AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Intersectoral and interagency partnerships to investigate
youth help-seeking and the responses of at-risk young men to intervention services
Coralie J. Wilson, Frank P. Deane, and Joseph Ciarrochi, Illawarra Institute for
Mental Health and Department of Psychology, University of Wollongong
Debra Rickwood, Centre for Applied Psychology, University of Canberra
Summary
Introduction
Body
Framework
Conclusions and recommendations
Acknowledgement and references
One in four young people will experience mental health problems at some point in their
lives, but less than one third of these youth will receive appropriate services. Young men
are particularly likely to avoid using mainstream professional services. Evidence suggests
that intersectoral and interagency collaborations will help bridge the gap between those
in need of help and those who receive it. The aim of our research program is to
investigate appropriate youth help-seeking, particularly the responses of at-risk young
men to intervention services. This paper describes how our research program itself mirrors
and parallels processes by which different agencies might better coordinate their efforts
to facilitate youth help-seeking. We provide an overview of our research program and
suggest a framework that incorporates the principles and mechanics of partnerships that we
have found are necessary for partnerships to be successful and sustainable.
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A growing array of evidence suggests that simply to be young and male carries with it substantial risk for suicidal behaviour. Reports indicate that Australian young male suicides have increased while Australian young female suicides have remained less than that of males and relatively stable [1][2][3][4]. Since 1973, the suicide rate for young males aged 15-24 years has more than doubled. This has been paralleled by rates for men aged 25-34 years [5]. During 1999, 2500 Australian young males aged 15-34 years died. Of this number, one in four deaths was recorded as suicide [6]. Whilst these statistics are sobering, providing the most concern are rates indicating that within the already high risk young male population there are several groups at even higher risk for suicide completion [7][8][9]. Australian and international data have shown that young men aged 20- to 24-years, rural, unemployed, indigenous, incarcerated, substance abusing, and gay/bisexual represent groups at increased risk for suicidal behaviour. Compounding this level of risk, there is evidence that some of these high risk groups are more likely to drop out of helping services prematurely even if they are able to initially access mental health helping resources [10].
Unfortunately, an understanding of the contributing factors that lead to young male suicidal behaviour and the various points of entry into suicidal pathways remain unclear [11][12][13]. Certainly, in order to prevent youth suicide or intervene when young males are suicidal, it is vital to have some understanding of the processes that might be involved in the development of suicidal behaivours. One author suggests that we "must seek to identify risk and protective factors (stressors and supports) in the youth population that can be reduced or enhanced, respectively" [14].
Our current research program focuses on factors that protect against suicide in a project that examines Help Seeking and the Responses of At-Risk Young Men to Intervention Services. Within this 24-month National Health and Medical Research Council funded project [15], we are investigating reasons to explain why young men, particularly those subgroups at the highest risk, do not seek help and tend to drop out of helping services prematurely. Our research is based on evidence that (1) young men are least likely to seek help [16][17], (2) young men are most likely to complete suicide [18][19], and (3) young men with suicidal ideation are less likely to seek help [20][21][22][23]. Certainly, the relationship between high-risk young men, suicidal ideation, and help-seeking needs to be understood.
Appropriate help-seeking is particularly important as a suicide prevention strategy. It
is widely agreed that seeking appropriate help, on one’s own or one’s peers
behalf, offers generic protection against risk at any point on a suicidal pathway [24].
(Appropriate help-seeking occurs when an individual seeks help from a source that is
potentially able to offer useful help for distress reduction and increased
problem-solving.) Help-seeking can be protective and/or compensatory by mitigating the
exposure to risk and/or the effect of risk factors, such as substance abuse [25][26], for
the development of suicidal behaviour. (i.e., ideation, attempts, and completion)
[27][28]. Appropriate and early help-seeking has the potential to prevent young male
suicide by catching young men before their distress becomes severe and they become
suicidal.
