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Copyright © eContent Management Pty Ltd. Contemporary Nurse (2012)
42(2): 167–177.
T
his paper presents the fi ndings of a qualitative
study which identifi ed the intra-family
strengths and burdens within rural families who
care for a young man with emergent mental
health problems. The fi ndings explain why some
rural young men experience a lengthy duration of
untreated mental illness. Families were identifi ed
as skilled helpers of their sons, and their strate-
gies for coping with diffi culties which arise dur-
ing the emergence of mental health problems are
discussed. The real life experience of both parents
and their son, as well as the emotional impact of
helping and being helped, was an intrinsic part of
their stories.
Background and literature review
In Australia, health services in rural communi-
ties are usually limited by size, diversity of ser-
vice type, and clinical skills mix (Aisbett, Boyd,
Francis, Newnham, & Newnham, 2007; Boyd,
Hayes, Wilson, & Bearsley-Smith, 2008; Boyd &
Parr, 2008; Wilson, 2007). Frequently, specialist
services require the resources of larger clinical set-
tings to administer specialist treatments (Edwards
& McGorry, 2002). The limited mental health
services which are available in rural settings may
be either out-patient type services or visiting
Experiences of families who help young rural men with emergent mental
health problems in a rural community in New South Wales, Australia
RHONDA LYNNE WILSON, MARY CRUICKSHANK
+
AND JACQUELINE LEA
School of Health, University of New England, Armidale, NSW, Australia;
+
Disciplines of Nursing
and Midwifery, University of Canberra, Canberra, ACT, Australia
Abstract: A qualitative study was conducted in rural New South Wales, Australia, to understand the barriers to help-
seeking among young rural men with emergent mental health problems. Participants who had real life experiences of these
problems within their families were interviewed. Themes emerged from the data which explained some barriers to early
intervention. Despite these barriers, families had developed skills in helping and in providing early mental health help to
their sons. The fi ndings of this study showed that a substantial burden on the emotional and social integrity of the fam-
ily, combined with diminished psychological well-being, caused some parents to question how long they could cope before
they reached ‘the end of their strings’. This downward spiralling trajectory of mental health and well-being for both the
young men and their families has implications for clinical practice. Current models of mental health service delivery do
not adequately capture the early help-seeking dynamics of young rural men and their families. A more fl exible approach is
needed to identify and help the family and the young men, without the pre-requisite for a formal medical diagnosis. Future
research should involve health and well-being solution focused service delivery.
Keywords: young rural men, emergent mental health problems, barriers, early identifi cation
services which are delivered in an outreach mode
(Edwards & McGorry, 2002). Where case man-
agement is possible, the case-loads of rurally-
based mental health clinicians usually contain
longer term clients with high levels of morbidity
and chronicity (Alexander & Fraser, 2008; Allan,
2010; Alston et al., 2006; Bambling et al., 2007;
Battye & McTaggart, 2003; Hoolahan, 2002).
Such a saturation of service capacity reduces the
scope for clinicians to expand the development
of their practice and to meet the needs of local
clients with emergent mental health problems.
In addition, it is unlikely that these services have
the capacity to stretch suffi ciently towards the
delivery of specifi cally targeted mental health pro-
motion and literacy campaigns within the com-
munity (Bartlett, Travers, Cartwright, & Smith,
2006). Priority is given to managing the chronic
mental health problems of the rural population,
while too little emphasis has been placed on pre-
vention, early identifi cation and early interven-
tion service provision.
