When and how do young people seek professional help for mental health problems?

Abstract

• Despite the high prevalence of mental health problems and disorders that develop in adolescence and early adulthood, young people tend to not seek professional help. Young men and young people from Indigenous and ethnic minority groups tend to be those most reluctant to seek help.
• Young people are more inclined to seek help for mental health problems if they:

• have some knowledge about mental health issues and sources of help;
• feel emotionally competent to express their feelings; and
• have established and trusted relationships with potential help providers.

• Young people are less likely to seek help if they:

• are experiencing suicidal thoughts and depressive symptoms;
• hold negative attitudes toward seeking help or have had negative past experiences with sources of help; or
• hold beliefs that they should be able to sort out their own mental health problems on their own.

• Young people may seek help through talking to their family and friends, with family being more important for younger adolescents, and friends and partners becoming more influential later on.
• The professionals most likely to act as gatekeepers to mental health services for young people are school counsellors, general practitioners, and youth workers.
• Increasingly, Internet‐based information and interventions are being used to engage young people in the help‐seeking process.

Full text

MJA • Volume 187 Number 7 • 1 October 2007 S35
GETTING THERE: PROTO-PSYCHIATRY
The Medical Journal of Australia ISSN: 0025-
729X 1 October 2007 187 7 S35-S39
©The Medical Journal of Australia 2007
www.mja.com.au
Getting there: proto-psychiatry
he reluctance of young people to seek professional help for
mental health problems is increasingly acknowledged as a
challenge to effective early intervention approaches. Engag-
ing in appropriate help is widely recognised as a generic protective
factor, and early treatment and prevention are vital during adoles-
cence and young adulthood (12–24 years) because of the high
prevalence of mental health problems at this stage of life. A recent,
large study from the United States reported that half of all life-long
mental disorders start by 14 years of age, and three-quarters by 24
years of age.
1
In Australia, the National Survey of Mental Health
and Wellbeing (NSMHWB) found a prevalence of mental disorder
of 27% for those in the 18–24-year age range.
2
While young
people have the greatest need for mental health interventions, they
are the least likely to seek help.
Reluctance to seek professional help
A wide range of studies, nationally and internationally, attest to
young people’s reluctance to seek professional mental health care.
For example, a school-based survey of 11 154 Norwegian youth
aged 15–16 years reported that, even at the highest symptom
levels for anxiety and depression, only a third had sought profes-
sional help.
3
Similarly, the most recent national survey data for
Australia show that only 29% of children and adolescents with a
mental health problem had been in contact with a professional
service of any type in a 12-month period.
2
In a Queensland study
of 3092 young adults aged 15–24 years, 39% of the males and
22% of the females reported that they would not seek help from
formal services for personal, emotional or distressing problems.
4
Young men tend to be even more reluctant to seek help than
young women. In the Queensland study mentioned above, 30% of
males, compared with only 6% of females, reported they would
not seek help from anyone.
4
While the sex difference in help-
seeking varies according to type of problem and source of help,
greater unwillingness is shown by young men.
5
This is of special
concern partly because of the substantially higher rates of com-
pleted suicide in men.
6
Young people who are Aboriginals or Torres Strait Islanders or
from other cultural and linguistic minority groups may be even
less likely to voluntarily seek professional help when needed.
There are very few studies specifically of help-seeking for these
population groups, and we have no knowledge of the process of
help-seeking among young people from ethnic minority groups.
7
This is a particular problem, given evidence of a very high level of
unmet need for Aboriginal and Torres Strait Islander young
people
8
and of reluctance to voluntarily seek help from mental
health services among people from some cultural and linguistic
backgrounds.
9,10
It has been argued that the key to increasing access to mental
health services by Indigenous people is greater integration of
cultural and clinical competencies at both a system and practi-
tioner level.
11
For example, at the engagement level, introductions
between practitioners and Indigenous clients should recognise the
importance of land, country and genealogy, along with potential
barriers associated with language groups or tribal boundaries.
Forms of questioning that are open-ended, positively phrased, and
focus on narrative have also been suggested.
11
However, better
understanding of help-seeking processes and preferences of people
from Aboriginal and Torres Strait Islander backgrounds is urgently
needed.
When young people do seek help
Help-seeking is not a simple process of experiencing psychological
distress and seeking help. Although awareness of a problem (by
self or others) is a starting point, the symptoms of mental health
problems and mental disorders play a smaller role than might be
expected in prompting help-seeking.
12
A wide range of other
factors are involved, including appraisal of a problem as something
to seek help for, willingness to seek help and social norms that
encourage such behaviour, access to appropriate services, and
choosing a source of help.
When and how do young people seek professional help
for mental health problems?
Debra J Rickwood, Frank P Deane and Coralie J Wilson
ABSTRACT
• Despite the high prevalence of mental health problems and
disorders that develop in adolescence and early adulthood,
young people tend to not seek professional help. Young men
and young people from Indigenous and ethnic minority
groups tend to be those most reluctant to seek help.
• Young people are more inclined to seek help for mental
health problems if they:
¾ have some knowledge about mental health issues and
sources of help;
¾ feel emotionally competent to express their feelings; and
¾ have established and trusted relationships with potential
help providers.
• Young people are less likely to seek help if they:
¾ are experiencing suicidal thoughts and depressive
symptoms;
¾ hold negative attitudes toward seeking help or have
had negative past experiences with sources of help; or
¾ hold beliefs that they should be able to sort out their
own mental health problems on their own.
• Young people may seek help through talking to their family
and friends, with family being more important for younger
adolescents, and friends and partners becoming more
influential later on.
• The professionals most likely to act as gatekeepers to mental
health services for young people are school counsellors,
general practitioners, and youth workers.
• Increasingly, Internet-based information and interventions are
being used to engage young people in the help-seeking
MJA 2007; 187: S35–S39
process.
T