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Given the protective nature of appropriate help-seeking, the core objectives of our current research program aim to inform early intervention strategies and the modification of barriers and facilitative factors which increase the probability that those most in need of assistance, specifically high risk young males, seek help appropriately. Our project involves focus group discussions with high risk young males (aged 19- to 24-years, substance abusers, rural, indigenous, unemployed/dropped out from high-school, incarcerated, homo/bisexual, conduct disordered, currently engaged in intervention services, or dropped out from intervention services) and community gatekeepers (general practitioners, teachers, school counsellors, youth workers, parents/caregivers). Our project also includes questionnaire completion by a sample of young males (n = 1000), half who are currently in services and half who are not. Project questionnaires comprise measures of variables that are associated with help-seeking and which show potential for intervention programs for young men in high risk populations. All project questionnaires comprise measures of core variables: help-seeking barriers (Brief Barriers to Adolescents Seeking Help Questionnaire [29][30]); help-seeking intentions (General Help-Seeking Questionnaire [31][32][33]); and help-seeking behaviours (Actual Help-Seeking Questionnaire [34][35]); symptom distress and suicidal ideation (Suicidal Ideation Questionnaire [36]) in addition to specific variables associated with different target groups (e.g., social connectedness, social problem-solving, masculinity, restrictive emotionality). Participants have been and are currently being recruited from intervention services, educational institutions, and a range of community organisations (government and non-government) keen to participate in this study.
In order for us to recruit young male participants from across the community and the wide number of target groups needed for our study, we have formed a number of collaborative relationships with services and organisations. This has required a substantial time commitment from us with representatives from different organisations to explain our research at their pace, to find common ground and needs, to listen to the practical experience of service providers in order to better inform our research, and to negotiate levels of organisation participation. Our networking has included a variety of organisations, some with research backgrounds and others without. Therefore, during our early meetings with organisations, we often had to reassure our potential partners that our research is transparent and that our purposes and processes ethical and honest. It has also been important to show that we are willing to give and not just take. For example, our research team has been represented on a regional suicide prevention committee. The committee comprises representatives from a variety of government and non-government community organisations, all with different levels of expertise and experience with research. Over the course of a year, our research program has been discussed in terms of benefits to the community and how we can help the committee reach its goals. From the interest generated, our research recently became the basis of workshops that were supported by the committee as a suicide prevention initiative (YES! Workshops for Community Gatekeepers [37][38][39]). As a result of our willingness to be actively involved in community iniatives, we have been able to run focus groups with community gatekeepers and have developed strong relationships with many organisation personal who support our research and are keen to be involved. Furthermore, from the collaboration that occurred between organisations for the development of different workshops, partnerships for future research have been established. For example, partnerships for ongoing research projects have been established between the Illawarra Institute for Mental Health (iiMH) and Lifeline (e.g., the development of a help-seeking video for schools; Gould, Granger & Deane, 2001), and between the iiMH and the Illawarra Division of General Practioners (e.g., the development of the Essential Youth Friendly GP Kit; Wilson, Smith, Preston & Deane, 2001). We have also been invited to be involved in several Illawarra Youth Networks and offer advise for various community-based prevention initiatives (e.g., Mission Australia: Rickwood, 2000; Lifeline South Coast: Deane, 2001; AdraCare Cabramatta: Wilson, 2000).
Another example that clearly describes the necessity of relationship and reciprocation
in the development of partnerships has been in our work at a local high school. The Do
It Together Kit [40] is a booklet that promotes appropriate help-seeking in young
people. It is an outcome from a collaborative relationship between the iiMH, the Student
Representative Council and the school Welfare Staff. Consistent with the some of the aims
of our larger research program, the DIT Kit focuses on variables that show potential for
intervention programs for young people who are in high risk populations for suicidal
behaviour (e.g., attitudes, intentions, emotions, barriers, knowledge). As a result of
spending time developing the Kit, we have the school’s full support and approval from
the New South Wales Department of Education and Training to evaluate its influence
on student mental health using our project questionnaire. We have also established a
long-term partnership with the school for future research.
