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ORIGINAL ARTICLE
“I'm tired of being pulled from pillar to post”: A qualitative
analysis of barriers to mental health care for trauma-exposed
young people
Carli Ellinghaus
1,2
| Katie Truss
3
| Jocelyn Liao Siling
3
| Lisa Phillips
3
|
Oliver Eastwood
1,2
| Carmen Medrano
1,4,5
| Sarah Bendall
1,2
1
Orygen, Parkville, Victoria, Australia
2
Centre for Youth Mental Health, The
University of Melbourne, Parkville, Victoria,
Australia
3
Psychological Sciences, The University of
Melbourne, Melbourne, Victoria, Australia
4
Sant Joan de Deu Terres de Lleida Mental
Health Service, Lleida, Spain
5
Maimonides Institute of Biomedical Research
of Cordoba (IMIBIC), Córdoba, Spain
Correspondence
Sarah Bendall, Orygen, 35 Poplar Rd, Parkville,
Victoria, 3052, Australia.
Email: sarah.bendall@orygen.org.au
Funding information
McCusker Charitable Foundation, Grant/
Award Number: N/A
Abstract
Aim: Traumatic experiences in childhood are pervasive and associated with a range
of deleterious mental health outcomes. Despite this, trauma-exposed young people
often do not seek help from mental health services. While barriers to care for general
mental health concerns are well established, less is known about those specifically
facing young people who have experienced trauma. The present paper sought to
examine the barriers in seeking mental health care faced by trauma-exposed young
people through a qualitative analysis of online forums where individuals discuss and
seek informal support for trauma.
Methods: This study used a qualitative, netnographic design, following the six-step
LiLEDDa framework, developed for the analysis of online forums. Posts about trauma
written in 2016 from five Internet forums targeting young people were included and
analysed via thematic analysis.
Results: Barriers to mental health care for trauma-exposed young people were cate-
gorized into two interrelated themes: (a) structural and (b) relational barriers. Struc-
tural barriers related to practical challenges faced when accessing and engaging with
mental health services. Relational barriers focused on interpersonal relationships with
mental health service providers and how these influenced experiences of, and conse-
quent engagement with, services.
Conclusions: Trauma-exposed young people appear to experience multiple barriers
to mental health care, whereby interactions between structural and relational barriers
determine ongoing engagement. Service-wide reform including trauma-informed
mental health training for practitioners is urgently needed to improve access to care
and engagement for this vulnerable group.
KEYWORDS
abuse, barriers, help-seeking, internet forums, mental health services, trauma, young people
1|INTRODUCTION
Traumatic experiences in childhood, such as physical or sexual abuse
and neglect, are common and associated with a range of negative
health outcomes. In an American sample of 1698 high-risk young peo-
ple (aged 20-22), 82.5% reported one or more lifetime traumatic
events and 59.9% reported four or more (Breslau, 2004). A meta-
analysis of childhood sexual abuse estimates places global prevalence
Received: 30 April 2019 Revised: 23 October 2019 Accepted: 14 December 2019
DOI: 10.1111/eip.12919
Early Intervention in Psychiatry. 2020;1–10. wileyonlinelibrary.com/journal/eip © 2020 John Wiley & Sons Australia, Ltd 1
at 11.8%, with the highest rates found for girls in Australia and boys in
Africa (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg,
2011). Trauma-exposed young people are more likely to develop post-
traumatic stress disorder (PTSD), anxiety, depression and psychotic
spectrum disorders, to self-harm or suicide, to have insecure relational
attachments, and to engage in antisocial behaviour and substance use
(Cook et al., 2005; Gaweda et al., 2018; Gladstone et al., 2004; Layne
et al., 2014; Varese et al., 2012).
Despite the prevalence of trauma in this population and its negative
mental health impacts, young people have low rates of mental health ser-
vice use. Findings from the 2011 Australian Census indicated that less
than 10% of young people (aged 15-24) had used subsidized mental
health-related services (Australian Bureau of Statistics, 2011). This is a
major public health concern given that the highest burden of mental
health disorders rests with young people, with almost one in four meeting
criteria for a probable, serious mental illness (Gulliver, Griffiths, &
Christensen, 2010; Mission Australia & Black Dog Institute, 2017).
An understanding of the factors that prevent young people from
engaging with mental health services is paramount to increasing men-
tal health service use and providing accessible, relevant and high-
quality services that respond to the needs of consumers. Previously
reported barriers to care for young people with general mental health
concerns include negative public attitudes about mental illness (i.e,
stigma), issues with confidentiality and trust, concerns regarding the
characteristics of the provider, lack of knowledge concerning mental
health service availability, fear or stress about the source of help, lack
of accessibility, (eg, time, cost), discomfort speaking with a general
practitioner, and negative past experiences (Gulliver et al., 2010;
Martinez-Hernaez, DiGiacomo, Carceller-Maicas, Correa-Urquiza, &
Martorell-Poveda, 2014; Rickwood, Deane, Wilson, & Ciarrochi,
2005). While the literature addressing barriers to care for young peo-
ple with general mental health problems is extensive, less is known
about the barriers specifically facing trauma-exposed young people.