A signifi cant factor is the limited availability of
mental health care professionals who choose to live
and work in rural communities, with many com-
munities having diffi culty in recruiting experienced
clinicians to rural clinician employment vacancies
Rhonda Lynne Wilson, Mary Cruickshank and Jacqueline Lea
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Signifi cance
This study is signifi cant because it describes fac-
tors that infl uence the early help-seeking behav-
iours of young rural men and their families. It
reports on the struggles that rural people have
in identifying emergent mental health prob-
lems and in selecting suitable professional help
to address these problems. It is well known that
early identifi cation and intervention of mental
health problems has a signifi cant impact on the
extent of disability and the prognosis trajectory
(Amminger et al., 2006; Berk et al., 2007; Catts
et al., 2010; Edwards & McGorry, 2002; EPPIC,
1998; Henry et al., 2007; McGorry, 2004;
McGorry, Killackey, Yung, 2007). The earlier that
interventions are applied, the better the progno-
sis, while conversely, long durations of untreated
illness adversely infl uences recovery (McGorry,
2004; McGorry, Killackey, Yung, 2007). Rural
people experience signifi cantly longer durations
of unidentifi ed and untreated mental illness, than
their urban counterparts which is frequently the
consequence of their general rural stoicism, cohe-
sive social proximity despite geographical dis-
tances, and a lack of conveniently located health
service resources (Catts, 2007; Catts et al., 2010;
Kelly et al., 2010; Wilson, 2008). The fi ndings
of this study can be utilised by policy makers and
clinicians to assist in the reduction of detrimen-
tal and lengthy delays in early help-seeking. This
paper reports on the actions that would be nec-
essary to close the gap between service providers
and the early help-seeking public.
Study aims
This study aimed to understand the experiences
of young rural men, and their families, who cope
with emergent mental health problems; and to
identify any barriers that might prevent young
rural men from accessing early intervention men-
tal health services available locally or regionally to
them.
The research questions included:
Do young rural men or their families know what to
do when something is not quite right and when early
mental health problems start to emerge?
What is it like to try and fi nd appropriate help in rural
areas?
(Buikstra, Fallon, & Eley, 2007). It is problematic
that few clinical resources exist for health promo-
tion, prevention, early intervention or ongoing
mental health clinical service to effectively support
rural young people with emergent mental health
problems. According to several authors (Edwards
& McGorry, 2002; Johannessen, 2001; McGorry,
2004; McGorry, Killackey, & Yung, 2007), this
problem should be considered a clinical priority in
order to reduce the duration of untreated mental
health problems of young rural people.
Timeliness
The research study was conducted at a time where
State and Federal Governments in Australia were
striving to address the need to improve young
peoples’ access to appropriate mental health ser-
vices across Australia (McGorry, 2007; McGorry
et al., 2007). One particular model, headspace, has
been subject to a great deal of popular public and
professional discourse (McGorry et al., 2007).
The headspace service delivery model, while hav-
ing a clearer youth focus, is underpinned by the
traditional primary care model of service which
is intrinsically medical in orientation (Hodges,
O’Brien, & McGorry, 2007; McGorry, 2007;
McGorry, Purcell, Hickie, & Jorm, 2007). A sig-
nifi cant limitation of the national public policy
which resources this model of service delivery is
that the distribution of service is confi ned to dis-
creet locations, most of which are in major popu-
lation centres, leaving many rural populations
universally under-resourced and vulnerable.
The access to these types of service models are
at odds with the experiences of participants in
this study, who reported their initial help-seeking
actions outside of the medically orientated primary
care frameworks. This is congruent with leading
mental health nurses who have indicated that early
intervention approaches to helping young people
with early mental health problems refl ects a health
service culture which leaves helping at a rather-
too-late phase (Wand, 2010). This research paper
highlights the mental health service needs experi-
enced by young rural men and their families, and
the fi ndings suggest that additional innovative
models of service delivery are required to meet the
current unmet needs of the rural population.
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health problems with symptoms of psychosis, with
either themselves or of a young man in their fam-
ily. All participants willingly participated in one or
two digitally voice recorded interviews at times and
locations convenient to them.
Procedure
Participants were provided with a plain language
information sheet about the research, and given the
opportunity to ask any questions before signing an
informed consent form. The interview schedule
consisted of an initial open ended question:
You indicated on the phone (that you have a son, and)
you’ve had some experience of an emergent mental health
problem with him. Can you tell me a little bit about that?