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Using a Working Alliance Framework for Developing Intersectorial and Interagency Partnerships
Admittedly, we did not set out with a framework for partnership building. However, as we have reflected on those partnerships which are strong and lasting and those that were tenuous but which are now strengthened, we sought to understand the processes and various "events" which have lead to the different levels of partnership. In retrospect, our experiences highlight processes and principles of collaboration that seem to provide a framework that can be applied prospectively to research and the development of future collaborative relationships. (i.e., processes by which different agencies might better coordinate their efforts to bring distressed youth to the right help for their problems). In our view, the principles that we have successfully employed are consistent with those of the Therapeutic Working Alliance [41][42].
According to Bordin (1994), the Working Alliance comprises three essential components: Tasks, Goal, and Bond. Congruent with Working Alliance theory, we have found that each component works in combination to determine the quality and strength of our collaborative relationships and partnerships. We have also found that our partnership building has hinged on the degree of concordance and joint purpose that exists between our team and our potential partners. In terms of Bordin’s theory, our success at partnership development between ourselves (as individuals on a research team) and as a research team with community services and organisations, has been dependent on mutual goals and common beliefs in the necessary tasks to achieve these goals within a context of mutual understanding and trust. For example, our research team was formed with the goal of being involved in youth suicide prevention research and with the desire to work together within the context of trust, respect, and a common commitment.
For the purposes of extending Bordin’s theoretical framework to act as a template for prospective partnership building, we have extended the definition of Goals to refer to mutually identified targets for working together in partnership and Tasks to refer to the behaviours and cognitions that "get the job done". In our experience, as in the Working Alliance literature, within our well-functioning partnerships, tasks have to be defined and assigned following open and honest discussion between all partners. It is important that partners perceive the tasks as relevant and efficacious and each partner accepts the responsibility to perform those tasks to which they have agreed (and follows through). Consistent with Working Alliance theory, it is our experience that explicit negotiation of the detailed aspects of goals and tasks is an important step for both partnership building and attaining and maintaining the strength to overcome the inevitable strains and alliance ruptures that occur when working together in a team.
Bond refers to the complex network of personal variables that exist between people. When applied to the context of partnership building, we have found that whilst our partnerships have been primarily established on the basis of mutual goals and shared tasks, our partnerships have developed in large part as the result of trusting personal relationships. We have found that at the basis of most partnerships is a personal relationship between a research team member and an organisation representative. In many cases, the social and personal aspects of our working relationships have been vital for the maintenance of our partnerships and for continued research. For example, many of our partnerships are maintained through ongoing email contact, over lunch or coffee, and in discussions that go well beyond the scope of our current research.
When describing the therapeutic working alliance, Bordin [43] states that "the
bonding of persons in a therapeutic alliance grows out of their experience of association
in a shared activity" (p. 16). We have found that bonding during the development of
our partnerships has grown in the same way. We have also found that this process can be a
slow and delicate. However, the results that come from persistence and purposefully
allowing time for bonds to grow may ensure the development of collaborative relationships
that must exist for successful partnerships to develop.
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Conclusions, Thoughts and Recommendations
We believe our experiences provide practical examples of how a Working Alliance framework can be used to direct the development of partnerships. Our experiences also provide an example of how the lack of attention to Working Alliance principles can lead to poor partnership development.
The way in which partnerships developed as a function of the YES! Workshops provides some retrospective insight into how a Working Alliance framework can be applied. The regional suicide prevention committee on which we were represented, was convened by the Illawarra Division of General Practice and formed on the basis of broad goals. These included the need to "establish and maintain partnerships with relevant stakeholders in mental health" and to "facilitate an area-wide approach in consultation with key stakeholders to adolescent mental health" (Illawarra Division of General Practice Strategic Plan, July 2000-June 2003, p. 4). Initially, there was a high turn over of committee members and a large drop-out rate. Reflecting on working alliance theory, early drop-outs could have been predicted on the basis of unclear and perhaps non-mutually defined goals and inadequate relational engagement [44][45]. In our experience, as time went by, the goals of the remaining committee became more specific and refined. Subsequently, a core of regular committee members became established. Certainly, different levels of goal were needed for partnerships to be established. Some goals needed to be global while others needed to be specific. Without specific goals, it seemed likely that relatively weak partnerships would have formed. If people didn’t know what they are working toward, it seems likely that they will have a weak commitment to the relationship. In this example, the initial lack of specific goals might at least in part explain the observed member drop-out. In our view, it is necessity to establish both global and specific goals early in the life of a partnership.