To date, most research investigating barriers to mental health care at
the service or provider level for trauma-exposed individuals has focused
on adult populations, predominately war veterans. In a systematic review
of 36 studies, barriers to care for war veterans and trauma-exposed
adults from the general population included concerns regarding stigma,
privacy and confidentiality, reactions and sensitivity of the provider, a
sociocultural environment discouraging of disclosure, fear of the negative
consequences of help-seeking, a lack of encouragement to seek help,
and negative past experiences with services and accessibility issues such
as time, distance and costs (Kantor, Knefel, & Lueger-Schuster, 2017).
To the best of our knowledge, there have only been two studies
investigating barriers to mental health care for trauma-exposed young
people. One of these surveyed professionals and the other was a case
study of four Hispanic young people (Damian, Gallo, & Mendelson,
2018; Stewart, Orengo-Aguayo, Gilmore, & De Arellano, 2017). These
studies found that barriers included distance to clinic, the caregiver's
work schedule, confidentiality concerns, socioeconomic constraints,
and a lack of cohesion among services. These studies are limited by
their specific focus and emphasis on the perspectives of service pro-
viders and are therefore lacking the voices of service users. For these
reasons, the barriers faced by young people who have experienced
trauma remain largely unknown.
Given the negative impacts of trauma, its prevalence in young
people and their tendency not to seek help for mental health issues,
understanding barriers to care from the perspectives of trauma-
exposed young people is vital to increasing mental health service use
and reducing the negative outcomes associated with trauma. The
present study examined barriers to mental health care for trauma-
exposed young people through a qualitative analysis of Internet forum
content where young people discussed their subjective experiences
of trauma in an informal and anonymous context.
2|METHOD
2.1 |Study design
This study used a qualitative, netnographic design adapted from the
LiLEDDa framework, developed for the analysis of Internet forums.
Grounded in ethnography, netnographic research methods seek to
understand social interaction in contemporary digital communities.
The LiLEDDa framework is one such method that was developed in
the context of nursing research, where online help-seeking and com-
munication can mitigate power structures defining traditional health
care systems (Salzmann-Erikson & Eriksson, 2012). LiLEDDa is an
acronym designating the six steps involved in the framework, includ-
ing: (a) review of existing literature and identification of research
questions; (b) locating the field online; (c) making ethical consider-
ations; (d) gathering the data; (e) data analysis and interpretation; (f )
evaluating abstraction and the trustworthiness of findings.
2.2 |Ethical considerations
The current study was purely cross-sectional and observational, ana-
lysing data from a publically available source without any intervention or
interaction with forum posters. The study was therefore not considered
human subject research and consent was not required, a common per-
spective in Internet research scholarship (Bassett & O'riordan, 2002;
Kozinets, 2010; Wilkinson & Thelwall, 2011). Nevertheless, a number of
steps have been taken to protect poster anonymity and minimize data
traceability given the sensitivity of the research topic (McDermott,
Roen, & Piela, 2013). Poster nicknames and handles have been withheld
along with specific forum names. Extended quotes have been para-
phrased and potentially identifying information removed where doing so
has not altered the original meaning of the text. This study was approved
by the University of Melbourne Human Research Ethics Committee.
2.3 |Identifying forums
To identify forums, a Google search was conducted using terms
related to trauma (trauma, posttraumatic stress, PTSD), young people
2ELLINGHAUS ET AL.
(young people, adolescents, teens, youth) and Internet forums
(forums, discussion, chat). The first 20 pages of Google results for
each search were scanned. Forums were included if they specifically
identified themselves as targeting young people, were publicly avail-
able without membership or password, and had at least 100 posts
made on the forum within 3 months to confirm it was a living commu-
nity (Salzmann-Erikson & Eriksson, 2012). For each combination of
search terms, two authors (KT and JL) looked through each of the
forums listed on the first 20 pages of the Google search results to
check if they met the inclusion criteria. After working through all the
search terms, five eligible online forums consistently came up in
the search results. Two of these were based in Australia, two in the
United States, one in the United Kingdom, and one was international.
We determined that a point of saturation had been reached on
account of no new eligible forums emerging in the results.
Threads within each forum were included for analysis if the lead
post: was written in English; included the words “trauma,”“PTSD,”or
reference to an event considered within the literature to be traumatic;
and the trauma discussed was experienced by the poster. In an
attempt to capture a youth sample, any threads where the lead poster
could clearly be identified as an individual over 25 years of age or
below 13 years of age were excluded. Explicit demographic data,
including precise geographical information, was unavailable as posters
were anonymous.