How do young rural men and their families select help
and where do they seek help?
When help is forthcoming, is it useful?
METHODS
Design
A qualitative, interpretive phenomenological
research design (Smith, Harre, & Van Langenhove,
1995; van Manen, 1990), underpinned the inves-
tigation of the real life journeys of 13 participants
who had experience of emergent mental health
problems of young rural men. Some participants
were interviewed on a second occasion to develop
a vertical depth in data saturation, resulting in 17
qualitative semi-structured in-depth interviews,
from the participants who
were residents of a rural
community New South
Wales, Australia.
Recruitment and
sampling strategy
Participants were recruited
from responses to a media
release and further snow-
balling and purposive
selection followed (see
Table 1 below). The sam-
pling method required that
participants were inter-
viewed initially and then
following preliminary data
analysis, some participants
were re-interviewed.
Participant selection
criteria
The participants for this
study were either young
rural men, 18 years of age or
older, or a parent of a young
rural man, and all were
residents of a rural com-
munity in NSW. None had
any current orders under a
Mental Health Act. Each
participant had some expe-
rience of emergent mental
TABLE 1: PARTICIPANT PROFILE
P Age Role Ethnical
background
CUP of
identifi ed
young male
Employment
type
S/D I
Pp1 50–60 Mother Anglo
European
Life long Self employed –
tourism
42
Pp2 50–60 Father Anglo
European
Life long Self employed –
farmer
42
Pp3 50–60 Mother Anglo
European
Early
childhood
Teacher 1 2
Pm4 23 Young
male
Anglo
European
Life long,
escalating
after 16-year
olds
Apprentice –
shop fi ttings
32
Pp5 30–40 Mother Aboriginal
Koori
Mid
adolescence
Administration
assistant
41
Pp6 30–40 Mother Aboriginal
Koori
Mid
adolescence
Human
resource offi cer
41
Pp7 50–60 Mother Anglo
European
Mid
adolescence
Administration
assistant
21
Pp8 50–60 Father Anglo
European
Mid
adolescence
Self employed –
tiler
21
Pp9 50–60 Mother Anglo
European
Mid
adolescence
Disability
pensioner
11
Pm10 24 Young
male
Anglo
European
Late high
school
Apprentice –
tiler
11
Pm11 21 Young
male
Anglo
European
Mid
adolescence
Apprentice –
builder
01
Pp12 50–60 Mother Anglo
European
Late high
school
Farm worker 1 1
Pp13 50–60 Mother Anglo
European
Mid
adolescence
Administration
assistant
11
Pp, participant parent; Pm, participant male; CUP, commencement of untreated
psychosis; S/D, siblings/dependants; I, number of interviews
Rhonda Lynne Wilson, Mary Cruickshank and Jacqueline Lea
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Face-to-face in-depth interviews then
proceeded, each with a duration of approximately
one hour. Data was digitally voice recorded, tran-
scribed and thematically analysed using paper
based and computer software assisted (NVivo8)
processes (QSR International, Melbourne, VIC).
Common themes were identifi ed which emerged
from the data and were organised into a model
which described the phenomenon under inves-
tigation. Ethical approval was obtained from the
University of New England’s Human Research
Ethics Committee prior to the commencement of
the study.
Data analysis
Consistent with phenomenological inquiry, the
fi ndings from this study have been presented in
themes. Thematic analysis was used in this study
because it enabled the researcher to understand
the dynamic of lived experiences in relation to the
research question and to extract meaning using an
organised and valid process (van Manen, 1990).
F
INDINGS
Following thematic analysis, three major themes
and seven subthemes emerged from the data.
Only two major themes and seven subthemes are
reported in this paper.
