A Qualitative Exploration of Help-Seeking Process

Matriculation to college life can often pose adjustment problems that require identification and help. This is especially true in societies where gender separation is the norm. This qualitative study explores the help-seeking process from the subjective and cultural perspective of Omani students. The processes of help-seeking behavior within the Omani cultural framework are explored in terms of recognizing, defining a problem, making decision, and selecting sources of help. A triangulation methodology was used in this study that included two and half months of observation and interaction at Sultan Qaboos University in the office of Deanship of Student Affairs, the Counseling Center, and the Psychiatric Department of the university hospital. Individual and focus-group interviews were conducted. The interviews were, for the most part, extensive dialogues. Statistical documents in regard to students’ academic probation as well as newspaper articles aided in understanding the Omani help-seeking process. The results show that Omani students experience multiple challenges that impact their psychological adjustments. These challenges can be associated with the novelty of academic life and the coeducational culture of the institution. Some freshmen face with new expectations of learning as well as separation from their close ties, and struggle to find a balance between some of their traditional points of reference and the new sets of values to which they are exposed at Sultan Qaboos University. The influence of traditional culture on the dynamics of problem recognition may be expressed by anger and rejection, declining academic achievement, and violation of religious principles. For these students, traditional values and religious practices are seen as key coping mechanisms.


Introduction
Students frequently experience complex and difficult personal and psychological issues throughout their journey in higher education (Archer & Copper, 1998).Due to the increase in the number and complexity of problems, the need for services has been growing within the past 50 years (Gallagher, Golin, & Kelleher, 1992).For example, the 1998 U.S. national survey of counseling center directors indicated that more than 75% of universities and colleges reported an increase in the severity of psychological problems (Bishop, Gallagher, & Cohen, 2000).In one study, one fourth of 1589 university students indicated the presence of a psychiatric disorder (Johnson, Ellison, & Heikkinen, 1989).A large percentage of students (43%) seen in counseling centers were judged by their therapists as seeking help for developmental issues, 29% were rated as exhibiting underlying pathologies, and 28% came as a result of situational problems (Keutzer et al., 1998).Such findings confirm that students on college campuses are experiencing psychological distress of one sort or another (Bishop et al., 2000).
College students also frequently need help with issues related to education and career.In a study of 608 students, it was found that over half of the students reported a need for help with job search strategies and dealing with procrastination (Gallagher et al., 1992).Another study found that 53% of the total sample of 2574 freshmen reported an interest in seeking help for educational and vocational concerns (Hill & Sedlacek, 1995).However, a relatively small percentage of college students use the services provided by counseling centers.For every student that seeks help, there are six to eight students with identified needs who do not seek help (Bishop et al., 2000).Moreover, more than three fourths of first-year college students currently have distress not using counseling for emotional problems (Rosenthal & Wilson, 2008).It thus appears that students underutilize such services (Bishop, Bauer, & Becker, 1998).Researchers emphasized the need for further investigation of the factors that impact students to acknowledge a need for assistance and the types of assistance students perceive as appropriate (Bishop et al., 1998;Eisenberg, Downs, Golberstein, & Zivin, 2009).
A reluctance to seek help from counseling services has been noticed in Arab cultures as well.One of the few studies that was conducted with Arab college students found 65% of the 235 students reported a need for support to deal with stress, 61.70% wanted assistance to achieve a goal, 60% needed help to deal with academic problems, 47.60% needed guidance to deal with a financial issue, and 47.60% had a need to understand themselves better.In spite of the reported needs, the study indicated that professionals, such as psychology counselors, academic counselors, or social workers were those least consulted (Soliman, 1993).Soliman speculated the reason for students' reluctance to utilize counseling services was due to unfamiliarity with the concept of counseling, the belief that counseling was for sick people, and the belief that a personal problem was considered to be a family matter.
Arabs often seek help only after years of delay.This behavior raises a question regarding Arabs' perceptions toward counseling and psychotherapy (Dwairy, 1998a).Avoidance was found to be common among Arab students (Al-Bahrani, Aldhafri, Alkharusi, Kazem, & Alzubiadi, 2013).According to Dwairy (1998b), avoiding psychotherapy is related, in part, to the stigma attached to mental health.Also, physicians, native healers, religious personnel, and family members are more likely to be the most preferred sources for alleviating distress.
Arab and international counselors and educators argue that counseling and mental health services can play an important role in facilitating students' development and helping them to deal with their problems (Moracco, 1979;Soliman, 1987).Students also point to the importance of the services that counseling can provide.The need to conduct research on psychological health has been seen as a need by many Arab educators, especially in determining what is normative and what is considered abnormal (Ibrahim & Alnafie, 1991;A. Ibrahim & R. Ibrahim, 1993;Soliman, 1993).In that essence some researchers suggested enforcing the referral system within college campus since external locus of control contributed significantly in Arab students' attitude towards psychological help-seeking (Al-Bahrani, in press).
This study was exploratory.The exploration was guided by research questions in four areas: 1) How do students recognize their problems?2) How do students define their problems?3) How do students make their decision regarding seeking help?4) What source of help do they choose?Context and culture were integrated in this study because literature showed that they had distinct roles in defining the problems, seeking help, and identifying the source of help (Cauce, Roderiguez, Paradise, & Shea, 2002).

Methodology
Acknowledging the relationship between people's subjective perceptions and mental health may assist in bridging the gap between addressing the dynamic interaction of culture and the therapeutic systems, as Higginbotham (1979) stated.Higginbotham argued that the planners of mental health in developing countries ignored the rela-tionship between the dynamic of culture and therapeutic system.He based his argument on the fact that the mental health services are led by the notions of western psychiatry.
This study was based on ethnographic phenomenological terms.During two months at Sultan Qaboos University, the objective was to identify and understand the help-seeking process from participants' perspectives.Through observations, extensive conversations, interviews, and gatherings, jalsāt, students' ideas and stories regarding the culture of the help-seeking process were collected.