2.4 |Data collection
Data collection was conducted over a 2-week period beginning
November 25
th
2016. Collection was restricted to posts published
between January first and November second 2016, and to the most
recent 100 pages of posting due to the large quantity of available data
and to standardize extraction across the forums. The final data set
comprised 295 Microsoft Word document pages of forum posts,
including 78 different threads written by a total of 176 unique posters.
2.5 |Data analysis
Data were analysed using thematic analysis (Braun & Clarke, 2006) and
followed the LiLEDDa protocol (Salzmann-Erikson & Eriksson, 2012).
Authors KT and JL, first read all data and independently conducted line-
by-line coding of a subset of the data, giving full and equal attention to
the semantic and conceptual content of the data. Initial codes of were
discussed and a coding framework was agreed on. When inter-rater reli-
ability reached 90%, the remaining dataset was coded independently by
KT or JL. Once codes were determined, all were clustered into themes.
For the purposes of this study, all codes organized under the theme
“barriers to help-seeking”were examined and only codes at the service
or provider level were included. The broadest possible definition of bar-
riers to care was adopted when identifying the data subset, where any
statement referring to the difficulties a young person faced when
accessing or engaging with care were included. Codes were then
critically analysed to identify themes at the latent level. Themes and
sub-themes were discussed between co-authors until a consensus was
reached.
2.6 |Evaluation of rigour
Koch's (2006) hallmarks of qualitative rigour (credibility, transferability
and dependability) were employed to ensure the trustworthiness of
results. Credibility was ensured by discussion of codes and themes within
the research group to reach agreement. Transferability was addressed by
including as much detail as possible (given ethical considerations and rela-
tive anonymity of forums) about the sample. Dependability was ensured
by detailed reporting of how the data were collected, including decisions
for inclusion and exclusion, and the process of coding, as well as reflec-
tion upon the author's own biases to allow for transparency.
3|RESULTS
The barriers identified through the analysis of internet forum data were
categorized into two interrelated themes: (a) structural and (b) relational
barriers of mental health care. At the inception of this project, we set
out to identify the structural barriers that prevented young people with
trauma-exposure from accessing professional care. During the analysis,
we discovered that young people encountered barriers to care for the
effects of their trauma throughout their engagement with services and
that structural barriers were intrinsically conntected with barriers that
we have termed relational. It was impossible to disentangle the rela-
tional barriers from structural barriers within forum posts. Thus, a deci-
sion was made to present these two themes together in the current
article. Themes are presented in Table 1.
3.1 |Theme 1: Structural barriers
Structural barriers were those related to practical and logistical chal-
lenges faced by trauma-exposed young people when accessing and
TABLE 1 Themes and sub-themes related to barriers to mental
health care for trauma-exposed young people
Theme Sub-theme
1. Structural
barriers
1a. The system is logistically complex
1b. Ineffective gateways for mental health
1c. Lack of availability of professionals
1d. Insufficient treatment
2. Relational
barriers
2a. Disruptions to the therapeutic relationship
2b. Invalidating responses from professionals
2c. Lack of power over therapy process
2d. Non-disclosure in the context of an ongoing
therapeutic relationship
ELLINGHAUS ET AL.3
engaging with mental health services. Although these barriers were
structural at their core, young people often described relational ele-
ments within them that influenced their service experience. The fol-
lowing themes are arranged in order of the extent to which they were
also interpreted relationally by the young people on the forums.
3.1.1 |1a. The system is logistically complex
Young people described difficulties negotiating the administrative and
logistical requirements of mental health services once they had initi-
ated engagement, and their frustration about having to navigate a
complex, fragmented and unaffordable system:
“I just keep hitting the wall. I am trying my hardest to
get help and there is just no one here who seems to be
able to offer any unless you're well off. I'm done with
this system. I'm here in the waiting room as I write
this…I really do not know anymore why I was put on
this earth. I wish I never woke up from ICU [Intensive
care unit] and I don't have the guts to end it myself
today. I have been to [de-identified] trying to get a dis-
ability support plan, then to the district court to see
victims support and now I am at the doctors.”
Posters frequently described effortful attempts to seek help, but
voiced frustration and despair directed towards a complex and diffi-
cult system that did not provide appropriate care when it was needed.
It was not that young people were unwilling to engage with services,
but rather, that multiple negative experiences or unanswered calls for
help eroded faith in professional services. A number of posters also
commented on the disjointed nature of mental health care during
their transition into adulthood, where services and professionals were
no longer available to them once they turned 18. Many voiced con-
cerns about having to move to a new service in this situation, an expe-
rience described as “scary”and “traumatic”in of itself. Indeed,
consistency of care may be of particular importance for this group
due to the relational attachment difficulties that are often experi-
enced by young people with trauma exposure.
