AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Engaging young people in mental health services: Overcoming
barriers to appropriate help-seeking
Coralie J. Wilson & Frank P. Deane, Illawarra Institute for Mental Health and
Department of Psychology, University of Wollongong
Summary
Introduction
Body
Conclusions and recommendations
Acknowledgements and references
There is a growing body of research that addressing issues surrounding the engagement of young people in mental health services. Research has identified a number of barriers that interfere with appropriate youth help-seeking. However, few studies have either investigated the relative importance of different barriers or youth opinions about how important barriers might be reduced for increased mental health service engagement. Our current research is aimed at identifying strategies that might assist in reducing youth help-seeking barriers and facilitate appropriate help-service engagement. This paper presents the results of three of our recent studies in which we used qualitative and quantitative methodologies to investigate the importance of different adolescent help-seeking barriers, identify ways to reduce adolescent barriers, identify ways to encourage adolescents to stay engaged in appropriate help, and investigate teachers help-seeking tendencies. Student and teacher perceptions of barriers and help-seeking behaviours are compared.
Effective mental health programs are important for the safety of youth and adolescents.
A number of suicide prevention programs have focussed on lowering barriers to
self-referral and increasing appropriate help-seeking by various forms of training and
support (e.g., school gatekeeper training, community gatekeeper training, general suicide
education screening programs, peer support programs, crisis centers and hotlines
[1][2][3]). Despite the obvious potential of these programs, there is little international
evidence to suggest they actually offer effective protection against suicidal risk [4][5].
This is also true for Australia.
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Appropriate help-seeking is considered protective or compensatory. It is a generic protective factor that can act to mitigate exposure to risk, or the effect of risk factors, in the development of adolescent distress and mental health problems [6][7][8][9]. Nevertheless, evidence suggests that few adolescents who experience significant psychological distress seek help from a professional or report intentions to seek appropriate help should they have a need [10][11][12][13][14]. Instead, many youth who experience distress or suicidal thoughts, indicate they would not seek help at all or they would do so from sources that may not be appropriate. For example, many distressed adolescents seek help from peers that may not be able to provide appropriate help [15][16][17][18], and many suicidal adolescents refuse help rather than seeking it from an appropriate source such as a mental health professional or an adult who can facilitate access to professional help [19][20][21][22]. Although help-seeking prevention programs have clear theoretical foundations, it seems likely that barriers still exist between program purpose and efficacy, particularly when youth are suicidal.
There is a growing body of research that shows appropriate help-seeking to involve a
network of interwoven personal and social variables that affect both the utilisation and
success of mental health services [23][24][25][26][27]. Within this research, a number of
barriers to youth help-seeking have been identified. These include fear that
confidentiality will be breached, increased emotional and psychological distress, negative
perceptions about potential help-givers, negative attitudes to help-seeking, beliefs that
help will not be useful, and seeking inappropriate help [28]. In addition, there exists a
consistent finding that youth most in need of help (i.e., those with suicidal ideation)
are least likely to seek it [29][30]. Together, these findings raise several questions.
Are there barriers that exist in addition to those we already know about? How can barriers
be reduced? And, how can actual help-seeking be increased for all types of problems,
including suicidal behaviours? In two of our recent adolescent help-seeking studies we
have addressed these questions [31][32].
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In the first study we used focus group discussions and questionnaires to explore adolescent help-seeking barriers [33]. The study used a relatively small sample of 23 high-school students aged 14 to 17 years (n = 11 male and 12 female students). Importantly, qualitative and self-reported data seemed to be consistent. Transcript analysis highlighted several factors that had been previously cited as risk factors for suicide (e.g., cognitive distortions [34]), but not to our knowledge, as specific help-seeking barriers. Analysis also extended previous findings [35] revealing that cognitions (beliefs, perceptions, knowledge, cognitive distortions) and emotions (experience and expression) had an influence on decisions to not seek help for non-suicidal and suicidal problems.