Geographic and Sociologic Aspects
In terms of geography, religion, and ethnicity, Oman is one of the more complex countries of the Arabian Peninsula (Eickelman, 1984).The country is surrounded on three sides by the Arabian Gulf, the Gulf of Oman and the Arabian Sea respectively, and on the fourth by the great sand sea of Al-Rimal, the so-called Empty Quarter.Oman is located in the southeastern corner of the Arabian Peninsula.The society consists of four basic categories: the people of the sea who live by fishing, seafaring and trading; the agriculturalists of the Batinah coast and the south, and those of the interior who employ the, falj, system of irrigation; the mountain people of south and the Musandam; and the Bedouin of the desert areas (Oman'95, 1995).
Along with these distinctive geographic features, various religious sects contribute to the diversity of Omani culture.Three main Islamic groups are identified in Oman: the largest is the Ibadhi group, which is an integral part of the Omani national culture and a political force (Riphenburg, 1998), the second significant sect the Sunni group while the third Islamic group being Shii (Clements, 1980;Riphenburg, 1998).
The tribal system contributes also to the heterogeneity of Omani culture.The tribe is an organization of law and security.It organizes its membership into a larger structure characterized by cultural pluralism.There are hundreds of tribes in Oman that vary in size and cohesiveness.In Oman, lineal descent and male authority combine to tie family organization firmly to the genealogical framework of the immediate past.Family origins are regarded as important, and, to this extent, most Omanis regard themselves as belonging to a tribe (Wilkinson, 1987).

Sultan Qaboos University (SQU)
The setting for the study was Sultan Qaboos University (SQU).The SQU is located in a suburban area of Muscat, the capital city of Oman.The first students were enrolled in 1986.The university started with five colleges: Agriculture, Education, Engineering, Medicine, and Science.The colleges of Arts and Commerce Economics were added in 1987 and 1993 respectively.

The Deanship of Student Affairs
One of the facilities that were part of this study was the Deanship of Student Affairs.The aim of the Deanship of Student Affairs is to help students in enhancing their personalities with spiritual, physical, social, and cultural aspects.Its purpose is also to strengthen students' adherence to the Islamic way of life inside the university and ensures their compliance with the objectives of the university.

The Counseling Center (CC)
Another facility that was used in the study was the Counseling Center (CC).The counseling center, established in 1999, exists as a separate agency on the college campus.The center provides free services, including individual and group counseling, consultation, and outreach activities, such as presentations for classes, workshops for students and departments at SQU.The purpose of the center is to enhance students' educational experiences and assist with academic problems and to help students to grow in self-understanding and awareness.

The Department of Behavioral Science (Psychiatric Department)
The third facility used for help seekers that was included in the study is the Department of Behavioral Science.It is located at the university hospital and operated under the umbrella of the SQU hospital administration.It operates two clinics that are located in different places on campus.The Student Clinic is located at the center of the university near the Deanship of Student Affairs building and the Family and Community Clinic (FAMCO) also available to students and is located close to the hospital building.

Criteria for Selecting Participants
Participants were selected on the following criteria.First, students were from a variety of majors.Second, participants were from both sexes.Third, students were from different regions in Oman.Fourth, some students were on academic probation.The reason considering these factors was to acquire variation and richness in student reflections and perceptions about the help-seeking process (Punch, 2000).Morse (1998) stated that maximizing the variety of sampling was one of the most useful methods when exploring abstract concepts.Studies that had been conducted with college students documented that such factors as gender were associated with student attitudes towards mental health (Dwairy, 1998a;Salami, 1998;Solberg, Ristma, Davis, & Piroshaw, 1994).

Participant Recruitment
The method was used in selecting informants to enrich the phenomenon under study was purposeful selection (Strauss, 1987).Bogdan and Biklen (1998) defined purposeful sampling as choosing particular participants to enrich and add depth to a study.Purposeful sampling varies from convenient, to unique, snowball, and maximum variation (Merriam, 1998).The convenient participant refers to the informant who is available for study (Creswell, 1998).In snowball sampling, cases of interest are identified and or referred by other participants.Unique participants are those who can contribute significantly to the study.In maximum sampling, the process of selecting the participants is deliberately heterogeneous (Morse, 1998).
Accordingly, the participants of this study were recruited in three ways.First, they were recruited through researcher's presence in the field (SQU).The researcher had been given an office in the Deanship of Students Affairs because it was always full of students; it placed her in contact with students who were available and willing to talk.In informal conversation with students, the researcher was able to introduce her research.Female students were recruited when they visited the dean or inquired about particular offices.Some of those female students chose the researcher's office as a waiting room or information directory.They were too shy to ask or wait in the coordinator's office of the dean since the coordinator was male.In addition, at the Behavioral Science Department, the researcher had an office, which enabled her recruit help seekers.The researcher also recruited help seekers through her encounter in the halls or when they asked about social workers.Sometimes help-seekers approached the researcher out of curiosity about what she was doing there.
A second mean of recruiting was through the staffs at the Deanship of Student Affairs who were contacted to help recruit willing participants for the study.The male staff referred male students and female staff provided the researcher with female students.The staff in the Deanship of Student Affairs became a valuable source, directing the researcher to rich informants, either from students or from the staff population.The researcher encouraged the staff to give student who had an interest in participating in the study the contact and office number.
In addition, the researcher asked some of the instructors to provide her with specific students that were considered unique cases.Students on academic probation were unique cases because Academic probation was a theme that was offered by many students during their interviews.Many students described the fear of the possibility of falling under probation and its ramifications on their well-being.
The third source of recruiting was through a snowball sampling technique whereby participants were involved in the selection process.Participants helped to locate other potential participants through their social networks (Bogdan & Biklen, 1998;Merriam, 1998;Punch, 2000).Participants were also inspired to distribute the researcher's phone number to any student who showed interest in participating in this study.They referred her to heterogeneous cases.One of these cases, for example, was a student who was struggling with a compulsive behavior.

