0 = urban area, 1 = rural area)

0.04 		

0.07 < 0.05

0.06 		

0.04

School (0 = junior high school, 1 = high school)

0.14 < 0.001

0.11 < 0.001

0.08 < 0.05

0.07

Gender (0 = male, 1 = female)

0.09 < 0.001

0.06 		

0.04 		

0.02

Family structure (0 = single, 1 = with family)
0.01 		Image of psychiatric medicine 			0.05 		0.22 < 0.001

0.04 		0.19 < 0.001

0.05
0.19 < 0.001

Image of psychological counseling 			0.19 < 0.001

0.20 < 0.001

0.24 < 0.001

Stigma 					–0.09 < 0.01

–0.09 < 0.05

Knowledge of mental illness 					

0.06

P

0.07 < 0.05

Model 4P

Mental health status							0.09 < 0.05

Other (self esteem, social network, experience of volunteer)					 —R0.17 		0.40 		0.42 		R20.03 		0.16 		0.18 		R2 with model 1			
0.13 		0.15 		

0.44
0.18
0.15

NS

, standard partial regression coefficient; ASPH, Attitudes toward Seeking Professional Psychological Help scale; NS, not significant; R, coefficient of determination; R2, adjusted R.
Model 1, the fundamental attributes as the explanative variables in the 1st step; model 2, the image variable as the explanative
variables in the 2nd step; model 3, the stigma and knowledge variables as the explanative variables in the 3rd step; model 4,
the other variables as the explanative variables in the 4th step.

according to how a participant thought otherpeople would generally act during mental distress.
General aspects yielded more positive responses,
while items related to specific individual actions
showed fewer positive answers.

logical counseling image scale (r = 0.33, P < 0.01).
The ASPH correlated with knowledge of psychiatric disorders (r = 0.17, P < 0.01), stigma (r = –0.15,
P < 0.01), impaired cognitive function, (r = 0.14,
P < 0.01) according to age group and sex (females)(r = 0.09, P < 0.05).

Correlation analysis of the ASPH
Multiple linear regression analysis of the
ASPH

We examined the ASPH and each scale of the
explanative variables using correlation analysis. Two items regarding subjects’ perception ofcounseling and psychiatric treatment, or image,were deleted from the results that compared correlations between each item. Analysis was doneon the psychiatric image scale, which consistedof 8 items (Cronbach = 0.66), and the psychological counseling image scale, which consisted of 6
items (Cronbach = 0.73). The ASPH was strongly
related to the image variable on the psychiatricimage scale (r = 0.34, P < 0.01) and the psycho-

Through hierarchical multiple regression analysis(Table 3), we used fundamental attributes as explanative variables in the first step. Then the image variable was analyzed using multiple regression. Stigma and knowledge variables, along withother variables were analyzed in strict continuous
step-by-step order of correlation. As a result, thestrongest scale items connected to the ASPH were
the image variables and there was some connection to stigma and knowledge. The image vari-43

S. Takamura et al.

Table 4. Distribution of related factors
Junior high school students[508]

High school students
[660]

P

13.2
9.9
2.22
9.9

14.3
10.0
1.96
11.7

< 0.01†NS†< 0.05†< 0.001†

24.6
30.9

42.4
48.6

< 0.001‡< 0.001‡

17.9
3.5
42.7
52.8
30.2

13.0
4.3
53.8
56.8
30.2

NS‡
< 0.001†

Image of mental health specialist
Image of psychiatry (mean)
Image of counseling (mean)
Stigma toward disorder (mean)
Knowledge of disorder (mean)
Knowledge of specialist
Psychiatry “know” (%)
Counseling “know” (%)
Experience of consultation to specialist
The group of “had experience” (%)
Mental health status (mean)
GHQ over 4 points (%)
Having a stress in the past year (%)
Self esteem (mean)

NS‡
NS†

[ ], number of students.
† t-test.
‡ 2 analysis

ables for counseling (0.24) and psychiatry (0.19)
were the strongest and the value of the partial regression coefficient during all variable operations
was the same as the correlative analysis results.
An adjustment of difference in correlation of determination (0.13) occurred after the image variable was compared with fundamental attributes
by multiple regression Model 1, but the values of
0.15 and 0.02 increased with the operation of all
variables.

are more affected by outside influences than highschool students. Participants replied “a lot” or“often” (24%) for the item “Experienced stressthat I was not able to control within the previous
year”. We compared this finding to the national
average (9.8% for the same question administeredto adults in a national survey). Our participants
had a score more than twice the national average(Yamamoto et al., 1982). Four points was thecutoff for the GHQ (Cronbach = 0.82). Basedon this cutoff, 49% were considered at high-risk
for mental health disorders. Our participantstended to have lower mental health status thanother groups in the Japanese national survey.
We compared the ASPH scores of the high-risk
group to the low-risk group using GHQ scores,
and found no significant differences between the
ASPH scores and the former consultation orientation scores. In other words, even if a participant
had sufficient mental health distress to be in thehigh-risk group, HSB was essentially the same as
the low-risk group. In making comparisons according to age groups, 44% of junior high school
students and 55% of high school students were in
the high-risk group. The mental health status ofDifferences between the 2 age groups
Differences in the scales related factors compared
between the 2 age groups (Table 4). Factors related to HSB were compared between the 2 agegroups (Table 5) and the average score of the
ASPH was significantly higher for high school
students and showed positive attitudes towards
HSB. When we compared related factors to the
ASPH, junior high school students had a higher
correlation concerning image than high school
students. This suggested that a positive attitude
towards HSB was an explanative variable. These
results showed that junior high school students
44