Consistent with prior research, strong themes (indicated by recurrence and consistency
across discussions) emphasised the important influence of fear, anxiety and shame
[36][37][38], adolescent autonomy [39], and the cognitive distortions of
over-generalisation and rumination [40]. It seems possible that cognitive distortion might
act as a help-seeking barrier or as a trigger for other help-seeking barriers.
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Closer theme inspection revealed that aversive emotions often co-occurred with knowledge deficits about appropriate help-seeking and limited or poor professional help-seeking experience. It seems that aversive emotions and knowledge deficits were two distinct barriers that might interact to function as a substantial barrier to appropriate help-seeking. Participants indicated that cognitions and emotions acted together to influence problem perception and appraisal, problem solving strategies, and the decision to seek help as a functional step towards solving a problem. Importantly, this cognition-emotion interplay seemed to be reflected across all help-seeking themes, especially in tendencies toward avoidance behaviour once problems were recognised. Themes also suggested that students experience difficulty recognising problems and have a limited knowledge about functional ways to solve problems (in this case, match problems with appropriate help sources and seek appropriate help).
Importantly, help-seeking intentions showed a similar overall pattern to that previously identified in a college sample [41]. Consistent with the previous findings, there was a significant overall interaction between problem-type and help-source (F = 3.68, df = 12, p = <.001). There were also distinct differences between young men and women and a significant sex effect (F = 4.42, df = 1, p < .05). It is notable that even with small sample sizes (n = 11 young males, n = 12 young females) there were significant relationships between professional help-seeking barriers and intentions. Young men reported higher barriers and lower intentions to seek appropriate help. Correlations between barriers and intentions highlighted different reasons for why each gender would not seek appropriate help, particularly that of mental health professionals. Young men revealed more reasons that were associated with aversive emotions, and beliefs about the futility of help than young women. Young women seemed more concerned about the opinions of others (e.g., family). If investigated further, these differences might help elucidate why men are less likely to seek appropriate help [42][43][44][45] and are at more risk to complete suicide than young women [46][47][48].
In the second study we used focus group discussions to explore adolescent opinions
about reducing help-seeking barriers and increasing appropriate help-source engagement
[49]. Transcript analysis provided a note of optimism as most participants seemed to have
positive attitudes towards help-seeking. Most agreed that getting some kind of help was
good. Consistent with previous research, participants suggested that strong positive
relationships with potential help-givers were very important for their current
help-seeking [50][51][52]. A context of trust and confidentiality was also very important.
Consistent with previous findings, participants explained they were more likely to seek
help if they trusted a potential help-source to understand their problem and to offer
useful help [53][54]. When discussing ways to encourage continued appropriate help
engagement, students described approaches consistent with assertive outreach, follow-up
and therapeutic alliance [55][56][57][58]. Once again, participants articulated the
importance of strong relationships with help-givers for maintaining engagement.
Participants also explained that feeling help is efficacious and that they are free to
make choices are other important aspects of continued engagement. Participants felt this
was particularly true for mental health services. In our view, all strategies to promote
appropriate help-seeking must be implemented within a context of relationship and trust.
Furthermore, all strategies must to be implemented in such a way that young people are
empowered.
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Consistent with [59] view that education is a key feature of comprehensive prevention programs, participants suggested that help-seeking barriers would be reduced by education about help-seeking. In the participant’s view, education needs to promote the importance and benefit of appropriate help-seeking, describe different problems, match appropriate help-sources to different problem-types, teach about different help-sources, teach how to go about seeking appropriate help to solve a problem, and include help-seeking practice. We suggest that help-seeking programs give ideas about appropriate help choices for different problems, attempt to reduce help-seeking uncertainties, and give opportunities for positive help-seeking experiences. As highlighted in other studies, students explained that prior help was an important influence on current help-seeking [60][61][62][63][64]. If participants could recall memories of successful prior help-seeking episodes, they seemed more likely to seek help from that source again. This is not surprising, given that relationship and trust were consistently described as strong approach factors. We suggest that prevention programs should include exploration of prior unsuccessful attempts to seek help.