S36 MJA • Volume 187 Number 7 • 1 October 2007
GETTING THERE: PROTO-PSYCHIATRY
Recent reviews of studies about help-seeking emphasise the
importance of distinguishing between individual and structural
determinants of young people’s help-seeking behaviour.
13
Individ-
ual determinants include factors such as mental health literacy,
attitudes and perceived stigma. Structural determinants comprise
family, school or community support systems, referral pathways,
health system structures and payment systems. Individual and
structural factors interact to determine when and how young
people seek and access help for mental health problems.
Mental health literacy and emotional competence
Young people are more likely to seek help when they recognise
that they have a mental health problem and have the knowledge,
skills and encouragement to seek help (see Kelly et al, page S26).
Mental health literacy comprises the ability to recognise mental
health problems; knowledge and beliefs about risks, causes and
effective treatments; and knowledge of how to seek mental health
information and services.
14
Lack of recognition of mental health
problems among young people
3
and their parents
15
is a major
“filter” to help-seeking. Poor mental health literacy is common
among young Australians, particularly adolescent boys, and is a
significant barrier to professional help-seeking.
16,17
More specifically, a certain level of emotional competence is
required to seek mental health help. When young people do not
know how to identify and describe emotions, or manage their
emotions in an effective and non-defensive manner, this impedes
help-seeking.
18
On average, this competence appears less devel-
oped in young men.
19
Established and trusted relationships
For all types of health and mental health problems, if young people
want to talk to anyone, it is generally someone they know and
trust.
20
Consequently, they are more likely to seek help from their
friends and family for personal and emotional problems than from
other sources, including mental health professionals.
5,21
When
young people do seek professional help, it is from the more
familiar sources — family doctors and school-based counsellors.
2
When young people don’t seek help
Suicidal thoughts
Suicidal thoughts are quite common during adolescence and have
been shown to have a significant negating effect on help-seeking
behaviour.
2
In two Australian studies using non-clinical samples of
university students
22
and adolescents,
23
young people’s intentions
to seek help decreased as their level of suicidal ideation increased,
and they became more likely to indicate that they would not seek
help from anyone.
The mental health problems most commonly experienced by
young people — depression, anxiety and substance use —
similarly act to negate help-seeking by increasing social with-
drawal and young people’s preference to keep their distress to
themselves.
5,24
Reliance on self
As young people progress through adolescence they have a
growing need for autonomy and independence, and increasingly
believe they should be able to handle problems themselves.
23
A
large US study found that a third of adolescents with serious
suicidal ideation, depression, or substance use problems believed
that people should handle their own problems without outside
help.
24
Similar findings are apparent in Australia, with the Child
and Adolescent component of the NSMHWB finding that 38% of
adolescents endorsed a desire to solve their own problems as a
barrier to seeking help.
2
Negative attitudes and fears regarding mental health
services
Stigma and negative attitudes toward seeking help from profes-
sionals are further barriers to professional help-seeking. Young
people are particularly concerned about being seen as “mental” by
their friends and others,
25
and the stigma of mental illness is
associated with less intention to seek help.
17
Believing that seeking help won’t be useful also presents prob-
lems; “thinking that nothing could help” was the second most
endorsed barrier (18%) in the NSMHWB.
2
Young people are often
unsure whether specific sources of help will actually make a
difference. For example, while general practitioners are one of the
most frequently accessed initial sources of professional help,
young people often do not know whether seeing a GP for a mental
health problem will be helpful.
26
Furthermore, young people have
been shown to prefer active treatment to watchful waiting, and
counselling approaches to medication.
27
Past experiences of seeking help that proved unhelpful also
contribute to negative attitudes. This can include experiences in
which the young person felt that they were not listened to or their
problems were not taken seriously.
5
Occasions when confidential-
ity was not kept, and fears about breaches of confidentiality, also
contribute to negative attitudes toward mental health services,
such as school counsellors.
19,28
How to reach out to young people
Parents and peers
Friends and family are often consulted first and therefore have a
significant role in the pathway to professional services. Parents are
particularly important for younger adolescents. In childhood,
parental perception of problems is the starting point for referral to
professional services, and there is little evidence that children self-
refer.
29
The capacity for self-referral develops over adolescence, as
independence and autonomy from parents increase, but parents
continue to play a significant role, particularly until young people
are financially independent.
In understanding pathways to care, it should be recognised that
adolescents who are in their early to mid teens are still reliant on
adults, particularly parents, to help them recognise the presence of
a problem, facilitate access to appropriate help, and model appro-
priate help-seeking behaviour.
15
Parents’ and other adults’ (eg,
teachers’) perceptions of problems are critical to whether teenagers
are identified and referred to mental health services. Interestingly,
despite recent initiatives to encourage young people over 15 years
to independently seek mental health care,
30
there is some evidence
that parents do not think their children should make their own
appointments with doctors until about the age of 17 years.
31
As young people progress through adolescence, the role of
friends becomes more prominent, and peers increasingly have a
role in the help-seeking process.
5
For example, some visits to
school counsellors are from young people seeking help for one of
their peers.
28