Participants
In deciding how many individuals should participate in the study, it was deferred to several researchers.Kvale (1996) said, "Interview as many subjects as necessary to find out what you need to know" (p.101).H. J. Rubin and I. S. Rubin (1995) and Punch (2000) stated that the "saturation point" is the principle in identifying the number of interviewees.
The participants of this study were the students, physicians, psychiatric outpatients, staff, counselors, instructors, and a traditional healer.Approximately 30 students were included in this study.There were approximately 20 for individual interviews.Two focus groups, one for females and the other for males were conducted.Each focus group had five participants.The duration of each interview varied from one hour to three hours.In addition to these interviews, the researcher was able to conduct lengthy informal conversations with students while attending some of their evening activities, trips, and during random encounters.
The researcher conducted several interviews with clinical outpatients at the psychiatric department at SQU because "Psychiatrist" was repeated term that was used in students' conversations and interviews.The researcher discovered from my interviews and informal conversations that psychiatrists were more likely to be mentioned as a source of help, particularly when the problems were extremely complex.Six interviews were conducted with physicians at Student Clinic and the Family Community Clinic at SQU because social workers stated that many students sought help from the medical sector on campus.They stated that student physical complaints had psychological roots.
The researcher had three interviews with staff members at the Student Affairs, three interviews with counselors at CC, and one interview with a part-time counselor at the education college.Lengthy interviews with instructors in the Islamic department at college of education from who have often sought help for their problems were included.Along with these interviews, there were informal conversations with staff at Student Affairs, psychiatric department, and instructors.The researcher also included a known traditional healer, because all the participants in the psychiatric clinic identified the first source of help they sought to be a traditional healer.Some of them decided to go by themselves, but for others it was a family decision.The researcher decided to explore the phenomenon from a traditional healer's perspective.Therefore, the researcher searched for a distinguished traditional healer who lived in the capital, Muscat.The researcher was encouraged to see the mu'lam, Saber, who agreed to have an informal conversation with her and who took her to visit some of his "patients" in their houses.

Data Collection Methods
A triangulation methodology was employed to gain a more holistic perspective of the phenomenon (Morse, 1998).In triangulation, as noted by Denzin and Lincoln (1994), researchers make use of multiple different sources, methods, investigators, and theories to provide in-depth understanding of the phenomenon and provide alternatives to validity.The primary methodology used to collect data for this study was an interview process.Individual and focus group interviews were conducted.Observation and document analysis were included to add depth and gain a thorough understanding in regard to the help-seeking process among Omani students at SQU.

Interview
Qualitative interviewing was the primary method of collecting data in this study.Punch (2000) described the interview as a good way of accessing perception, meaning, definition of situation, and construction of reality.According to Fontana and Frey (1994), interviewing is powerful for understanding human beings.Interviewing allows the participants to describe what they experience, feel, think, and act (Kvale, 1996;H. J. Rubin and I. S. Rubin, 1995).
As described above, two types of interviews were conducted, individual and focus group.After few individual interviews had been conducted, the focus groups were initiated.The reason for beginning with some individual interviews was to capture an initial essence and understanding of the phenomenon.This preliminary understanding provided some significant themes that became the focus points for group discussion.
Group interviews can produce different levels of data pertaining to the research phenomenon that are unobtainable through individual interviews (Fontana & Frey, 1994).The focus group permitted the researcher to observe the social interplay among students and capture their interpretations of the help-seeking process.The focus groups with Omani students produced two types of information.The first data was neither valuable nor rich because students were cautious in regard to what they said.This hesitancy revolved around the perception of gossip; especially since culturally, an individual's value depends upon maintaining a good reputation.The second type of information was rich because students were comfortable and initiated highly personal issues to illustrate their positions regarding the recognition of problems.Nevertheless, students were sensitive regarding the possibility of information being shared outside the group.

Observation
The adjunct data collection technique used in this study was unstructured observation in order to generate richer information pertaining to the phenomenon and to acquire an overview of the situation and what was transpiring.As this study proceeded, the observations became more focused on specific aspects, such as the types of cases that sought help from the CC and Behavioral Science Department respectively.Yet, the observation that occurred spontaneously produced valuable data.The observation for this study followed Merriam's (Merriam, 1998) list of areas that could be observed in the settings such as: 1) the context of the physical setting, where the attention was directed, for example, to the location of the building and the contents and arrangements of the waiting rooms, 2) the participants, where the observation was directed at the participants' behaviors, 3) activities and interactions, where the focus was on what was occurring and how students and staff interacted with each other, 4) conversation, which was directed at the dialogue that occurred in the setting, and 5) the observer's own behavior, where the focus of the observation was on the observer's behavior and assumptions that could affect observation of the setting.

Documentary Data
Document analysis was another ancillary source of collecting the data.According to Bogdan and Biklen (1998), the purpose of qualitative research is not to look for the truth but to understand the phenomenon.Documentary data is a good source for a qualitative case study.Merriam (1998) stated that documentary data could ground an investigation in the context of the problem being investigated.
It was included in this study all documents and written materials that had assisted in understanding and assembling data from multiple sources (Punch, 2000).Statistical documents in regard to students on academic probation were a supportive source for understanding probation.All written material that appeared in the newspaper regarding the phenomenon of curing or healing any physical and psychological problems that emerged during that time also aided in understanding of help-seeking behavior within the social context.