"After it happened I was seeing my counsellor at school
2-3 times a week for a couple of months. Since I have
recently graduated I can't go to my counsellor any-
more…I plan to try and find someone else…I'm just so
terrified.”
3.1.2 |1b. Ineffective gateways for mental health
Posters described feeling as though the gateway services and mental
health service staff did not have adequate training, were difficult to
access or were ineffective at managing mental health issues. In many
cases, posters specifically referred to general practitioner (GP) services
or school counsellors as not having met their needs when they sought
help. One poster explained
“I consider that the GPs I went to when I began to seri-
ously suffer from stress let me down by not extrapolat-
ing from my reported symptoms to find others and to
unearth the link between them and the underlying
cause or anticipate worsening.”
Another poster described feeling as though general practitioners
were unable to provide adequate mental health support due to a lack
of training:
“GP's and mental health are not a good combination.
Don't get me wrong, doctors are very qualified people,
but unless they have chosen to specialize in psychiatry
(psychiatrists) they seem to know very little about
mental health and psychiatric treatments.”
Young people commented on the limitations of current mental
health service pathways, generally describing them as ineffective routes
to access appropriate care. Many posts highlighted ways in which these
services may not be fulfilling their intended role as a mental health
“home base”from which one can begin their recovery journey. Addition-
ally, posters commented on the way the current system impacted the
care they received. They described difficulties obtaining referrals, receiv-
ing conflicting information, treatment environments that did not provide
a full account of their symptoms and being referred on due to staff not
being trained to manage their needs. One poster explained:
“I went to the doctor and have been diagnosed with
anxiety. I also started to see a school counselor, only it
didn't work out and she recommended I need a differ-
ent type of therapy as I probably have PTSD due to a
number of events that have happened to me and that
all the anxious and depressed states I go into are a
result of this.”
3.1.3 |1c. Lack of availability of professionals
Young people described feeling unsupported by the mental health
system due to an insufficient supply of professional help; being placed
on waiting lists; receiving delayed responses to help-seeking attempts;
and the distance and unavailability of professionals. Young people
appeared to interpret the unavailability of services and professionals
as a reflection of the extent to which they were cared about and their
lives valued. One poster described:
“Hospital doesn't care. They kicked me out and there's
no beds anyway so there's no point going back there.
It would be better for everyone if I just did what I am
planning.”
4ELLINGHAUS ET AL.
The posts from young people indicated that seeking professional
help often came as a last resort when posters were not receiving this
support from their community. When these calls for help went unan-
swered, posters described experiencing feelings of isolation and losing
hope in their recovery:
“I've been through the ringer with mental health ser-
vices etc. I just want to know if anyone has experi-
enced the same as me. I'd like to feel less alone.”
Despite service and professional availability being a structural, sys-
temic issue, many young people described experiencing this on a per-
sonal level, where being denied access to care had a psychological
impact on them. Forum posts from young people indicated a personifica-
tion of the mental healthcare system, where posters believed access to
be granted based on the extent to which the system “cared”about the
help-seeking individual or perceived their needs as worthy of support.
“I am waiting to see my psychologist, but I won't see
him until November and that is a really awfully long
time for me. I am in more pain now then I have been in
recent months. All this psychological burden I carry
now is really hurting me so much and I don't know
how much more I can take."
There was a sense of desperation in the posts from young people,
where delays or a lack of response from services sometimes resulted
in extremely negative consequences for the young person.
“I want to do more than self-harm. I tried calling triage
for the mental health team but they said it could take a
while. I've been trying to follow my safety plan but I
gave up and self-harmed. I can't f***ing do this
anymore.”
Other posters highlighted the extreme measures taken in efforts
to access help:
“Do you think you keep overdosing in the hope that
someone will finally notice and give you the help you
need? I went through a stage where I felt like I had to
do this because the mental health services weren't tak-
ing me seriously.”
Forum posts indicated that when a young person was experienc-
ing a crisis, unanswered calls for help often justified feelings of worth-
lessness. “The system”appeared to function as a representation of
the overall value society placed on the young person as an individual.
When access was denied, particularly in crisis, young people seemed
to perceive this as indicative of the fact that they had been devalued
or abandoned by society. These sentiments are perhaps unsurprising
given that fear of abandonment is often characteristic of individuals
who have experienced trauma.
3.1.4 |1d. Insufficient treatment
Young people shared their distress over having to limit, delay, or cease
treatment with a trusted organization due to resourcing issues and
the difficulties negotiating support when subsidized care ran out.