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GETTING THERE: PROTO-PSYCHIATRY
For young adults, intimate relationships become an important
source of support; this applies particularly to men. Intimate
partners have been shown to exert a strong influence on men who
seek specialist psychological services.
32
Schools
Schools are an ideal and opportunistic setting in which to reach
out to young people.
33
For those aged up to 16 years, the school
setting is central, as school attendance is compulsory. Even for
older adolescents, school is central, as most remain at school to
complete Year 12.
34
For adolescents aged 13–17 years, the child
and adolescent component of the NSMHWB revealed that 16% of
those identified with a mental health problem had received
counselling in school.
2
School-related problems themselves have been shown to play an
important role in the help-seeking process for school-aged youth,
as these can be important indicators of other mental health
problems.
35
Within schools, teachers, school counsellors, and
other welfare and pastoral care staff have a major role in recognis-
ing mental health problems and referring young people to appro-
priate services.
A major initiative in Australia has been the development of
partnerships between schools and general practice to improve
young people’s access to mental health care. A resource kit has
been released based on what has been learnt from the MindMatters
Plus General Practice program to further encourage and support
such initiatives.
30
Importantly, ways to build referral pathways — a
series of steps, shared understanding, and agreed ways of working
together between services in a local area — are becoming better
understood. To address the mental health needs of teenagers at
school, schools need to be fully linked into referral pathways to
local health, mental health and community-support services.
Another approach to increasing help-seeking has been to train
GPs to conduct classroom lessons in high schools. These presenta-
tions cover a range of physical and mental health issues, and
provide both encouragement and practical advice on how to seek
help from a GP. This approach has shown encouraging results in
preliminary feasibility studies in regional and rural locations, with
adolescents reporting decreases in perceived barriers and increases
in help-seeking intentions for mental health problems up to 10
weeks after the class presentations.
36
Significant positive relation-
ships were also found between help-seeking intentions and the
frequency of actual consultations with GPs after the presentation.
General practice
General practice is essential to young people’s mental health and is
often the point of initial contact with professional services. Impor-
tantly, the presence of medical problems increases help-seeking
and provides an opportunity to investigate mental health issues.
35
However, there is a need to improve the ability of GPs to
recognise mental health problems in young people. For example, a
recent review showed that, in the US, the median rate of recogni-
tion of mental health problems in children by GPs was only
18%,
and was often dependent on parental expressions of concern.
29
Older youth who visit GPs on their own are reluctant to mention
their personal emotional problems, often because of concerns
about confidentiality and being viewed as weak or abnormal.
25
Recognition can be improved by GPs more frequently asking
parents, or young people themselves, about stress or personal
emotional difficulties. The process can be enhanced by providing a
welcoming environment, and taking time to listen carefully and
build rapport with young people. Also important is ensuring
privacy and clearly explaining confidentiality. Finally, GPs can
provide reassurance that it is common to feel distress at times, and
that symptoms can be a normal response to stressful events. At the
same time they can provide information and choices about
treatment.
19,25
Young people may also require additional support and follow-
up from GPs as part of the referral process to specialist or other
mental health services. For example, discussing issues of confiden-
tiality, while explaining the need to share information and allowing
the young person to specify the information they don’t want
shared, can facilitate referral processes. Describing the potential
benefits of receiving mental health services, and explaining the
likely duration of therapy and what to expect in an initial mental
health consultation, including any costs that might be incurred,
are all reported to be helpful. GPs also need to explain how they
will continue to support young people throughout this process.
26
Specialist services
Barriers to seeking help early from specialist mental health ser-
vices, and from alcohol and other drug services, can be particularly
strong. Studies exploring how young people with psychosis access
care highlight the highly variable pathways taken.
37
Interviews
with 62 people aged 16–30 years experiencing first-episode
psychosis revealed a total of 307 previous contacts with various
professionals, 52% with mental health professionals and 17% with
GPs.
37
In general, non-psychiatric contacts occurred first, followed
by psychiatric consultations, and the single most frequent initial
point of contact was with GPs (35.5%). The delay from the point
of recognition of first symptoms to first service contact averaged
112 days (median, 31 days) and was even longer to initial
treatment (mean, 273 days; median, 120 days). Reasons for such
delays include lack of knowledge regarding the presence of a
mental disorder, or inability to recognise it; stigma; uncertainty
about treatment effectiveness; and service structures being focused
on acute presentations.
38
Focus groups with youth found the dominant barrier to help-
seeking for substance use problems was a lack of self-motivation,
39
highlighting the relevance of motivational interviewing skills for
service providers. Other prominent themes were related to family
dynamics (eg, poor communication), and societal concerns related
to labelling and stigma. Young people’s perceptions of ideal
responses to harmful alcohol and other drug use included
improved relations with service staff, such as an initial compas-
sionate and non-judgemental reception, and greater access and
diversity of treatment options. These factors are consistent with
other studies showing that the first contact between the therapist
and youth is crucial and strongly determines the young person’s
decision to continue.
40
Confidentiality remains of utmost impor-
tance when engaging young people, and this is particularly
important in the context of accessing alcohol and other drug
services.
Youth services
It is essential to recognise that many young people at high risk of
mental health problems do not have links to work, school, or even
a family doctor. For example, in 2004, 15.5% of teenagers and
22% of those aged 10–24 years were not in full-time study or
work, and these young people are at greater risk of mental health

