Community Mental Health Journal

https://doi.org/10.1007/s10597-019-00464-y

BRIEF REPORT

Barriers in Seeking Psychological Help: Public Perception in Pakistan

Waqar Husain1 

Received: 2 February 2018 / Accepted: 12 September 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Mental health services are globally less utilized because of several psychosocial barriers that vary from culture to culture.
Regarding Pakistan, a serious knowledge gap existed in this regard. The current study was aimed at exploring the barriers for
Pakistanis which stop them from seeking psychological help. The survey involved 3500 participants from 5 cities. The sample
was sufficiently rich to be categorized based on gender, age, education, profession and income. Data was gathered through
interviews and a self-report questionnaire. Lack of faith in psychological treatment, prior personal experience, religious
fatalism, carelessness for mental disorders, social defame, personal shame, bad reputation of mental health practitioners,
prohibition by family, and fear of treatment were found to be the barriers in seeking psychological help. To overcome these
barriers, the participants of the current study suggested the mental health practitioners of the country to raise awareness on
mental health and improve mental health services.

Keywords  Barriers in seeking psychological help · Under-utilization of mental health services · Psychotherapy · Mental
health

Health related stigma exists cross-culturally. Research has
confirmed that mental illnesses are more stigmatized as
compared to physical illnesses. People having severe mental
disorders e.g. schizophrenia are more stigmatized as com-
pared with people with less severe disorders e.g. depres-
sion and eating disorders. Seeking professional psychologi-
cal help has been considered a source of fear itself and can
be conceptualized as an approach–avoidance conflict. It
stays the last option to overcome psychological problems.
Only one-third of individuals who need professional psy-
chological help actually receive it (Corrigan 2004). People
tend to avoid professional psychological services and try
to receive help from their family and friends. Several stud-
ies have tried to explore the decisions to seek psychologi-
cal help and suggested several personal and socio-cultural
factors involved. These factors include gender, emotional
openness, self-construal, self-concealment, self-disclosure,
prior help-seeking experience, treatment fearfulness, public
stigma, opinions about mental illness, feelings of distress,
coping, past counseling experience, access to care, cultural
factors, social support and insurance coverage.
Pakistan, being a developing country, lacks enough
literature on mental health and its correlates. The earlier
studies by the researcher revealed that 27% of the country’s
population has tendencies towards a variety of mental dis-
orders (Husain 2017a); 36% population is aware of mental
disorders (Husain 2017b); and the majority has positive and
favorable attitudes towards mentally ill (Husain 2017c). The
researcher did not find any local studies which could have
explored the barriers for Pakistanis in seeking psychological
help. The current study was, therefore, conducted to meas-
ure and analyze the publicly perceived barriers in seeking
psychological help.
Method
Participants

The study involved 3500 conveniently selected Pakistanis

from different major cities e.g. Islamabad, Rawalpindi,
* Waqar Husain Peshawar, Abbottabad, and Lahore. They included both
drsukoon@gmail.com
males (n = 1621) and females (n = 1879). Excluding minor
1
Department of Humanities, COMSATS University, Park children, the participants of the study belonged to all the age
Road, Islamabad, Pakistan