ASPH-related factors in Japanese students

Table 5. Correlation and regression analysis of ASPH with putative factors between junior highand high school students
ASPH

Junior high school

Image of psychiatric medicine
Image of psychological counseling
StigmaKnowledge of mental illness
Mental health status

0.40
0.46
–0.10
0.10
0.03

< 0.01< 0.01< 0.05< 0.05NS

Explanation of ASPH†
The first 2 ASPHs‡ (R2)
All related factors (R2)

0.25		
0.27		High school
0.28
0.24
–0.17
0.16
0.03

< 0.01< 0.01< 0.01< 0.01
NS

0.09
0.11

ASPH, Attitudes toward Seeking Professional Psychological Help scale; NS, not significant; R2, adjusted coefficientof determination.
† Results of multiple linear regression analysis.
‡ Images of psychiatric medicine and psychological counseling.

high school students (the ratio of over the cutoff
point GHQ-12 were 53.8%) was lower than that ofjunior high school students (over the cutoff point
were 42.7%).

parents or friends rather than locating a specialist.
When they experienced poor mental health, theydigressed before they consulted an appropriate
expert. Henderson et al. (1992) emphasizes theimportance of person(s) whom students encounter “along the way” in the search for help before
finally arriving at professional support. However,there is a risk of prolonging the problem and earlyintervention is likely to be delayed, especiallywhen the confidante is ignorant of professional
resources. If students initially choose an appropriate adviser for consultation, successful early intervention is possible. In other words, there is animmediate need for specialized consultation whena mental health problem is first noted. A key toimproving future mental health services is to promote the acceptance of specialized consultation.
We found that students’ impressions werelargely influenced by the general public imageof psychiatry and counseling. We hypothesizethat HSB is primarily controlled by these images.
But “image” as analyzed on the psychiatry scaleshows a low reliability (Cronbach = 0.66), so
we think that a consistent image has not formed
because the subjects had little contact with psychiatric services. Furthermore, although the explanative variables were weak, stigma for persons
with mental illness and knowledge variables wereconnected. Therefore, for future intervention, we

Discussion
In our study on current status of adolescent mental health, 24% of participants answered that theyfelt stress “a lot” or “often”. This is a high ratio
compared to any group in the 2000 Japanese national survey (average, 9.8%). Likewise, 49%of participants crossed the GHQ cutoff point forhigh risk of mental health disorders. This is about
twice the average compared with other age groups(Zenkoku Shogaisha Kazokukai Rengokai Hoken
Fukushi Kenkyusho, 1998). These findings are
similar to past studies and reaffirm that juniorhigh and high school students experience stressthat exceeds their coping abilities and begin having mental health problems at a young age.
In the present sample of students, we observed their psychological distance in consulting
specialists. One type of HSB would be the desire
to talk about or openly disclose problems to an
expert. However, among them, we found that “If I
had distress” had a negative correlation with HSB,
and when students were distressed, they chose45

S. Takamura et al.

think that a program to increase knowledge about
disorders is a priority. A plan that decreases the
stigma and thereby counters the poor image ofcounseling is also necessary. While impartingknowledge of mental health has received someattention, activities that target stigma, improve
the image of mental health services among young
people and enhance coping skills are rarely taughtor reinforced in the current Japanese school system. Early intervention is part of such a program,and is expected to produce positive mental healthoutcomes. In addition, when we compared thefactorial connection of HSB among high schooland junior high school students, we found that
help-seeking behavior was related to image, stigma and knowledge according to each age group,
while the strength of explanative and related
factors decreased with increasing age. HSB for
specialized mental health services was positiveand related factors were affirmative. Among highschool students, HSB for consultation resources
improved with maturity. However, high school
students had more mental health distress.
The ASPH scores did not reveal significant
differences in HSB between the high- and lowrisk groups in the two age groups. However, we
believe that there is a need to intervene in highrisk groups. A factorial explanation may help to
explain why some high school students are more
likely to seek help compared to junior high students. However, it is expected that there are otherunpredictable influences on high school students.
Intervention that addresses the variables of image
and knowledge may be more appropriate for junior high students than for high school students.
The selection of public schools is a limitation, so in the future participants from private
schools should be included in research samples.
Furthermore, this was a cross-sectional study andtherefore, changes among participants may occur
over time between junior high and high schools.
A longitudinal study will be needed to compare
age groups as they mature.
We confirmed that Japanese adolescents are
at great risk of mental health problems and that

there is a need for preventive intervention. Juniorhigh and high school students have a tendency tochoose family or friends rather than specialists
for consultation. In addition, the general public
image of psychiatry and counseling strongly contributes to HSB. We demonstrated that knowledge and stigma variables are areas for target intervention to counter the negative image of mental
health disorders and treatment. Working towards
improving mental health services through knowledge of mental health and decreasing stigma will
increase HSB in the future. In addition, we advocate a plan for junior high students as the target
participants for intervention because we show
evidence that mental health services are needed
and because this group is less likely to initiate appropriate action on its own behalf.
Acknowledgments: We would like to thank all student
participants as well as the teachers and school nurses
who helped with this study.
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Received April 4, 2008; accepted June 16, 2008
Corresponding author: Soichi Takamura, RN, MS

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