Data Analysis
All interviews were conducted in Arabic.Most interviews were taped, except for some students, psychiatric patients, and staff who refused to be taped.All interviews in Arabic were transcribed and all analysis was done in English.Data analysis started while the interviews were still under way.This initial analysis shed light on the areas that should receive additional attention and needed to be examined in more detail; thus, the researcher would refine the research questions to pursue emerging paths of inquiry.As noted by Merriam (1998), analyzing the data in the field inevitably occurs in the qualitative research, because it is difficult not to speculate regarding what was heard or seen.
The first aspect of the data analysis was descriptive.Descriptive analysis demanded little or no conjecture beyond the data itself (Punch, 2000;Strauss, 1987).The researcher developed a notebook for each of the places where fieldwork was conducted: the Deanship of Student Affairs, the CC, and the Behavioral Science Department in the hospital at SQU. Field notes assisted in describing what subjects said and how they acted.The notes included descriptions of what the subjects said before the interview was under way and their demeanors when they entered.The descriptive field notes presented the people, places, and activities in detail, rather than in summarization or evaluation.Researcher's field notes were written during and/or immediately after leaving the site of the interview.Sometimes it was impossible to write thorough notes during some of the observations and interviews; thus, notes were in the form of brief sentences, phrases, words, and quotes, which were later, expanded.
The descriptive notes also helped to assess unplanned impacts on the data.The issues of subjectivity needed to be taken into consideration.According to Hoskins (2001), subjectivity should not be ruled out, but brought to light through reflexivity.Bogdan and Biklen (1998) and Merriam (1998) also suggested that reflective questions can be part of the field notes and can help to assess unwanted influence on the data.Some of the inquiries that were taken into account while conducting this research were: What did the researcher feel?What kind of impression did the subjects seem to be trying to create?What was said or not said that surprised the researcher?Why was the researcher surprised?What was interesting, striking, and important to this study?
Disappointed and somewhat discouraged by the slow process of securing permission and then the rejection of conducting research at the CC, the reflective notes regarding the researcher feelings challenged any bias in the process of interpreting and analyzing the data.In addition, some conditions observed produced personal feelings of helplessness because the researcher had no control to change the situation.Reflective notes helped to separate the researcher perception of reality as she hoped it should be with people's reality, as it existed.
The second type of analysis was data reduction.Information was generally reviewed through writing memos.According to Punch (2000) and Sharmaz (2002), writing memos and reflective notes helped to spark fresh ideas, create concepts, clarify categories, and find connections among other categories.Daily time was allocated to reviewing notes and placing momentary themes in the margin.In this open coding phase, the aim was to develop salient categories of information.Another goal of this initial coding was to identify inquiry categories.This was achieved through scrutinizing the field notes or interviews line by line to define concepts that supported the data (Strauss, 1987).All information was coded in categories and titled by the words or phrases used by participants (Bogdan & Biklen, 1998;Strauss, 1987).The concepts were characterized as provisional where they were likely to be modified and elaborated as the research proceeded (Strauss, 1987).
The third step was to develop an axial coding.This analysis revolved around one category at a time.A single category was identified as the central phenomenon, and the interrelationship with its subcategories was explored.The data was categorized based on the frequency of specific information that arose and indicated an important or unique dimension (Strauss, 1987).Since the information was from different sources, informal displaying for personal use diagrams, tables, or graphs helped in seeing the connections among the categories.
Another form of coding was selective, as a systematical analysis of the central coding was conducted.As an example, selective interviews with freshmen regarding the central issue of adjustment were conducted.The initial aim was to validate the relationship between a core category and its subcategories by disconfirming examples.This was also seen as a means of filling in a category that needed additional modification and development.The core aim of this step was to integrate a theory that accounted for a pattern of behavior that revolved around the phenomenon under study.

Discussion
Two categories of themes emerged from the data: the first category contains themes relating to student struggle associated with SQU culture and the second category consists of themes related to the sources of help and coping strategies.In the process of answering the questions of this research, the steps of recognizing a problem and defining the problem were combined, and the steps of deciding to select help and selecting the source of help were combined.

Recognition and Definition of a Problem
Students' responses to this area emerged from the following questions. 1) Describe your experience at SQU; 2) What types of struggles have you experienced?In analyzing the observations and participant responses as well as their extended narratives, it was found almost all students experienced cultural shock, şadma thaqāfiyya, by attending the university.The participants experienced multiple challenges impacting their psychological adjustment.These challenges were usually related to the novelty of academic life and the coeducational environment of SQU.Both female and male students, particularly freshmen, described the SQU culture as "new world", "strange", "overwhelming" and "disorganized".

The Novelty of Academic Life
The first aspect of this challenge can be related to the academic factor.SQU is a huge leap for students given the incongruency between high school and university life.The major components of this incongruency are inadequacy in English, unfamiliarity with the SQU culture, and new ways of learning.Therefore, students, and more specifically freshmen at SQU, may be at greater risk for experiencing psychological distress.Female students added that they felt psychological pressure because they needed to familiarize themselves with the way of teaching, to use different ways of learning, and to learn how to deal with their instructors.Another student, Mohammed, considered his first two weeks to be the most difficult of his life.One of his friends delayed entry for a semester and another left the university.
That Omani students' experience difficulty in adjusting as freshmen is not unique to Omani culture.As Hirsch (2001) indicated, the personal and academic transition to college is difficult for anybody.Tasks such as learning new academic skills and dealing with physical separation from one's family are problematic for the adolescent who is in the transition from high school to college.
Another source of distress in regard to academics that is frequently cited by students is making an oral pres-entation.A freshmen male student indicated that he felt tightness in his chest when he made a presentation.A physician at the student clinic noted that oral presentations are one of the primary reasons for students coming to the clinic.This coincides with findings of studies that surveyed college students' needs in the U.S. Studies reported that students need assistance with learning skills to overcome presentation anxiety (Bishop, Bauer & Becker, 1998;Gallagher, Golin & Kelleher, 1992).Two aspects explain, in part, students' concerns regarding making presentations.The first aspect is that they lack presentation skills.Another aspect that students referred to was concern with the heterogeneous environment.Some female students stated that they were shocked when they learnt that they had to make a presentation, but became further distressed when they discovered that they had to make their presentations in front of males.