As the committee started to identify and work toward specific goals such as "train youth workers to be better able to identify psychologically distressed young people and successfully support them to appropriate help sources", the committee began to specify the tasks needed to reach these goals. Initially global tasks such as "develop a training program then do some training" were outlined. This was followed by the identification of specific tasks such as "determine modes of training, determine needs for training, determine key people to conduct training, and determine key people for the organisation and planning of the training".
As a function of goal and task negotiation and specification, various levels of bond developed. At a macro level (i.e., the committee as a whole), collegial relationships were formed within the context of a shared purpose and group membership. At a micro level (i.e., the YES! Workshop sub-committee), strong individual relationships were formed as we worked together to overcome challenges and obstacles to perform specific tasks and goals. These interpersonal relationships were fostered and maintained through the reinforcement of contact and successes (i.e., praising each other’s efforts) and meeting in informal as well as formal contexts. Importantly, each of our sub-committee relationships has provided the basis for discussions and negotiations about further research and applied projects that we currently share (e.g., extension of the YES! Workshops for Community Gatekeepers: Wilson & Booth, 2001; Wilson, O’Tool, Hudoba, & Cambourne, 2001; development of the Youth Friendly GP Training Workshop Series, Workshop 1: Wilson & Deane, 2001; examination of GP youth referral practices: Wilson, Biro, Deane & Preston, 2001; development of the YES! Workshops for Adolescents: Wilson & Cambourne, 2001; development of the Life Strategy Workshops for Adolescents: Wilson & Cambourne, 2001). Most importantly, each interpersonal relationship has facilitated the formalisation of partnerships between the services represented and ourselves for on-going research and development.
In addition to good examples of positive partnership building, our research has provided us with one example of how limited attention to the Working Alliance framework can result in poor partnership development. Recently, we were involved in the development of a proposal to extend our current research and include a broad range of government and non-government organisations. Fortunately, we already had strong partnerships with most of the organisations with which we wanted to work. However, due to very tight time lines, we did not adhere to all Working Alliance principles with one partner. Although our proposal had good global and specific goals and we had a strong bond with one individual within the organisation, we did not pay appropriate attention to the communication of our goals with other key individuals within the organisation. In retrospect, we can see how important it is to set goals collaboratively to avoid potential partners experiencing our goals as being imposed upon them, regardless of how appropriate the goals may be. Furthermore, we didn’t pay necessary attention to defining the specific tasks needed by this partner or to developing the important introductory bonds with other key individuals within the organisation. Our inattention lead to a rupture.
Retrospectively, we have considered a Working Alliance framework to identify issues that may lead to the rupture. This enabled us to clarify what was not done and how we were responsible. It also enabled us to identify what we needed to do in order to grow from the rupture and develop a strengthened partnership. Initially we worked on building bond. We accepted responsibility for our part in the rupture and acknowledged our lack of attention to the issues leading to the rupture [46][47][48]. Fundamentally, we needed to establish trust. Next, we worked to establish and refine our mutual goals. We spent time discussing goals and found mutual interest in improving access to psychological services and overcoming organisational barriers that impede access for young people. On the basis of these goals, we clarified the tasks required for reaching our goals in the context of our new project proposal. Finally, we extended our bond by inviting each other for information sharing meetings that were unrelated to our proposed project. We also began the process of working on smaller projects to maintain links and our developing relationship.
In sum, our experiences have highlighted Working Alliance principles that we have now
successfully applied in further partnership building: (1) Allow time for partnerships to
develop, remaining cognisant of the relational needs during the entire process (e.g.,
recognition, validation, and support needs). Time needs to be both formal and informal in
context. (2) Start partnership building by collaboratively defining and developing global
goals. (3) Negotiate specific short-term goals that will enable global goals to be met.