S38 MJA • Volume 187 Number 7 • 1 October 2007
GETTING THERE: PROTO-PSYCHIATRY
problems.
41
Extra effort must be put into reaching young people
who are unemployed, homeless or otherwise marginalised from
mainstream health and community services.
Youth workers, particularly those working in neighbourhood
youth centres or shelters come in contact with young people who
are disconnected from social supports and who might otherwise
not be seen by other common gatekeepers, such as teachers,
school counsellors, GPs, and community health. Youth workers
are able to engage distressed young people by being highly
accessible, “befriending” them, and acting as advocates.
42
They
potentially have a critical role in linking more marginalised youth
with mental health services, but may need additional training to
better identify mental health problems and to more effectively refer
and collaborate with other services.
43
Self-help and complementary treatments
It is worth mentioning that young people often use self-help and
complementary treatments to deal with mental health problems. A
recent review argues that incorporating this understanding into
service delivery can enhance the therapeutic alliance, as well as
discourage the use of potentially harmful treatments and encour-
age the use of helpful ones.
44
Some particularly worthwhile
adjuncts to treatment include Internet-based sources of help, such
as MoodGym (http://moodgym.anu.edu.au/), which have been
shown to be successful.
45
Internet-based information and support
are increasingly being taken up by young people.
46
Youth participation
A final point to make about when and how young people seek
mental health help is that it is essential for services to respect and
build upon young people’s growing independence and mastery.
This is acknowledged through the full and genuine participation of
young people in developing and implementing services to meet
their needs. Research evaluating programs that focus on young
people with substance use problems confirms that limited results
are achieved unless there is the opportunity for young people to be
directly involved and have active roles in service development and
delivery.
47,48
To encourage and support adolescents and young
adults to seek professional help early for emerging mental health
problems, services must be informed and guided by the young
people themselves.
Competing interests
None identified.
Author details
Debra J Rickwood, PhD, MAPS, Professor, Psychology
1
Frank P Deane, DipClinPsych, PhD, MAPS, Professor, School of
Psychology; and Director, Illawarra Institute for Mental Health
2
Coralie J Wilson, BA(Hons), PhD, MAPS, Theme Coordinator, Personal
and Professional Development; Curriculum Coordinator, Behavioural
Health Sciences, Graduate School of Medicine; Visiting Senior Fellow,
Illawarra Institute for Mental Health
2
1 School of Health Sciences, University of Canberra, Canberra, ACT.
2 University of Wollongong, Wollongong, NSW.
Correspondence: debra.rickwood@canberra.edu.au
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(Received 7 Mar 2007, accepted 1 Jun 2007) ❏