“I had a therapist but the amount of sessions for the
year has finished so until then that's all my supports at
the moment. I hate that you only get a small number of
sessions with a psychologist for free through mental
health care plans; they need ways or options to get
more especially for people who need it.”
This rationing of services resulted in young people describing
feeling as though the care they received was inadequate for them to
effectively address their mental health needs and reach a stage at
which they felt they could continue their recovery independently. For
example, one young person on an Australian forum expressed concern
when having to stop sessions for 9 months until their annual sessions
were renewed, due to the limited number of subsidized sessions avail-
able under Australian funding schemes:
“I told them straight up that I wasn't ready to leave and
that if I didn't have any support I'm not sure what
would have happened.”
Additionally, having to limit or cease treatment with a service pre-
maturely appeared to have a psychological impact on young people,
where having to prove the legitimacy and urgency of their struggles
was experienced as distressing and hurtful:
“About a year ago I asked for more time and sessions. It
took a long time to prove to his [counsellor] boss why I
was asking for more time. After a long time and
explaining why I would like more time and sessions they
were granted to me, but it was a distressing time for me.”
3.2 |Theme 2: Relational barriers
Relational barriers were those associated with the elements of the
young person's relationship with mental health service providers and
how these influenced their experience of, and engagement with, men-
tal health services.
3.2.1 |2a. Disruptions to the therapeutic
relationship
Young people described their frustration with having to rebuild
trusted relationships with professionals and cope with changes to
therapy arrangements that were sometimes abrupt and unwanted.
Posters described changes in therapists as a hindrance to their
ELLINGHAUS ET AL.5
recovery, something that influenced the information they were willing
to share about their experience, and a factor that reduced their moti-
vation for ongoing engagement with formal services:
“I wondered if anyone knew of any services other
than [mental health service] I could be referred to? I
don't have anything against [mental health service] it's
just that I'll be 18 soon and then I'll have to leave
there too. I just feel like by the time they get my
referral I'll get just a couple of sessions and then I'll
have to find yet another counsellor. I'm tired of being
pulled from pillar to post and not getting enough time
to get well again.”
Additionally, young people described experiencing feelings of
abandonment, betrayal and rejection when therapy with a trusted
professional came to an end:
“I've been abandoned by a lot of people in my life and
now I am being forced not to go to counselling and it
seems I have no opinion on the matter, so my counsel-
lor of 3 years is abandoning me.”
Feelings of abandonment were described by young people even
when the therapeutic relationship was longstanding and therapy
ended gradually and in a planned way. Some posters described believ-
ing that their therapist would always be there as a support and did
not foresee an end to the therapeutic relationship.
“It really hurt me when I heard this as so many people
in my life have left and I even told my counsellor that I
was convinced she would do the same to which she
replied, ‘no, I won't give up on you, far from it’but now
all of that seems to have gone out the window.”
3.2.2 |2b. Invalidating responses from
professionals
Young people described feeling blamed, dismissed, patronized, not lis-
tened to, and being met with insensitivity and a lack of empathy. One
poster described feeling blamed when reporting an assault:
“One of my friends came forward to the school and
told the office what happened, so I had to go in and
talk to the counsellor. I stressed how desperately I
didn't want to get my parents involved, but the
counsellor said there were so many layers to my
case…. By the ‘many layers’she meant that because
I had initiated everything up until it happened—I
invited him to do stuff that day, he was in my car, I
was the one driving, I basically put myself in that
situation.”
Although the context varied, a number of posters described feeling
judged when providing an account of things that had happened to them,
or symptoms they were having difficulty managing. There was a sense of
disappointment and discouragement in the way posters articulated these
experiences, and in many cases, this appeared to set a precedent for the
way young people engaged with services and professionals in the future.
This precedent manifested as pessimism or ambivalence towards the role
of mental health services. These sentiments often came after receiving
conflicting information from multiple professionals or when young peo-
ple felt their explanatory model was dismissed:
“I went back to the doctor and tried to explain only he
completely dismissed what the counsellor, who I have
been seeing every week for a year, had recommended.
He said it is all just anxiety before I had even explained
what has happened to me in the past four years, as I
was struggling to bring it all up. I left feeling completely
dismissed and not listened to and I have managed to
cope on my own since then.”
Young people described not feeling heard by professionals. Young
people highlighted that professionals made quick judgements about
their presenting issues and rushed to provide advice and solutions to
issues before they had heard the full account of the young person's
experience. Young people stressed wanting to feel listened to, empa-
thized with, and believed, rather than be provided with answers and
advice. One poster noted:
“I want to go back to the doctor to prevent it getting
bad again only I'm scared they won't listen to me again.
I've seen two different doctors at the surgery and both
haven't helped or listened to me.”