Help-seeking strategies within the family
The fi rst major theme to emerge was a descrip-
tion of the help-seeking strategies utilised by the
respondents in this study. This theme will be
reported fully in a subsequent paper.
Reluctance to identify as having a mental
health problem
Subtheme one recognises the reluctance to iden-
tify as having a mental health problem experienced
by both family members and/or the young man.
This subtheme supports the notion that emer-
gent phases of early psychosis are extremely dif-
fi cult to detect and that the symptoms are often
vague (EPPIC, 1998). For one young man, the
idea that his problems could be explained as a
mental health problem, had not occurred to him.
However, he recognised he was sad and wanted
to be alone:
I have gotten to the point where I really just wanted
to end it. Kill myself … and there are times when I
feel really, really sad and just lethargic and just want
everybody to leave me alone …
Thus a gap existed in the way this young man
interpreted his problems and how a mental health
clinician might interpret the problems.
One parent participant described the process
he had taken to gain help outside the family when
he considered that a crisis was developing which
represented a major risk for his son. The follow-
ing statement illustrates his proposed solution.
… legally he is an adult. There’s nothing legally we can
do to stop him from doing anything … and you talk
to your solicitor about it and he says you can get him
sectioned …
Even though the term ‘sectioned’ was used, it
was not used in conjunction with his son having a
mental health problem, rather it was a strategy to
curb the unwanted behaviour. This is interesting,
because throughout the conversation, it did not
occur to the parent that a mental health problem
was the major reason for the developing crisis.
In his view, it was a behavioural problem which
required a legal opinion in order to solve it.
The barrier of limited vocabulary
Vocabulary barriers were identifi ed as the second
subtheme. Frequently, the respondents had diffi -
culty in fi nding terms to describe the problems that
they were experiencing. A lack of vocabulary was a
barrier in selecting appropriate help outside of the
family setting. One mother struggled to describe
what the problems might be for her son, but was
aware that they had always been there, and in hind-
sight, could refl ect that the problems had been pres-
ent since her son was aged eight years. Later during
her son’s year 11 at high school she was aware that
things were getting worse, but she had no vocabu-
lary to articulate what it was that was worsening, as
demonstrated in her comment below.
He had always been a different child. … He was just
odd … we knew things were changing …
Unpredictability and social discomfort
The second major theme which emerged from the
data revealed the unpredictability and social discomfort
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Parents struggle to fi nd help for their sons
The third major theme describes how parents
struggle to fi nd help for their sons. Parents found it
extremely diffi cult to ascertain what type of help
outside the family might be available to them,
and where they might locate any helpful services.
When asked where one might fi nd help, a moth-
er’s response was:
I don’t know! I don’t know who to go to …
Another mother said:
I don’t think there is a lot of support in the rural areas.
I know … it should be better.
One father respondent had become dissatisfi ed
with services that he found for his son. He had
been helping his son for many years within the
family setting, but found that professional mental
health services could offer nothing more than he
had been able to offer for his own son.
And so, now, my confi dence in these so-called ‘help’
people is ZERO. Anyhow, because I think that they
are concerned about this thing NOW. This kid is
extremely depressed and all the rest of it, and so what
we do is look at the here and now. But, we never give
them the bad news that ‘hey – you’ve gotta make a
whole heap of changes’. Right?
Other respondents reported occasions of seek-
ing assistance with the general practitioner (GP), or
at the accident and emergency department of the
local hospital but how the lack of physical illness or
injury delayed access to an appointment, on some
occasions, for weeks. One mother indicated that
she had to plead with reception staff at the local
GP in an attempt to gain an earlier appointment.
I’ll just keep ringing you until you can get this man an
appointment, he’s really, really, really unwell.
Then, later:
I took him to the outpatients and sat with him for two
hours … they said, ‘off you go to your GP’. And he
is BAD; I tell you he is really bad … they are either
untrained or uncaring those people that go through
that system.
How long is a piece of string?
The fi fth subtheme is denoted by a phrase used
by one participant: How long is a piece of string?