Expectations Are Challenged
The second aspect of students' challenges encompasses influential interconnected factors related to students' stereotypic expectations, their families, and the reality they experience at SQU. Students who are admitted to SQU are those who have obtained the highest grades in their high schools.Those students are expected to maintain the same academic excellence that they had previously exhibited.Students experienced distress when they fail to achieve high grades at SQU and struggled to deal with the situation.The degree of difficulty of performing the tasks related to some courses at SQU and lower grades of other courses was a source of frustration that made some students doubt their academic competency.
Students' families also expect that their children will achieve the same academic excellence.Their expectations are based on the students' previous performance in high school.Since the majority of participants in this study were the first generation in their family pursing a four-year college degree, parents place a great emphasis on academic achievement, which becomes an essential part of student anxiety about achieving high grades.Pleasing and living up to parental expectations regarding academic achievement add up to student stress, A. Ibrahim and R. Ibrahim, (1993).A female participant, Lila, did not tell her family about her second academic probation.She felt pain in her heart because she disappointed her family and let them down.
SQU has high standards for academic achievement.A senior female student described the academic system at SQU as "difficult and demanding".Students are subjected to continuous pressure even before enrolling.SQU has a highly selective admission policy which places students in a stressful competition.This is obvious in student narratives about repeating a year in high school in order to improve grades to enter SQU.Some students developed maladaptive behavior to deal with these pressures while in high school.In one case, a female student's strategy for coping with the pressure of achieving high grades in high school was to pull out her eyelashes and eyebrows.During the interview, she was struggling to control her compulsive behavior as she talked about her feeling of hopelessness.
Students' failure to meet the academic demands of SQU and to live up to their own expectations, as well their families expectations, are significant factors contributing to student psychological distress.Their narratives regarding academic probations demonstrated that clearly.Students on probation are at high risk for psychological distress, because the college degree is perceived as a vehicle for higher economic status and is a symbol of family pride and prestige.Joseph (1994) explained that in the Arab world the value of family honor is crucial.Family honor implies that one's senses of dignity, identity status, and self, as well as public esteem, are closely connected with how a family is perceived by the community at large.The cultural assumption is that a student's actions reflect on the family as a whole.In this sense, failure is not only distressing psychologically, but also places a student at even greater risk for further problems, especially if it is accompanied with other concerns such as relationships.Extreme actions such as suicide at SQU should set off an alarm for these greater risks that are significantly associated with the academic rigors to which students are subjected.However, the data does not confirm this correlation even though all the participants offered the academic factor as a reason.

The Coeducational Culture of SQU
The third influential challenge of the struggle is the uniqueness of Arab cultures, including that of Oman, which praises separation of the sexes.The social system in Oman is based on mixing and socializing only with the same gender.However, the implementation of this aspect of culture varies from one family to another.Even the education system in Oman promotes separation, although it is more flexible in private schools.Students who participated in this study were taught in a segregated environment from elementary to secondary school.Yet, when they enrolled in SQU, they found themselves enrolled in heterogeneous classes.
It appears that the coeducational culture of SQU is a significant factor for the psychological distress of some students.Culturally students are not accustomed to interacting with unrelated members of the opposite sex.These opposing views and lifestyles to which students are exposed when they enroll at SQU can be a significant stressor that may place them at risk for developing complex problems as demonstrated in Sana's case.Sana was depressed and cried during the interview.Sana attributed part of her depression to being in a coeducational culture and worrying about her future, because with her major, commerce and economics, she had no chance to work in a feminine environment.Some students partially blamed their low Grade Point Average in their freshmen year on the difficulty of adjusting to the coeducational environment.
The lack of interpersonal skills in interacting with the opposite sex emerged as a significant concern within the coeducational category.Because the value of segregation is embedded in the social structure of Omani society, students lack the experience of interacting with unrelated persons of the opposite sex.This lack threatens students' self-esteem and their sense of self-competency.Male students voiced this clearly in their narratives and conversations.Some of them showed interest in interacting with female students, but were uncertain of how to go about it and the consequences of this action.