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groups i.e. adolescents aged 13–19 years (n = 266), young
adults aged 20–29 years (n = 1446), adults aged 30–59 years
(n = 1702) and elderly aged 60 years and above (n = 86).
They included single (n = 1696) and married (n = 1804)
both. Their educational qualifications varied as Primary
(n = 19), Middle (n = 55), Secondary (n = 184), Higher Sec-
ondary (n = 479), Graduation (n = 1318), Masters (n = 916),
MPhil (n = 397) and PhD (n = 109). The study also included
illiterate participants (n = 23). The participants belonged to
different professions i.e. Teachers (n = 578), Housewives
(n = 481), Businessmen (n = 262), Students (n = 1128), Engi-
neers (n = 118), Soldiers (n = 65), Lawyers (n = 27), Medi-
cal Doctors (n = 141), Bankers (n = 10), Laborers (n = 59),
Managers (n = 180), Government Servants (n = 206), Nurses
(n = 6), Journalists (n = 1879), Policemen (n = 14), and Psy-
chological Counselors (n = 5). The study also included job-
less participants (n = 40). Based on their socio-economic
status, the participants were divided into four categories
i.e. Poor whose monthly income was lesser than Rs. 30,000
per month (n = 815), Lower Middle Class whose monthly
income was between Rs. 31,000 and Rs. 60,000 per month
(n = 1121), Upper Middle Class whose monthly income was
between Rs. 61,000 and Rs. 90,000 per month (n = 607), and
Well-off whose monthly income was above Rs. 91,000 per
month (n = 957).
Instrument
A questionnaire in Urdu (language) was developed to gather
the required data. The first part of the questionnaire con-
sisted the demographic information of the respondent i.e.
gender, age, profession, marital status, educational qualifi-
cation, and approximate monthly income. The second part
of the questionnaire consisted of open-ended questions to
gain the responses on (a) the perceived barriers in seeking
psychological help, and (b) suggestions for mental health
practitioners. The respondents were supposed to write five
possibly perceived barriers in seeking psychological help
in a prioritized order. The responses which came from the
respondents in a prioritized way were thereafter labeled and
categorized into nine categories i.e. lack of faith in psy-
chological treatment, prior personal experience, religious
fatalism, carelessness for mental disorders, social defame,
personal shame, bad reputation of mental health practition-
ers, prohibition by family, and fear of treatment. This should
be noted here that these responses (labels) came from the
respondents through open ended question and were not pro-
posed by the researcher in the questionnaire. The barrier
which was written first by a respondent was assigned with
a value of 5 and the barrier which was written fifth was
assigned with a value of 1 to keep the weightage of a barrier.
Values of 2, 3, and 4 were likewise assigned to the barri-
ers mentioned second, third and fourth. The respondents,
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Community Mental Health Journal
furthermore, were asked to suggest practical ways for the
mental health practitioners so that they should consult them
comfortably. Their suggestions were later analyzed through
content (sentences by the respondents) and categorized
into two main categories i.e. Awareness Raising on Mental
Health and Improving Mental Health Services. Frequencies
were thereafter calculated and converted into percentile. The
entire questionnaire could take 10 to 15 min to be completed.
23 research participants were illiterate. The same question-
naire was used as an Interview Schedule to obtain data from
them while conducting individual interviews.
Procedure
The researcher paid frequent visits to the aforesaid cities and
approached the conveniently selected participants in differ-
ent educational institutions, governmental and non-govern-
mental offices, private companies, etc. The respondents were
briefly informed about the objective of the study and their
consent was obtained. The data gathered was analyzed in the
Statistical Package for Social Sciences.
Findings and Discussion
The respondents mentioned nine different barriers in seek-
ing psychological help. These barriers in a descending order
included lack of faith in psychological treatment (M = 3.82;
% = 76.4), Prior personal experience (M = 3.61; % = 72.2),
Religious fatalism (M = 3.31; % = 66.2), Carelessness for
mental disorders (M = 3.23; % = 64.6), Social Defame
(M = 3.18; % = 63.6), Personal Shame (M = 3.16; % = 63.2),
Bad Reputation of Mental Health Practitioners (M = 3.12;
% = 62.4), Prohibition by Family (M = 2.96; % = 59.2), and
Fear of treatment (M = 2.95; % = 59.0). Females considered
Religious fatalism (M = 3.36 vs 3.26; p = .000), Carelessness
for mental disorders (M = 3.26 vs 3.20; p = .048), and Social
defame (M = 3.22 vs 3.14; p = .003) more significantly as
barriers in seeking psychological help as compared to males.
Males, on the other hand, considered Fear of treatment
(M = 3.02 vs 2.90; p = .003) as more significantly a barrier
in seeking psychological help as compared to females. Mar-
ried considered Bad reputation of mental health practitioners
(M = 3.20 vs 3.05; p = .000) significantly more as a barrier
in seeking psychological help as compared to unmarried.
Adolescents considered Carelessness for mental disorders
(M = 3.26 vs 3.22, 3.25, & 2.87 respectively; p = .001) more
significantly as a barrier in seeking psychological help as
compared to young adults, adults and elderly. Some sig-
nificant variations based on educational qualifications were
also found. Carelessness for mental disorders (M = 3.48 vs
2.55, 3.07, 3.29, 3.07, 3.24, 3,25, 3.38, & 3.28; p = .000)
was more significantly considered a barrier by illiterates.
Community Mental Health Journal
Prior personal experience (M = 3.84 vs 3.61, 3.64, 3.48,
3.54, 3.71, 3.58, 3.60, & 3.14; p = .000), Bad reputation of