This phrase implies a loss of hope and profound
which exists in the lives of young men with early
mental health problems, and for their families.
Families spoke about the strategies they used to
contain the unpredictable behaviours of the family
member, and their grief and loss in regard to the loss
of independence experienced by the young man.
Mothers spoke about their experiences of unpredict-
ability with their sons, and the need to monitor for
safety and to diffuse fl ash points as they recognised
heightened risk of harm within the family:
He is so unpredictable. I always have to see what he
is like before his father gets home … I don’t know
what the problem is … It has got to the stage where
I locked up all the knives in the house because I was
frightened …
He got to a stage where he was coming home and
threatening Mum’s life. Putting knives to her throat …
we would ring the police and dob him in because we
were scared for Mum’s life … he was psychotic.
Geographical issues of social stigma and social
proximity
The third subtheme which emerged from the data
is related to the geographical issues of social stigma
and social proximity. Social standing is very impor-
tant for young men in rural communities, and
once this is lost, it is extremely diffi cult to regain.
This prized rural attribute is risked as social dys-
function arises as a consequence of emergent psy-
chosis. The following comment of one mother
respondent illustrates this tension.
Well, I think 20 year old rural men are out and about.
Well, my son is. He plays footy and works in a pub
and goes out and … so having to admit you know
that there is stigma there, you know that he is not
well … he is very anti-counselling.
Emergent symptoms of psychosis and
depression
Emergent symptoms of psychosis and depression were
the experiences that made up subtheme four.
Respondents reported unsettling experiences
which included symptoms of psychosis and/or
depression. Families dealt with these experiences
by conducting ad hoc mood and behaviour surveil-
lances so they could act to avert a downward spiral
of the discomfort experienced by the young man.
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Belief systems and the role of the mother were
important for some respondents, and reinforced
the responsibility of the mother role and its inher-
ent obligation to care.
I was brought up in a very traditional Catholic family
… the mother is very important in your family, and
also in our faith. You know she is a very, very important
part. So, you know, we look after our mother and hope
that they look after us … it is a big part of our life.
However, a father described a different role
which was more objective and had an analytical
approach to problem solving. This father attrib-
uted gaining many of the skills he applied to help-
ing his son, as a result of the observation skills
he had developed in working in the agricultural
industry. The synergy between his work and his
helping role for his son gave him an operational
framework for caring.
… you’ve gotta be an observer, observer of body lan-
guage, environment … the whole works … I was trained
by my father. When I was seven or eight he’d say ‘come
on, we’re going for a drive … you can open gates for
me’. After you’d gone through the paddock and before
you got to the next gate he’d say: ‘Hold on, tell me about
the stock? What was the water like at the dam?’ He was
training me … to look at environmental things …
The emotional burden of parents
Lastly, the seventh subtheme identifi es the extraor-
dinary level of parental emotional burden. This
emotional burden demonstrates how the active
and stressful role of caring becomes entangled in
the parents own mental health and well-being.
It has always been a very emotional thing for me … I’ve
reached the end of my string (tears and sobs). This sounds
horrible, but, I wish he’d just go away … it is pulling our
family apart … we all tippy toe around his issues. His
brother is spending so much time anywhere BUT home.
I have got to the stage where I think ‘if you won’t take any
notice, just go off and do your own thing’ … I cry …
DISCUSSION
It is apparent that families in this study had devel-
oped skills as helpers for the young men in their
care, and that this commences early within the
family settings and this is congruent with similar
fi ndings by Rickwood, Deane, and Wilson (2007).
uncertainty about the future. Parents wondered
how long they could cope with the burden of care
and the diffi culties arising from helping a son
with an emergent mental health problem. One
mother reported that she could see matters build-
ing and getting worse over time.