(4) Collaboratively specify the tasks and responsibilities necessary for achieving
specific goals. (5) Ensure regular contact and meetings between partners. There should be
meetings to coordinate initiatives and provide feedback where possible. (6) Ensure
explicit recognition and reinforcement by marking progress being made regardless of how
small, recognising difficulties that partners endure, and encouraging perseverance to
achieve goals. (7) Review and reassess goals explicitly. (8) Maintain a relationship focus
that monitors and nurtures the relationships in addition to monitoring and facilitating
cohesian between partners.
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The project outlined in this paper is currently being funded by an Australian National Health and Medical Research Council Grant, awarded to the authors in 2000.
References
[1] Cantor, C.H., Neulinger, K., Roth, J., & Spinks, D. (1998). The epidemiology of suicide and attempted suicide among young Australians. A report prepared for the National Health and Medical Research Council. Canberra, Australia.
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[4] Cantor, C.H., Neulinger, K., & De Leo, D. (1999). Australian suicide trends 1964-1997: youth and beyond? Medical Journal of Australia, 171, 137-141.
[5] Ibid.
[6] Australian Bureau of Statistics (2000). Canberra: Australia.
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[13] NHMRC reports (1998): Beautrais (1998), Cantor et al., (1998), and Patton & Burns (1998).
[14] Kalafat, J. (1997). Prevention of youth suicide. In Weissberg, R.P. & Gullotta, T.P. (Ed.s.), Healthy Children 2010: Enhancing Children’s Wellness. Issues in Children’s and Families’ Lives, 8. Thousand Oaks, CA.USA: Sage. p. 179.
[15] Deane, F.P., Rickwood, D.J., Wilson, C.J., & Ciarrochi, J. (2000). Help-Seeking and the Responses of At Risk Young Men to Intervention Services. National Health and Medical Research Council of Australia Grant.
[16] Rickwood, D.J., & Braithwaite, V.A. (1994). Social-psychological factors affecting seeking help for emotional problems. Social Science and Medicine, 39(4), 563-572.
[17] Vessey, J.T., & Howard, K.I. (1993). Who seeks therapy? Psychotherapy, 30(4), 546-553.
[18] Cantor, C.H., Neulinger, K., & De Leo, D. (1999). Australian suicide trends 1964-1997: youth and beyond? Medical Journal of Australia, 171, 137-141.
[19] NHMRC reports (1998): Beautrais (1998), Cantor et al., (1998), and Patton & Burns (1998).
[20] Carlton, P.A. & Deane, F.P. (2000). Impact of attitudes and suicidal ideation on adolescents’ intentions to seek professional psychological help. Journal of Adolescence.
[21] Deane, F.P., Skogstad, P., & Williams, M. (1999). Impact of attitudes, ethnicity and quality of prior therapy on New Zealand male prisoners’ intentions to seek professional psychological help. International Journal for the Advancement of Counselling.
[22] Deane, F.P., Wilson, C.J., & Ciarrochi, J. (in press). Suicidal ideation and help-negation: not just hopelessness or prior help. Journal of Clinical Psychology.
[23] Saunders, S.M., Resnick, M.D., Hoberman, M.M., & Blum, R.W. (1994). Formal help-seeking behavior of adolescents identifying themselves as having mental health problems. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 718-728.
[24] Kalafat, J. (1997). Prevention of youth suicide. In Weissberg, R.P. & Gullotta, T.P. (Ed.s.), Healthy Children 2010: Enhancing Children’s Wellness. Issues in Children’s and Families’ Lives, 8. Thousand Oaks, CA.USA: Sage. p. 179.
[25] Baume, P. (1996). Suicide in Australia: Do we really have a problem? The Australian Educational and Developmental Psychologist, 13, 3-39.
[26] Juon, H., & Ensminger, M.E. (1997). Childhood, adolescent, and young adult predictors of suicidal behaviors: a prospective study of African Americans. Journal of Child Psychology & Psychiatry & Allied Disciplines, 38(5), 553-563.
[27] Rutter, M. (1985). Resilience in the fact of adversity: protective factors and resistance to psychiatric disorder. British Journal of Psychiatry, 147, 598-611.