mental health practitioners (M = 3.42 vs 2.83, 3.24, 3.14,
2.89, 3.16, 3.17, 3.22, and 3.06; p = .001) and Prohibition
by family (M = 3.32 vs 3.13, 2.82, 2.97, 2.88, 2.97, 3.00,
3.13, and 2.41; p = .000) were more significantly considered
barriers by people with Primary level of education. Fear of
treatment (M = 3.13 vs 2.43, 2.26, 2.64, 2.95, 2.87, 2.94,
2.98, and 3.05; p = .002) was more significantly consid-
ered a barrier by the ones with MPhil. Religious fatalism
(M = 3.44 vs 3.30, 3.16, 3.20, 3.10, 3.34, 3.34, 3.28, and
3.37; p = .009) was more significantly considered a barrier
by PhDs. Based on the economic status, the well-off class
considered Religious fatalism (M = 3.40 vs 3.27, 3.26, and
3.34; p = .000), Social defame (M = 3.33 vs 3.08, 3.15, and
3.16; p = .000) and Personal shame (M = 3.21 vs 3.13, 3.13,
and 3.19; p = .046) more significantly as barriers. The upper-
middle class considered Prior personal experience (M = 3.70
vs 3.64, 3.63, and 3.51; p = .011), Carelessness for mental
disorders (M = 3.30 vs 3.20, 3.18, and 3.28; p = .010) and
Fear of treatment (M = 3.15 vs 2.84, 2.88, and 3.02; p = .000)
more significantly as barriers. The poor-class considered
Bad reputation of mental health practitioners (M = 3.18 vs
3.17, 3.16, and 3.02; p = .015) more significantly as a barrier
in seeking psychological help.
Barriers in seeking psychological help have been studied
widely in different cultures. The researchers have proposed
several reasons why people do not avail psychological ser-
vices the way they are expected to. Intentions play the key
role in deciding and performing behavior and are influenced
by attitudes, subjective norms and perceived behavioral con-
trol (Ajzen 2005). Attitudes towards seeking psychological
help are the best predictors of seeking actual psychological
help. Studies conducted in different countries have revealed
that the societies in which attitudes towards seeking psy-
chological help are negative, have decreased utilization of
mental health services (Cramer 1999).
People who are willing to disclose their personal infor-
mation are more inclined to seek professional psychological
help (Leech 2007). Mostly, people feel shame in discussing
their painful emotions and therefore avoid seeking profes-
sional psychological help. This also reflects their low self-
esteem, low self-respect and low self-efficacy.
Lack of knowledge about mental health related problems
i.e. poor mental health literacy is an important barrier in
seeking psychological help. Codony et al. (2009) claimed
that two-third of people with mental illnesses don’t feel the
need for taking psychological help.
Fear of being stigmatized has been established as the
leading factor in avoiding professional psychological help
around the world. Stigma is even more harmful than the
actual mental illness. Stigma makes it difficult for peo-
ple with mental disorders to get inclined for professional
treatment. Stigma is generally typified into public or social
stigma and self stigma and both these types are considered
barriers in seeking psychological help. According to Link
and Phelan (2001) stigma comprises of five elements i.e.
labeling, stereotyping, separation, status loss, and discrimi-
nation. Stereotypes associated with mental illness further
include dangerousness, incompetence, and character weak-
ness. People mostly think that mental health services are
meant for “crazy” people. Their negative attitudes towards
people with mental problems are developed because of the
psychiatric symptoms, social-skills deficits, physical appear-
ance, and labeling of the mentally disturbed. People who
need psychological help avoid professional assistance for
maintaining a positive self-image in the society and do not
want to be thought as inferior, inadequate or weak. People
expect social rejection either before or after getting psycho-
logical help. Social stigmatization of people with mental
disorders may also affect their families negatively. The
relationship of the family with neighbors and relatives also
become stigmatized. The effects and dimensions of stigma,
however, may vary from culture to culture. In Chinese cul-
ture, for example, the intensity of stigma is quite high due
to the family bonding. Chinese families tend to hide their
members with mental disorders to save face in the commu-
nity (Mak and Cheung 2008). In Egypt, people with mental
problems are less blamed and more supported (Coker 2005).
For Indian families, the factors of family honor, shame and
moral responsibility are significantly associated with mental
problems avoiding them to seek professional support (Mar-
row and Luhrmann 2012). The stigmatized individuals have
lesser chances to secure jobs, less likely to lease accommo-
dation and get intimate partners.
Prior help seeking experience has been positively associ-
ated with favorable attitudes towards seeking psychological
help (Carlton and Deane 2000). There are studies, however,
which have found that many mental health patients had bad
experiences with mental health practitioners (Mead and
Copeland 2000).
To advance mental health practice in Pakistan, the
respondents provided different suggestions for mental health
practitioners through open ended questions. Their sugges-
tions were analyzed and categorized into two categories i.e.
Awareness Raising on Mental Health and Improving Men-
tal Health Services. The respondents advised mental health
practitioners to raise public awareness on mental health
through Seminars/Workshops (24.8%), through Public Cam-
paigns (16.2%), through Electronic Media (14.4%), through
Print Media (4.2%), and through Social Media (3.1%). The
respondents, furthermore, advised mental health practition-
ers to improve Mental Health Services by improving the
quality of therapeutic techniques (7.5%), by offering free
of cost therapeutic services (6.9%), by organizing recrea-
tional activities within the therapeutic process (6.9%), by
13