… his odd behaviour seems to be escalating … he
has changed. His behaviour has changed. His attitude
has changed … I am very concerned that he is going
to (starts to become tearful) … to crack (her voice
quivers and softens to almost a whisper). He’ll either
run away, or do something really rash … end up in
a heap.
This respondent was very concerned that a
threshold was nearing whereby she might be
unable to help her son, and was fearful of what
this might mean for her, her family and her son.
I won’t be able to do anything. Just too many disap-
pointments building. I might be wrong. He might be
able to control himself … everything just seems to be
very negative … I wonder where it might go for him
… it bothers me that he might suicide … it comes
down to how long is a piece of string mostly.
This subtheme identifi es the helplessness that
is experienced by parents and the powerlessness
surrounding the escalation of problems, the vul-
nerabilities and inherent risks including the possi-
bility of suicide and the frustration of not having
someone to effectively intervene.
The role of the parent
Parental roles and concerns emerged as subtheme
six. An active strategy of practical caring oper-
ated within the family settings. The young
men recipients were not always appreciative of
the care given to them, but it was delivered by
family members despite the recipient’s inter-
est or engagement. Functional roles distributed
amongst family members, and especially parents
were important in the overall family coping and
functioning, although succession and sustain-
ability in caring roles was cause for concern by
parents.
I am really worried about who will look after him …
would someone else notice all the things I do? … if he
moves out of home, how will I manage that? How will
I know he is OK? …
Rural men with emergent mental health problems
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were applied to their sons where incongruent with
the life problem that they were experiencing. This
inconsistency served to reinforce the barriers to
professional mental health help-seeking experi-
enced by respondents.
The respondents in this study indicated that
the health service systems had let them down,
and they could not understand why early help
had not been more readily available to them
and their sons in their rural settings. While they
reported a profound depth of emotional burden,
they also told their life stories of searching for
inner strength to cope and to care for their sons
and that they had developed their own ways of
helping within the internal structure of the fam-
ily. The families’ skills and successes in helping
for long periods of time, and the lack of locally
available rural mental health infrastructure may
explain why some rural young men experience a
lengthy duration of untreated psychosis as con-
curred by other researchers (Sutton, Mayberry, &
Moore, 2011).
The fi ndings of this study showed that the
helping family members’ psychological well-being
diminished as they increased their active care- giving
for young men with emergent mental health prob-
lems. The burden of care which families experience
during their son’s emergent phase of illness creates
a substantial burden on the emotional and social
integrity of the family, and this burden causes some
parents to question how long they can cope, before
they reach ‘the end of their strings’.
Practice development implications
Policy and practice implications for the improve-
ment of mental health practice development
arise from the fi ndings of this research study.
Traditional service models which are under-
pinned by medical classifi cation systems, and
which are reinforced by state and national fund-
ing strategies, leave little capacity for innovative
practice development within health services,
which might more adequately address the men-
tal health needs of the young rural male popula-
tion. Endacott et al. (2006) and Cashin (2007)
have previously proposed that while a medical
diagnosis may not refl ect the problems which
are experienced by the client, the fl exible health
Despite this, a vocabulary to adequately describe
the problems, and convey meaning specifi cally
about the mental health aspects of the problems
outside the family are extremely limited. This scar-
city of vocabulary inadvertently acts to reinforce the
containment of the mental health problem within
the family setting. The caring strategies within the
family are not seen by family members as a form
of mental health support, and problem solving is
not framed in any mental health orientation. On
the contrary, families attempted to curb unwanted
behaviours where a risk of safety or reputation was
identifi ed using a range of resources including pro-
fessional practioners. However, mental health clini-
cians were not usually identifi ed within that range
of resources.