Similar to previous studies, participants suggested that people in their social networks have important influences on current help-seeking processes [65][66][67][68][69]. They explained that most of their help-seeking knowledge has been gained by observing others, from word of mouth and by help-seeking carried out on their behalf. Participants also revealed that positive relationships with potential help-givers are important for their willingness to raise sensitive issues. Consistent with a variety of authors, participants suggested that encouragement from others in their social networks is another important approach factor [70][71]. The implications are two-fold. First, programs need to educate in ways currently used by adolescents (e.g., through peer networks). Second, key gatekeepers such as teachers need to be active help-seekers themselves in addition to being appropriate help facilitators.
It is generally agreed that teachers and the school context are second only to parents
and families in the strength of their influence on adolescent behaviour [72]. From a
social learning perspective, it is possible that if teachers are not help-seekers, they
may intentionally or not, exhibit behaviours or attitudes that deter appropriate
help-seeking in adolescents. Social learning theory proposes that humans learn by the
social and cognitive processes of observation, imitation, and reinforcement that can be
explained in terms of operant conditioning [73]. Put simply, we observe, we are reinforced
and we learn from it [74]. Theoretically, adolescents might be more willing to seek
appropriate help if it is modeled by gatekeepers such as teachers. Importantly,
gatekeeper’s attitudes and beliefs have been found to be important influences on how
they will respond to others’ distress [75][76]. However, several explorative studies
have identified teacher behaviours which may discourage help-seeking in adolescents
[77][78].
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In a third help-seeking study [79], we used focus group discussions and the General Help-Seeking Questionnaire (GHSQ [80]) to explore 18 high-school teachers opinions about appropriate help-seeking and their intentions to seek help for non-suicidal and suicidal problems. Transcript analysis revealed strong themes similar to those found in previous studies: Themes suggested that cognitions (beliefs and knowledge deficits [81][82]) and aversive emotions (anxiety, fear and shame [83][84][85][86]) might have a negative influence on teachers help-seeking intentions. Consistent with our student focus group findings, theme inspection suggested that aversive emotions co-occurred with help-seeking knowledge deficits and beliefs that also acted as barriers [87]. Common help-seeking sub-themes suggest a consistency between teachers and students knowledge deficits and help-seeking beliefs. Theory and some empirical findings suggest that aversive emotions and beliefs regarding help-seeking impact on teachers attitudes about appropriate help-seeking [88][89][90]. From a social learning perspective, it is possible that teachers general attitudes to appropriate help-seeking may influence their students. For example, it teachers do not seek help, or at least understand the importance of appropriate help-seeking as a positive coping strategy, they might inhibit their students help-seeking. It seems less likely that teachers would reinforce help-seeking in their students if they do not endorse it themselves. Worse still, if teachers do not reinforce appropriate help-seeking, they might inadvertently reinforce inappropriate help-seeking (e.g., seeking help from peers or self for all types of problem) or avoidance (e.g., denial of the existence of a problem on the avoidance of any strategies to solve a problem). Lending some support for this possibility, Kliewer found that teachers rated children as socially competent when they tended to endorse active problem avoidance as a coping strategy [91].
Reflecting the findings of several student studies [92][93][94], teachers identified the important influence which trust and relationship have on their help-seeking intentions. Teachers also explained they might seek professional help if a suitable relationship did not exist with other sources. This implies that teachers might opt to seek appropriate help, particularly professional psychological help, not because they view it as beneficial or the best solution for solving a psychologically distressing problem, but because they view it simply, as the "last resort". In light of the teachers limited knowledge about appropriate help-seeking, it seems likely that education programs which address teachers knowledge deficits might be beneficial in encouraging their help-seeking. It is also possible that such programs would in turn influence student help-seeking.