Conflicting Values
Students are conflicted about their traditional value system in the coeducational culture of SQU.They are experiencing social changes where traditional values are challenged and new values of coeducation are unclear.Peterson (1970) argues that when alternative values increase, comes fear and lose of direction.
An analysis of the data suggests that conflicting values are manifested in two ways.The first type of conflict occurs when students attempt to restrict their interaction and socialization with the opposite sex and the new expectations of coeducational environment where they need to normalize these interactions.This conflict induces a state similar to Seeman's (Seeman, 1959) concept of meaninglessness in which students expressed uncertainty of what they ought to believe because the standard of clarity for their decision-making was challenged.Some students questioned the moral appropriateness of communicating and having a relationship with students of the opposite sex.
The male students participating in this study also conveyed contradictory values regarding romantic relationships.A new value was male students' desire to have a romantic relationship with a female student.This value may have been compounded by feelings of loneliness, being away from home and family surveillance, and the coeducational culture.The other value is shaped by the relatively traditional view of a modest woman.Some male students viewed a good female student as one who is not recognized throughout her years at the university.Another male student viewed a female honor to be like a white cloth, if it is polluted even with a small taint, the whole cloth will be tarnished.
The consequence of the conflict in student values regarding the coeducational environment impacts both academic and social life, which along with other factors could place them at risk for experiencing significant stress and adjustment problems.The impact of academic life presents for some females a difficulty in interacting and communicating with their male advisors and faculty.Furthermore, it limits students' social interaction as, clearly illustrated by a male student who felt uncomfortable being in an area where there were females, and female students felt guilty about being curious, which challenged the cultural value of shyness.Females and males learn to behave modestly and to restrict their interaction with the opposite sex (Altareb, 1996).
The second type of conflict is related surprisingly to the issue of love relationships.Romantic love relationships were among the greatest concerns that students reported.Within some Arab cultures, marriage is a family matter and not based on the concept of romantic love.However, even with the change that Arab cultures are undergoing, this view of marriage remains the rule and romantic love is considered an exception (Abudabbeh, 1996).
Female students were reticent to open themselves to this issue; nonetheless, they were generous in recounting other female relationship tragedies.When some female students were directly asked about the effects of coeducational environment on them, they responded that since it was a mixed society, it would be normal for affection to grow between both sexes.Female students did not relate any personal relationship experiences, because in Arab culture, as Abu-Lughod (1988) stated, sexual shame and modesty are more essential to women than men, and correspondingly, males are less repressed to deny it.As a female student in this study said, if a man loves, that would be pride, but if a woman loves it is shame, ayb.
The fact that some female participants in this study quite consistently reported that there were a good number of female students who experienced relationship problems, it is likely that female students, who struggle with romantic relationship concerns, are vulnerable to devastating distress.First, forming a romantic relationship deviates from the cultural notion of a modest Arab woman who shows no interest in men, makes no attempt to attract them through behavior or dress, and represses any indication of a sexual or romantic attachment (Abu-Lughod, 1988).The second aspect is the possible grieving over a lost relationship.One reason of disappointment in the love relationship occurs as a result of difference in religious sects or tribes as indicated by some participants of this study, because marriage within the same lineage is still highly preferred in Oman (Riphenburg, 1998).This pressure is greater on women in Arab cultures because, as Joseph (1994) explained, Arab women, somewhat more than men, are expected to put others before themselves and to see their interests embedded in those of others, especially family members.That male students freely shared their personal romantic relationships was surprising.In fact it was easy to access the male point of view regarding the issue of relationships.Several factors did impact data collecting in this regard.The first factor was education, where male students identified me in a professional role.This afforded male participants more flexibility to share their romantic love relationships with me.The second factor was gender, which facilitated access to the male students' point of view regarding romantic love relationships.Almost all male students who participated in this study stated straightforwardly that they preferred a female figure with whom to discuss the issue of romantic love relationships.However, the gender factor limited my access to aspects of relationships especially those that deviated from the cultural moral code.For example, a male participant found it difficult to freely express the relevant information.
Even with gender playing a role in data collection in issues concerning romantic relationships, almost all male students participating in this study reported that they preferred to see a female counselor for a relationship matter, and a number of them would see a female counselor even for other matters.This finding is somewhat inconsistent with the studies that suggested that an Arab male student prefers a helper from the same sex, and that Arab clients respect male rather than female therapists (Dwairy, 1998a;Soliman, 1993).

Factors Influencing the Recognition of a Problem
Several contextual and cultural factors contribute to explaining, in part, the dynamics of problem recognition within Omani culture, and most specifically for students at SQU.These factors are related to external factors that are consistent with Arab social reality characterized by external control (Dwairy, 1998b).Problems are recognized when associated with expressions of anger and declining academic achievement.Problems were also identified through observations by others or when some social criteria regarding appropriate behavior were violated.
A contextual factor that can capture students' attention to their own problems is the decline in their academic achievement.Students whose grades declined, and who were then placed on academic probation, reported that they experienced feelings of frustration and loss.This recognition is associated with a change in self-image regarding their academic abilities.Academic probation captured students' complete attention and their primary concerns were maintaining their status as students at SQU.As a sophomore female student said, "We were high achievers; our high school grades were above 90%.Why can we not succeed?" Another contextual factor contributing to the recognition of problems is observation by others.Several participants pointed out that people around them contributed to drawing their attention to concerns before they themselves noticed them.Recognition of others took two forms: when a problem was confirmed and advice was given to overcome the problem, and when some participants were advised to seek help.This finding concurs with the notion that help-seeking behavior among Arab people is usually associated with outsider referral (Abudabbeh, 1996;Masalha, 1999).
A cultural factor contributing to the recognition of a problem is expression of anger and hatred towards parents.Such actions are seen as abnormal behavior because they are socially and religiously undesirable.Parents' contentment, ridā, entails God's ridā and is a religious and traditional ideology that characterizes children's interactions with parents.The same idea reiterated in the Prophet Mohammed's Hadith that what pleases one's parents is also pleasing to God, and what annoys them like-wise annoys God.In Oman acting aggressively and shouting at others is also considered to be a sign of abnormality.The norm of appropriate conduct in daily life in Oman is characterized by "pervasive civility and tact that marks all social conduct" (Eickelman, 1984: p.112).Emotional problems were easily recognized when they were associated with hatred and shouting at other people as demonstrated in participant narratives.A mother in one of the families, who was treated by a traditional healer, emphasized shouting and being violent as one aspect that demonstrated that her son's behavior was abnormal.