Posts from young people appeared to describe feeling stuck in an
in-between space, where they were fearful or pessimistic about mak-
ing further attempts to access professional care, but were equally
struggling to manage distress independently.
3.2.3 |2c. Lack of power over therapy process
Young people described feeling pressured by professionals to adopt
particular perspectives, engage in therapies and use strategies that
were in conflict with their own explanatory models. Within the forum
posts, there was an extended conversation between posters about
their experiences of feeling pressured to engage in therapies they
were not comfortable with:
“I did that ‘hit the tree with a stick’therapy'—I hated
it. The therapist was a twerp. Made me do it without
my shirt on- I was still so paranoid and neurotic about
my body, having been obese, that the whole process
made everything worse I was too young and naive to
6ELLINGHAUS ET AL.
say at the time, ‘NO, I don't want to do that kinda
THERAPY!’I was more stressed leaving that session
than when I actually arrived.”
It was clear that posters experienced anger and resentment when
feeling pressured in sessions, or when they were not engaged collabo-
ratively in the direction of therapy. Responding to the previous post,
another young person echoed strikingly similar sentiments:
“I refused, but he put the guilt on, and I felt pressured.
Not good…It made me angrier. I just wanted to slam
the therapist with the stick.”
While the above quotes come from one forum interaction, the
frustration and pressure experienced by posters, regardless of
whether or not they were indeed pressured to comply with a thera-
pist's demands, was something that was identified throughout all
threads analysed. Posters described complying with a therapist's sug-
gestions and demands even when this was in conflict with their own
explanatory model or individual needs. This is something that war-
rants further investigation in vulnerable groups.
Importantly, despite young people having complied with the
therapist's requests, it was unclear whether they had voiced their
concerns to their therapist. It may be that the therapist remained
unaware of the young person's feelings, and therefore the direction
of therapy may have continued along a path that did not meet the
young person's needs. The idea that posters did not feel able or
comfortable to voice their concerns about the direction of therapy
to their therapist is of particular importance given the power-over
dynamics that exist both in the therapist-client relationship and the
power-over dynamics that are often associated with traumatic
experiences.
3.2.4 |2d. Non-disclosure in the context of an
ongoing therapeutic relationship
Young people described not having disclosed their trauma to profes-
sionals' despite being engaged with formal support services. This non-
disclosure was present even for young people who had good relation-
ships with their therapists or who had been engaged with them for
some time. This resulted in young people describing feeling that their
treatment was ineffective, possibly given that it did not address the
core of their difficulties. In some cases, this led to young people dis-
engaging from services. One poster explained:
“I was abused and haven't told my psychologist or
psychiatrist. I don't know how to bring it up, because
even though I have always had issues before all that
happened, I feel like it is part of the problem why I
am not making progress and can't change. In the very
first consult, the psychiatrist flat out asked me and I
said no.”
Young people described feeling uncomfortable disclosing to ther-
apists, even when they had disclosed to another therapist previously
or undergone extensive trauma work:
“I still feel I have a lot more to process but I don't have
a therapist I am comfortable doing it with.”
Another poster described how having to end therapy with a
trusted professional prevented their disclosure. This poster was grad-
uating from university, and therefore would no longer have access to
the university counselling service and the therapist they were seeing:
“I have a good relationship with my counsellor and was
seriously considering telling her about it or making a
‘disclosure’as they call it, but before I did this I needed
to know whether the support from my counsellor
would be continued…sadly I've got four sessions left
and my counsellor will have to stop seeing me.”
4|DISCUSSION
The aim of this paper was to identify structural barriers to professional
services experienced by young people with trauma-exposure. Instead,
investigation of Internet forum posts by young people revealed two
interrelated themes: (a) Barriers related to the structural elements of a
service; and (b) those related to the relational elements. Structural
barriers appear to play an important role at the beginning, for exam-
ple, current pathways to mental health services and the complexity
and fragmentation of the mental health system made it particularly
difficult for young people to access appropriate care and have their
needs addressed. Structural barriers re-surfaced towards the end of
service engagement, where insufficient sessions due to funding and
resourcing limitations prevented young people from reaching a stage
where they could continue their recovery independently. Importantly,
forum posts suggested that the structural elements to services are
often paired with relational, interpersonal elements and these remain
central to the engagement of this vulnerable group. For example, how
positively a young person is received by professionals within gateway
services will have a huge impact on the decision of the young person
to (or not to) persevere with engagement.
The structural barriers identified in this study have previously been
reported in the industry, where the impact of funding limitations, a
complex and fragmented system, the high cost of care and lengthy wait
times limit service accessibility for young people (Bendall et al., 2018;
Bush, 2018). These barriers have also been highlighted by mental health
service providers, adult service-users in primary healthcare and young
people for trauma-related issues (Chung et al., 2012; Damian et al.,
2018; Stewart et al., 2017). These included a lack of coordination and
integration among services, workforce shortages, socioeconomic con-
straints and difficulties navigating the healthcare system.