As we have found in other help-seeking studies, teachers indicated they would seek help
from different sources for different problems [95][96]. Patterns of help-seeking
intentions were similar between the three studies. There was a significant interaction
effect between problem-type and help source (F = 3.75, df = 12, p
< .001). However, of concern was the finding that teacher’s intentions to not seek
help from anyone were higher, for non-suicidal and suicidal problems, than both our
college and high-school samples. When considered in the context of the focus group themes,
we believe teachers help-seeking beliefs and intentions are such that they could profit
form additional information about the processes and benefits of professional help-seeking.
This may be essential for the development of school-based programs that address students
social, emotional and educational needs [97][98]. It seems likely that the inclusion of
appropriate help-seeking training in teachers undergraduate and inservice courses would
benefit future prevention initiatives.
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Conclusions, Suggestions and Recommendations
Certainly, prevention programs need to be wholistic and embedded within a context of relationship and trust. Programs need to educate key adults who may be seen as role models and who can refer adolescents to appropriate help (e.g., teachers and parents and other key gatekeepers). We concur with Lindsay and Kalafat’s directive that potential help-givers need to be trained in relationship building strategies and to provide a supportive initial response to distressed adolescents and young people [99]. We recommend that help-seeking programs be integrated into all aspects of life as a normal life process. We also recommend that appropriate help-seeking is encouraged through assertive outreach and follow-up.
The studies outlined in this paper have been conducted within a larger Australian
National Health and Medical Research Council funded project: Help-Seeking and the
Responses of At Risk Young Men to Intervention Services. (Deane, Rickwood, Wilson,
C.J., & Ciarrochi, 2000).
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[82] Wilson, C. J., & Deane, F.P. (2000a). Exploring help-negation: Is it a manifestation of help-seeking barriers? Submitted for publication.
[83] Deane, F.P., & Chamberlain, K. (1994). Treatment fearfulness and distress as predictors of professional psychological help seeking. British Journal of Guidance and Counseling, 22, 207-217.
[84] Kushner, M.G., & Sher, K.J. (1989). Fear of psychological treatment and its relation to mental health service avoidance. Professional Psychology: Research and Practice, 20, 251-257.
[85] Kushner, M.G., & Sher, K.J. (1991). The relation of treatment fearfulness and psychological service utilization: An overview. Professional Psychology: Research and Practice, 22, 196-203.
[86] Wilson, C. J., & Deane, F.P. (2000a). Exploring help-negation: Is it a manifestation of help-seeking barriers? Submitted for publication.
[87] Ibid.
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[89] Deane, F.P., & Chamberlain, K. (1994). Treatment fearfulness and distress as predictors of professional psychological help seeking. British Journal of Guidance and Counseling, 22, 207-217.
[90] Deane, F.P., & Todd, D.M. (1996). Attitudes and intentions to seek professional psychological help for personal problems or suicidal thinking. Journal of College Student Psychotherapy, 10, 45-59.
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[92] Lindsey, C.R., & Kalafat, J. (1998). Adolescents’ views of preferred helper characteristics and barriers to seeking help from school-based adults. Journal of Educational and Psychological Consultation, 9, 171-193.
[93] Westcott, H.L., & Davies, G.M. (1995). Children’s help-seeking behaviour. Child: Care, Health & Development, 21, 255-270.
[94] Wilson, C. J., & Deane, F.P. (2000a). Exploring help-negation: Is it a manifestation of help-seeking barriers? Submitted for publication.
[95] Ibid.
[96] 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.
[97] Franklin, C., & Streeter, C.L. (1995). School reform: Linking public schools with human services. Social Work, 40, 773-782.
[98] 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. 175-213.
[99] Lindsey, C.R., & Kalafat, J. (1998). Adolescents’ views of preferred helper characteristics and barriers to seeking help from school-based adults. Journal of Educational and Psychological Consultation, 9, 171-193.
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