The Decision to Seek Help and the Source of Help
The data demonstrated that students experienced psychological distress associated with the challenges of the transition to college and the social changes that students were exposed to at SQU.These multiple challenges were the result of being thrown into a culture of new values in a coeducational environment that required new skills.Soliman (1993) argued that Arab students are exposed to the pressures of culture and expectations which conform to family standards.Because of this, he concluded that they need a support system for this stressful situation.
Despite these struggles in which students in this study reported feelings of distress, frustration, embarrassment, confusion, insomnia, absentmindedness, loneliness, emotional emptiness, grieving over lost romantic relationships, and depression, they did not report that they sought help from mental health services.Mandated referrals, such as when students were placed on academic probation, and the self-referral case of Sana, were exceptions to this rule.
Examination of the data and narratives illuminated several elements that contributed to the decision to seek help and select a source of help.This is consistent with the view of Greenley and Mullen (1990) that help-seeking behavior is complex and involves several factors.
The first element is that one's cultural orientation towards emotion in general, and emotional problems in particular, contribute to the dynamics involved in making the decision to seek help.Expressed feelings and emotions, as reflected in participants' conversations and narratives, are quite often missing in family dynamics.A significant theme emerged from the collected data in regard to emotional emptiness; the feeling of emptiness is, in part, related to a lack of expressing love within their families.This is consistent with Eickelman's (1984) observation that women in the oasis of the interior of Oman shy away from open expressions of their feelings.She noted that they did little kissing, and when she asked about the reason, she was told that they might only kiss the hand of their mothers or sisters if they had not seen each other for long time.A cultural aspect is the emphasis that Arab cultures, such as Oman, place on the value of appropriate behavior, so that a person is appraised to be rational āql for a man and āqla for a woman.Abu-Lughod (1988) explained that in the Arab Bedouin society the concept of aql is connected to self-control, where a person controls their needs and passions to maintain the ideals of honor and propriety in social life.In some cases, students were over-conscious about their behavior being appropriate within social and cultural norms.
Another element emerging from the data regarding emotional issues that plays a role in people's decision to seek help was that some families perceived emotional problems as a kind of dal (self-pampering).Some female participants complained that their feelings did not capture family attention as much as tangible aspects.Since emotion is equated to the dal, it is likely that some emotional problems may not be perceived as symptomatic because of lack of understating or family attention.A social worker demonstrated this clearly when a family did not bring their daughter to her appointment in the psychiatric department because they assumed that her behavior was kind of dal.However, she was brought when she tried to harm herself.This finding coincides with Dwairy's (Dwairy, 1998a) statement regarding Arab tolerance of emotional problems, as long it is not expressed by undue violence, shameful behavior, or uncontrollable over-activity.
The third element emerging from the data regarding emotional issues that plays a role in the decision to seek help was that students focused on struggles, as demonstrated in some cases.A student may give no attention to feelings, considering them to be related to a solvable problem, as demonstrated in academic probation cases.For example, Lila did not pay attention to her feelings of restlessness and helplessness because her focus was solely academic.This view is consistent with what has been written about Arabs' tendency to focus on complaints rather than emotions (Diba, 2000;Dwairy, 1998b).
The fourth element emerging from the data suggests that some students repress their emotions.This factor contributes, in part, to explaining the decision dynamics of help-seeking behavior among students.Repressing emotions is defining a problem that one is "thinking too much of it".Female and male students whom I interviewed at the Student Affairs Deanship indicated, "Thinking too much about an issue creates a problem".One female student stated, "A psychological problem starts when we think too much about an issue.By thinking too much, a problem will occupy us, and thus we will feel distressed".This same view was related by a depressed student who felt her condition was caused by too much thinking.Students suggested coping strategies such as joining group activities, sleeping, humor, and emailing.
The fifth element influencing the decision to seek help is students' belief that a problem is deemed to recede on its own.Students rationalize their struggles with the belief that things will become easier with time.This was clearly demonstrated in freshmen conversations.For example, a freshman participant that identified himself as Bedouin was struggling with adjusting to SQU.When researcher asked him how he was coping, he anticipated that by the end of the year he would be OK.
The sixth element contributing to the decision to seek help is the severity of a problem and its impact on students.Literature suggests that as the severity of symptoms increases, individuals are more likely to seek help (Eric, 1995;Goldsmith, Jackson & Hough, 1988).A problem is severe when one experiences several difficulties and feels there is no hope.This aspect suggests that students who are subjected to different sources of stress are likely to be at high risk for experiencing psychological distress.In one self-referral case, a female student who was experiencing depression from being in a coeducational environment, and did not have a quiet place in her home to study sought help from the psychiatric department.
The seventh element that influences students' decisions to seek help is when a mandatory referral is required.Students who are placed on academic probation are required to contact CC.Interviewed students stated that they had difficulty adjusting to SQU, but they did not regard that as a factor in deciding to seek help.However, when students are placed on academic probation, the decision to seek help is made for them and they are required to make a contact with CC.Four participants of this study reported that they sought counseling services because they were on academic probation.
One reason some students would consider returning to seek help from counseling services was having had previous experiences with CC.Students who had previous contact with CC and found the services helpful and relevant voiced a positive attitude about using counseling services again.Those students considered counseling services as a viable option if they were to encounter academic problems.On the other hand, inaccurate assessment and treatment, as well as seeing a non-native counselor who may not be sensitive to the cultural traditions, were seen as reasons for students to be dissatisfied with their experiences at counseling services.An example, a female participant stated that she sought help from CC because she wanted to get information about academic probation.Nonetheless, the focus of sessions was on her family.She stated that that there was nothing wrong with her relationship with her family but she said, "I felt somewhat pressured to say that I had a bad relationship with my family".Such experiences influenced student decisions to consider seeking further help from CC.