For the respondents in this study, traditional
medically oriented models of service delivery rep-
resented signifi cant barriers to the young men and
their families who wished to access appropriate
mental health clinical care, a fi nding congruent
with a number of other studies about this topic
(Francis, Boyd, Aisbett, Newnham, & Newnham,
2006; Jorm, Wright, & Moran, 2007). The help-
ing offered within the family did not articulate
with the services available. This was especially
apparent as young men or their families sought
access to either a GP or hospital emergency
departments, but with a lack of a physical injury,
their concerns were frequently dismissed or post-
poned to later appointment dates. Such decisions
were frequently made by receptionists and admin-
istrative assistants with no formal health qualifi -
cations. A subsequent study has highlighted this
occurrence as well (Duncombe, 2011). Where
immediate appointments were achieved, respon-
dents indicated that the clinicians would retread
old ground which had been covered previously
by the family, and any new ideas about appropri-
ate help were not forthcoming. Respondents also
indicated that they had sought assistance as a fam-
ily unit which included the young man, but that a
signifi cant frustration for them had been that the
health services used a rigid diagnostic classifi cation
system. Other authors have concluded similarly
from their respective research fi ndings (Cashin,
2007; Endacott et al., 2006). Respondents con-
sidered that the medical diagnostic labels which
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Wand, 2010; Wand, White, Patching, Dixon,
& Green, 2010). Evidence suggests that GPs
are not able to act as an early source of help
for a family/son with emergent psychosis, other
than to write a prescription for medication or
to suggest referral (Alexander & Fraser, 2008).
GPs report that they have diffi culty in fi nding
other clinicians to refer clients to within rural
communities (Callaly et al., 2010). This appar-
ently leads GPs to utilise more complex inter-
ventions such as hospitalisation (Alexander &
Fraser, 2008).
It may be that rural families hold traditional
views of medical paternalistic problem solving,
and are not familiar with alternative sources
of local help with problem solving for escalat-
ing emergent mental health problems, such as
mental health nurses and the federal govern-
ment’s relatively newly funded Mental Health
Nurse Incentive Scheme whereby consultations
are rebated by Medicare (Medicare Australia,
2010). Alternatively, mental health nurses in
private practice or nurse practitioners are cur-
rent service providers in some rural commu-
nities. Mental health nurses should have an
increased prominence in the rural health sector,
so that both clients and other health care work-
ers can utilise their skills appropriately. Further
research needs to be undertaken to understand
the rural communities beliefs about where
to access appropriate mental health help and
service.
Improve collaborative partnerships at
fi rst-point-of-call
The results of this study concluded that a range
of professionals are sought by families and young
men as a fi rst-port-of-call when helping strategies
had surpassed the threshold of available support
within the family. In this study it was shown that
professional helpers included non-traditional
professionals, for example, lawyers/solicitors and
teachers. Mental health and early identifi cation/
early intervention clinicians need to collaborate
with non-traditional professional helpers, which
could enhance referral to mental health pro-
fessionals at an earlier phase in the duration of
untreated illness.
and well-being focus of nursing models of prac-
tice may be more suited to meeting the needs of
this population. The fi ndings from this research
study supports the idea that contemporary non-
medical models are required to strengthen early
mental health service delivery and lends sup-
port to the introduction of nursing models of
care as an appropriate alternative (Frost, 2009).
It is important that rural services include local
rural mental health nurses or specialist general-
ist nurses because they represent social capital
beyond their employed nursing roles within
the community, vicariously extending nurs-
ing models of rural mental health care (Boyd
et al., 2008).
While traditional medical models remain
in place, rural medical centres and rural hospi-
tals emergency departments (including multi-
purpose facilities) should consider including
specialist mental health nurses in staff teams
with the express purpose of engaging with men-
tal health help-seekers. In this way, the gate-
keeping of inappropriately skilled or unskilled
workers would be alleviated, and helping could
be achieved at fi rst-point-of-call with the health
service.