Unique to the present study were the barriers concerning the
relational elements of a service. Although there is a large body of
ELLINGHAUS ET AL.7
research noting the importance that trauma-exposed individuals place
on the therapeutic relationship, young people in this study appeared
to perceive difficulties with the therapeutic relationship itself as a bar-
rier that is deeply intertwined with known logistical barriers (Cohen,
Mannarino, Kliethermes, & Murray, 2012; Wilson, Hutchinson, & Hur-
ley, 2017). It is likely that present findings differ from previous
research due to the method of data collection. Research in this area
thus far has had a narrow scope and has mainly focused on the per-
spectives of providers (Chung et al., 2012; Damian et al., 2018; Paul,
Gray, Elhai, Massad, & Stamm, 2006; Stewart et al., 2017).
4.1 |The centrality of the therapeutic relationship
A central finding in this study was the importance placed on the rela-
tional and interpersonal elements of mental health services, which
often played a role from initial engagement with general practitioner
services. Current gateways for mental health services appeared to be
lacking the interpersonal qualities that seem vital for trauma-exposed
young people. Time restrictions paired with the transactional style of
contemporary healthcare structures may lead young people to inter-
pret interactions with professionals as dismissive, insensitive and lac-
king in empathy. These same issues with the structure of mental
health services also played a role towards the end of engagement,
where young people experienced feelings of abandonment and
betrayal in response to having to limit sessions or delay further treat-
ment with a trusted organization or therapist. This finding supports a
large body of research recognizing the significance of the therapeutic
relationship for people who have experienced trauma (Cohen et al.,
2012; Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; Wilson et al.,
2017). These studies showed that relational collaborations, positive
human connections and an established positive and trusting relation-
ship with the therapist were key factors to facilitate healing from
trauma. Additionally, (Sweeney, Filson, Kennedy, Collinson, & Gillard,
2018) highlighted the importance of developing therapeutic relation-
ships formed on transparency, authenticity and openness given that
trauma-exposed individuals have often experienced betrayal, decep-
tion and power-over dynamics.
4.2 |Power, autonomy and choice
Young people in the present study expressed their anger and frustra-
tion when feeling as though their personal experiences, knowledge
and perspectives were not valued or acknowledged within the thera-
peutic environment. This resulted in young people describing feeling
pressured to take on particular perspectives or to participate in thera-
peutic techniques that they were uncomfortable with or not agreeable
to. The biomedical model largely adopted by health services positions
trauma reactions as symptoms rather than adaptive coping responses
to trauma (Elliott et al., 2005; Wilson et al., 2017). This can result in
professionals unintentionally invalidating the resilience and perspec-
tives of young people and the protective functions of symptoms and
behaviours (Elliott et al., 2005; Wilson et al., 2017). These findings
emphasize the importance of giving the trauma survivor a sense of
autonomy, control and choice within treatment, allowing them to
move away from the feelings of powerlessness and victimization that
often occur as a result of trauma. The findings also highlight the
unequal power dynamic that exists between the helper and helped in
the therapeutic relationship, which may be exacerbated for trauma-
exposed young people. Feeling pushed to participate when therapy
takes a direction that a young person is not comfortable with may
trigger the same feelings of powerlessness experienced during past
traumas. Furthermore, complying with the therapist's requests, even
when they felt strongly against doing so may have been a protective
mechanism developed by young people when they experienced past
abuse by an authority figure (Elliott et al., 2005; Wilson et al., 2017).
4.3 |Disclosure
An important finding in the present study was that some young peo-
ple described not having disclosed their trauma despite being engaged
with formal mental health services. In this respect, non-disclosure
functioned as a barrier within care, resulting in the young person
receiving treatment for more visible difficulties (eg, depression). This
may have accounted for why some young people found formal sup-
port services to be ineffective and subsequently disengaged. Another
key finding was the way in which young people described disclosure,
not as a discrete, single event, but rather, as an ongoing and deeply
considered process to determine whether the environment and/or
therapist was safe and appropriate for this. This is consistent with the
findings of a qualitative literature review investigating disclosures of
child sexual abuse, where, in the content of shame, self-blame and
fear, disclosure was similarly viewed as an ongoing, iterative process
facilitated within a relational context (Alaggia, Collin-Vezina, & Lateef,
2017). Young people have also described reluctance to approach
trauma memories and difficulty acknowledging that trauma has
occurred in trauma-informed psychotherapy (Tong, Simpson, Alvarez-
Jimenez, & Bendall, 2018). Continuity of care appears critical for
young people, as has been reported by adult survivors of child sexual
abuse (Chouliara et al., 2011), where abrupt changes to therapists can
lead to non-disclosure, particularly if relational elements of service
engagement have been disjointed and unstable. This is reflected by a
young person in the present study who decided against making a dis-
closure when they learned that care with their current therapist would
be discontinued. Ongoing, consistent care from the same therapist
where possible may promote a safe therapeutic environment facilita-
tive of disclosures.