Religious and Traditional Healing Systems
Religion was seen to be the most significant factor contributing to understanding why students on college campuses who experience psychological distress did not avail themselves of counseling services.The traditional and religious values are rooted in the social and educational system in Oman.Because religious and traditional values play an important role in the lives of people in Oman, the participants in this study identified their well-being as rooted to religious values.
Two religious values help students to cope with distress.The first value is the belief that the hardship and stress they undergo is from God, and accordingly, enduring the pain will reap good rewards.Almost all female and male students cited verses of the Quran and the tradition of the Prophet Mohammed while discussing their difficult experiences, such as struggling with the coeducational environment, academic pressure, and grieving issues.Students soothed themselves and bore the pain and struggles by reading the Quran and praying.Rahman (1987) explained that the Quran and the tradition of the Prophet explain several divine reasons for illness.The most frequently mentioned reason for illness and for other misfortunes is God's trial.
The second religious value for students coping with stress and crisis is the belief in predestination.Students talked about pressure, distress, and grief that they had experienced, tying these hardships to being inevitable and a manifestation of God's will.For example, two male students who participated in this study were grieving over the death of relatives.They acknowledged the pain; nonetheless, they soothed themselves by stating that it was God's will.In other words, the implication is that they must accept and tolerate the pain because it has a good return.With the orientation of predestination they also coped and dealt with their ambivalences regarding issues of their future.Some students emphasized that they performed prayers, called istkhāra, to help in making decisions regarding their dilemmas.This was demonstrated in two narratives: one in which a female student conducted the istkhāra prayer to help her make a decision regarding a marriage proposal, and another concerning a future job.A noteworthy aspect is that istkhāra did not emerge in male student responses.
It appears that the religious paradigm offers an explanation for why some Arab people declined to pathologize some behaviors and, thus, did not use mental health services (Dwairy, 1998a).Behaviors such as obsession and compulsion, which are connected to ritual cleaning, were perceived as being associated with religious rituals.Some students sought help from a religious figure for their obsessive and compulsive behaviors, believing they were related to ablution before each prayer and purification from menstruation.These behaviors start when individuals wonder if their act of purification meets the religious requirements in this regard.
A surprising factor is that a number of participants associated any sudden or drastic change in behavior with envy, magic spells and jinni.Different aspects influence students' perceptions regarding identifying a sudden or drastic change in behavior.The first aspect is rooted to religious context.Students, and most specifically females, legitimatize envy and magic spells as causes which inflict disturbance that are manifested in behavioral and emotional states, because they are mentioned in the Quran.The second aspect is also related to religious context.The participants regarded a sick person who refused to listen to the Quran (which is read over them as a part of faith healing) as a sign that the sudden change in the behavior was caused by envy or magic spells.The third aspect is lack of knowledge about the nature of mental health problems.Lack of information about the relationship between psychological and physical manifestation, in part, accounts for students' attributing a sudden change in behavior to envy and magic spells.Participants were unaware of the psychological etiology for behavior change with physical change.The participants in this study expressed curiosity if there was a relationship between psychological and physical states.
Data analysis shows repeated patterns regarding the path of help-seeking behavior for sudden and drastic change in behavior.Most help-seekers had sought help from a traditional healer, called a mu'lam, before coming to the psychiatric department.Failure to receive immediate relief influenced peoples' decisions to seek help from a physician, where they were referred them to a psychiatric department.If they did not benefit from the treatment, they turned again to a traditional healer.In one example, Alya sought help in the beginning from traditional healing, and then from general biomedical health center, and finally was referred to the psychiatric department.She stated if she was not cured by psychiatric treatment she would seek a traditional healer who was a popular phenomenon in Oman at the time the research was conducted.

The Medical System
Selecting a source of help is interrelated with the definition of a problem.The recurring words that participants used to describe discomfort or distress were "dīq fi alşadr".The literal translation for dīq fi alşadr is tightness in the chest.This expression carries a physical connotation, and was repeatedly mentioned by students and help seekers in the psychiatric department.A number of students who were distressed sought help from the student clinic.Freshmen especially sought help from the general medical sector for "first year syndrome", related to adjustment to university and relationship issues.This finding coincides with a prevailing statement in the literature that Arabs tend to somatize their psychological distress (Dwairy, 1998b;Masalha, 1999;Okasha, 1999).
Two factors were defined as contributing to students' decision to seek help from the student clinic rather than from mental health in general and CC in particular.The first was a lack of information about emotional troubles and the relationship between the psychological and physical states.Students were curious to learn if emotional troubles had an impact on the physical body.There was uncertainty about how to explain change in behaviors if associated with physical symptoms.The identification occurs within the biomedical paradigm because people in Oman are familiar with this mode of treatment.Culturally, a physical complaint is a legitimate condition for receiving empathy.Some participants' knowledge about emotional problems was limited to depression, the symptom being tightness in the chest.
The second factor contributing to students' decision not to use counseling specifically and mental health services in general is the stigma attached to these services.Students who are familiar with counseling services linked CC with academic problems.This perception contributed partially in discouraging other students from using counseling services or seeking help for other issues.A male student who was straggling with a relationship issue did not consider consulting someone from CC because he did not have an academic problem.
Some students perceived counseling services to be for students who were psychologically fragile.Some par-ticipants were discouraged by their friends from seeking help from CC, and other students feared they would be stigmatized.Some female students did not want to seek professional help from mental health services because they would be stigmatized as crazy, which might affect their chance for marriage.
The fear of being stigmatized as crazy was also noted among psychiatric patients.It was reflected in the psychiatric participant conversations regarding their dissatisfaction with their not having a separate waiting area for children with disabilities.Psychiatric participants expressed dissatisfaction by being mixed with children with disabilities, and some of them pointed out that they felt perceived as having mental problems.This finding is consistent with mental health research findings that the reason for presenting mental health problems as physical complaints is, in part, to avoid the stigma attached to mental health problems (Greenley & Mullen, 1990).

Conclusions
The research design of this study allowed various themes to emerge.The researcher was able to include and investigate emergent concepts and themes.However, the researcher was not able to access information regarding female struggles with romantic relationship issues, even though they indicated that such issues are a concern.I attributed their reticence to discussing their own relationship issues to my role as a researcher whom they believed could publicly reveal their issues.The researcher also attributed this to her identity as a cultural insider who was aware of the impact that romantic relationships have on a female reputation.The researcher wonders if this research had been conducted by a cultural outsider, and would the females have been as inhibited and restricted on their responses to this topic?Research on females in regard to their romantic relationships and the consequences on female psychological well-being from a cultural context would be both interesting and relevant to the counseling profession.It could stimulate discussion related to ethics.Case studies and positivistic approaches could also be used to explore this area.
The ambiguity and unfamiliarity of the concepts of mental health and counseling limited students' reflections in this study.The nature of the challenges limiting their reflections was due to its still being a new phenomenon, and lack of information created misunderstandings about the nature of counseling among people.This study was limited to Omani students at SQU.However, the data that were obtained from this study can provide a wider perspective in understanding the phenomenon of seeking help from mental health professionals within the Omani context.