[28] Jessor, R. (1998). New Perspectives on Adolescent Risk Behavior. Cambridge: Cambridge University Press.
[29] Rickwood, D., Wilson, C.J., Deane, F.P., & Ciarrochi, J. (2001). Properties of the Brief Barriers to Adolescents Seeking Help Questionnaire: A reduced measure of professional psychological help-seeking barriers in high-school samples. In preparation.
[30] Kulh, J., Jarkon-Horlick, L., & Morrissey, R.F. (1997). Measuring barriers to help-seeking behavior in adolescents. Journal of Youth and Adolescence, 26(6), 637-650.
[31] Deane, F.P., Wilson, C.J., & Ciarrochi, J. (in press). Suicidal ideation and help-negation: not just hopelessness or prior help. Journal of Clinical Psychology.
[32] Wilson, C.J., Ciarrochi, J., Deane, F.P. & Rickwood, D. (2001). Properties of the General Help-Seeking Questionnaire: A measure of help-seeking intentions in college samples. In preparation.
[33] Wilson, C.J., Deane, F.P. Ciarrochi, J., & Rickwood, D. (2001). Properties of the General Help-Seeking Questionnaire in high-school samples. In preparation.
[34] Ibid.
[35] Rickwood, D.J., & Braithwaite, V.A. (1994). Social-psychological factors affecting seeking help for emotional problems. Social Science and Medicine, 39(4), 563-572.
[36] Reynolds, W.M. (1988). Suicidal Ideation Questionnaire: Professional Manual. Odessa, Florida: Psychological Assessment Resources.
[37] Wilson, C.J., & Deane, F.P. (2000) Strategies to Facilitate Appropriate Help-Seeking. Youth Empowerment Series (YES!): Practical Workshops for Dealing with At-Risk Youth. A workshop for Youth Workers and School Counsellors. Blackbutt, Wollongong, & Corrimal. Australia.
[38] Wilson, C.J., & Booth, D. (2000) Strategies to Facilitate Effective Youth Problem-Solving. Youth Empowerment Series (YES!): Practical Workshops for Dealing with At-Risk Youth. A workshop for Youth Workers and School Counsellors. Blackbutt, Wollongong, & Corrimal. Australia.
[39] Wilson, C.J., Pickard, J., & Deane, F.P. (2000) Strategies to Identify Youth Mental Health Needs and Facilitate Appropriate Help-Service Engagement. Youth Empowerment Series (YES!): Practical Workshops for Dealing with At-Risk Youth. A workshop for Youth Workers and School Counsellors. Blackbutt, Wollongong, & Corrimal. Australia.
[40] Wilson, C.J. (2000). The Do It Together (DIT) Kit. An information pack to reduce help-seeking barriers and encourage appropriate help-source engagement in youth and adolescents, particularly young males.
[41] Bordin, E.S. (1979). The generalisability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.
[42] Bordin, E.S. (1994). Theory and research on the therapeutic working alliance: new directions. In A.O. Horvath & L.S. Greenberg (Eds.), The Working Alliance: Theory, Research, and Practice, 13-37. New York: John Wiley.
[43] Ibid. p. 16.
[44] Horvath, A.O. & Greenberg, L.S. (1994). The Working Alliance: Theory, Research, and Practice, 13-37. New York: John Wiley.
[45] Saunders, S.M. (2000). Examining the relationship between the therapeutic bond and the phases of treatment outcome. Psychotherapy, 37(3), 206-218.
[46] Safran, J.D. & Muran, J.C. (1996). The resolution of ruptures in the therapeutic alliance. Journal of Consulting and Clinical Psychology, 64(3), 447-458.
[47] Safran, J.D. (1993). Breaches in the therapeutic alliance: an arena for negotiating authentic relatedness. Psychotherapy, 30(1), 11-24.
[48] Safran, J.D., & Muran, J.C. (2000). Resolving therapeutic alliance ruptures: diversity and integration. Journal of Clinical Psychology, 56(2), 233-243.
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