4.4 |Clinical implications
The current gateways to mental health care for trauma-exposed youth
are not adequate to ensure appropriate triage and referral. This is
often via general practitioners, who in current service models do not
8ELLINGHAUS ET AL.
have time to appropriately engage and assess trauma-exposed young
people. This may in turn result in ill-fitting referrals that do not
address the core issues the young person is dealing with, significantly
delay the young person’s recovery, or result in them disengaging due
to inappropriate care.
Further mental health training is required for all mental health
practitioners, including general practitioners, in trauma-informed care
(Bendall et al., 2018). This should include training in the relational
needs of trauma survivors to create an environment more facilitative
of disclosures of trauma. Alaggia et al. (2017) found that positive dis-
closure experiences were those that involved feeling safe, believed,
listened to and not feeling judged by the person disclosed
to. Furthermore, there was evidence that the creation of safe spaces
and environments where information and education are provided
about traumas such as sexual abuse could promote open dialogue and
facilitate disclosure for young people with trauma-exposure. Even
without disclosure, health professionals should be aware that any
young person may have experienced trauma and should treat all help-
seeking young people accordingly. Mental health professionals should
strive to include young people in therapeutic decisions, make it clear
that the young person's perspective is valued and that they have
choices about the direction of treatment, providing them with a sense
of autonomy and partnership.
Finally, this study provides further evidence that the limited num-
ber of sessions and resources currently accessible under Australian
funding schemes are inadequate for the needs of trauma-exposed
young people (Bendall et al., 2018). Our findings show strikingly how
young people, particularly in regard to disruptions to a trusted thera-
peutic relationship, perceive this lack of resources in a relational way.
4.5 |Limitations
The present study has a number of limitations. First, we were unable
to ascertain sample demographics due to our method of data collec-
tion. The lack of information regarding the exact geographic location
of forum posters is a notable limitation given the importance that rural
and urban distinctions might have for access to care. While a number
of efforts were made to ensure posters were young people that had
experienced trauma, the anonymous nature of Internet forum posting
prohibited access to this information. However, this methodology
simultaneously enabled the unique perspectives of trauma-exposed
young people to be captured in an organic online environment. The
ability to capture the freely expressed views of those who may not be
engaged with formal support services, which may be due to prior neg-
ative experiences, the absence of government-subsidized treatment,
or general discomfort seeking formal support, is not possible with tra-
ditional methods of data collection, and is thus a notable study
strength. Second, it is important to acknowledge the possible influ-
ence of researcher bias during analysis. The first author is a white,
middle-class Australian female with undergraduate education in psy-
chology, 5 years of working experience in youth mental health
research and a keen interest in trauma, which likely influenced her
interpretation of the results. Additionally, the two authors who coded
the original dataset are also white, middle class, Australian females
with post-graduate education in psychology. A number of measures
were employed to maximize the rigour of the analysis during coding
and interpretation, which included independent double coding, ongo-
ing reflection, and a collaborative consensus-driven approach with the
wider research team (Koch, 2006).
4.6 |Future directions and concluding remarks
Given the long-lasting, negative impacts of trauma, investigating ways to
ensure that services are safe places for trauma-exposed young people is
vital to reducing the burden of mental-ill health and the suffering of
trauma-related difficulties. The themes identified within this study indi-
cate that the current structure of mental health services lack the inter-
personal qualities that appear to be vital for trauma-exposed young
people to remain engaged and establish the safe and stable environment
that is necessary for recovery. Urgent implementation of trauma-
informed care training for gateway practitioners is needed. Given this is
one of the few studies to capture service experiences of trauma-exposed
young people, further research is needed. Evaluation of the experience
of care of young people after the implementation of trauma-informed
careinyouthmentalhealthservicesisofhighpriority.
DATA AVAILABILITY STATEMENT
N/A
ORCID
Lisa Phillips https://orcid.org/0000-0003-1060-6068
Oliver Eastwood https://orcid.org/0000-0001-6801-2049
Sarah Bendall https://orcid.org/0000-0003-1486-6190
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How to cite this article: Ellinghaus C, Truss K, Liao Siling J,
et al. “I'm tired of being pulled from pillar to post”:A
qualitative analysis of barriers to mental health care for
trauma-exposed young people. Early Intervention in Psychiatry.
2020;1–10. https://doi.org/10.1111/eip.12919
10 ELLINGHAUS ET AL.