Review models of service delivery
It is noted that the families interviewed in this
study identifi ed the GP as an intervention or help
option, especially when the problems with their
sons were escalating and when the parents felt
that a high level of risk existed. It has been sug-
gested that GPs are not well prepared or situated
to help at the emergent phase of a pending mental
illness episode (Bambling et al., 2007). Evidence
from the literature suggests that rural GPs self
evaluate themselves as unconfi dent in the assess-
ment of schizophrenia (psychosis) and the mental
health problems of young people, however para-
doxically they do report confi dence with prescrib-
ing medication for these problems (Alexander &
Fraser, 2008).
Mental health nurses and nurse practitio-
ners are more appropriately skilled, especially
in regard to building and strengthening pre-
vention/resilience within young men (Baker,
2010; Cashin, 2007; Endacott et al., 2006;
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Conclusion
This study has provided an insight into the experi-
ences of families caring for their young adult sons
with emergent mental health problems in rural
communities. It has also explored the issues that
underpin the barriers to early identifi cation and
appropriate and timely treatment of emergent psy-
chosis amongst young rural males. In particular, it
highlights the extreme diffi culties that families have
in accessing and selecting appropriate mental health
services in their local geographical area. It also high-
lights the emotional and practical burden of care
which is thrust upon rural families who need to
support young rural men with early mental illness.
This study can make a valuable contribution to
the nursing and mental health literature as it has
identifi ed specifi c factors which infl uence a duration
of untreated psychosis amongst young rural males.
It has highlighted the challenges faced by families
and young people who have recognised that exter-
nal professional help is required. Finally, this study
has identifi ed the limitations of rural health sys-
tems to adequately communicate and invite mental
health promotion and intervention to individuals,
families and the wider rural community.
In summary, it is hoped that the fi ndings from
this study will be utilised by mental health clini-
cians and especially mental health nurses when
assessing and planning the mental health care of
young rural men and their families. Additionally,
mental health service managers and planners could
utilise the fi ndings when planning and reviewing
mental health service provision to rural commu-
nities to assist with developing systems which
engage young men and their families earlier in the
emergent phase of mental health problems. In so
doing, a reduction in the burden of mental illness
might be achieved including a lower acuity. The
duration of the recovery period will be reduced if
systems are able to support earlier identifi cation
and intervention of affected individuals. This is
a fundamental issue if earlier mental health inter-
vention is to be achieved for young rural men and
their families.
A
CKNOWLEDGMENTS
Our gratitude is extended to the respondents who
were generous with their personal stories.
Future research should target understanding
enablers of early participation in mental
health care
Further research should explore the enablers
of early mental health service participation of
young rural men and their families. This study
brings to light a number of possible factors
which may act to repel individuals from engag-
ing with health service providers. Understanding
these barriers has also attracted the attention of
other researchers in recent times (Aisbett et al.,
2007; Bromley, 2007) which adds further sup-
port to the fi ndings of this study. A useful way
forward is now to explore factors which invite
early engagement in mental health service par-
ticipation, and to understand how it might be
possible to instigate earlier mental health help
which encourages and enables client participa-
tion in earlier mental health problem solving. It
is useful for mental health service providers and
mental health clinicians to be conversant of the
current barriers to early client participation in
treatment so that plans can be made to remove
any barriers to client participation in early treat-
ment. However, future research efforts should
aim to identify enablers, rather than barriers, to
early intervention by young people with emer-
gent mental health problems and their fami-
lies because this is likely to reduce the lengthy
duration of untreated mental health problems
that exist in many rural communities.
Limitations
The small number of respondents in this study
was drawn from a limited geographical area
in a rural community in New South Wales,
Australia. The fi ndings of the study refl ect
the social and geographical constraints of the
respondents and so the theoretical propositions
cannot be extrapolated to describe popula-
tion wide generalisations (van Manen, 1990).
However, the fi ndings of this research are able
to report some common themes amongst par-
ticipants which explain their experiences. This
will assist in understanding others who have
similar life experiences, in particular young
rural men with emergent mental health prob-
lems and their families.
Rhonda Lynne Wilson, Mary Cruickshank and Jacqueline Lea
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