increasing the number of clinics (0.5%), by separating psy-
chiatric wards from hospitals (0.3%), and by offering psy-
cho-diagnostic services (0.3%). 15% of the respondents gave
no suggestions. Raising public awareness through media has
also been suggested by earlier researchers (e.g. Vogel et al.
2007). It could help in reducing stigma and shaping public
attitudes towards psychotherapy. An overview of the Inter-
net suggests that there are a very few psychotherapists in
Pakistan who market themselves though personal websites
and social media. The current study highly sensitizes the
stakeholders, especially the mental health practitioners in
the country, to initiate programs for raising public aware-
ness on mental health. They should also narrow down the
gap between religious beliefs and perceptions about psy-
chotherapy. This can be achieved by developing indigenous
psycho-diagnostic tools and psychotherapies to address the
culture-specific psychosocial issues. Initiating free of charge
mental health services could also advance mental health
practice in the country.
Funding  The study was not funded by any source.
Compliance with Ethical Standards  of Applied Research in Intellectual Disabilities, 21, 532–545.
Conflict of interest  The authors have no conflict of interest with the
publishing journal.
Ethical Approval  The ethical approval was granted by the departmen-
tal review committee at the Department of Humanities, COMSATS
University Islamabad, Pakistan. All the procedures performed in this
study were in accordance with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards.
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