Promoting Adolescent Help-Seeking for Mental-Health Problems: Strategies for School-Based Professionals
By Christy M. Walcott & Ajlana Music
People seldom refuse help, if one offers it in the right way.—A.C. Benson
Extensive research suggests that adolescence is a critical developmental period, especially when it comes to factors that influence mental health problems (e.g., Evans et al., 2005; Rickwood, Deane, Wilson, & Ciarrochi, 2005). Major emotional, physical, and cognitive changes that occur during adolescence significantly impact mental health outcomes in adulthood. For example, many disorders, such as depression, substance use, anxiety, eating disorders, and psychosis, can reach peak incidence during the adolescent and early adulthood years. Regrettably, study after study highlights the limited use of mental health services by adolescents with emotional and behavioral problems (e.g., Cauce et al., 2002; Saunders, Resnick, Hoberman, & Blum, 1994; Sourander et al., 2001; Zwaanswijk et al., 2003, 2007). As such, systematic efforts to promote adolescent help-seeking are essential for improving long-term mental health outcomes. Defined as a “behavior of actively seeking help from other people,” psychological help-seeking involves communicating with others to obtain help and support for troubling experiences (Rickwood et al., p. 4). There are two major sources of help-seeking in which adolescents can engage: informal help-seeking from family and friends and formal help-seeking from professional sources (e.g., counselors, psychologists, psychiatrists, clergy). School-based mental health professionals are one logical source of formal help for adolescents.
Seeking help and using social supports are protective factors for many adolescent outcomes, and adolescents generally display a greater preference for informal versus formal sources (e.g., Sheffield, Fiorenza, & Sofronoff, 2004). Despite the protective nature of seeking support from friends and family for mental health problems, it is important to question whether informal sources are sufficient for those experiencing significant emotional and behavioral problems. Although adolescents may find affiliative support from peers or family members, information and suggestions provided may be inaccurate, unhelpful, or even damaging. This article discusses various strategies to promote professional help-seeking for emotional and behavioral problems. As noted in a review by Power, Eiraldi, Clarke, Mazzuca, and Krain, (2005), we have much to learn about adolescent help-seeking strategies and how to improve service utilization. For this discussion, we assume that an adequate formal infrastructure of social services is available to adolescents, but that such services are underutilized. Although we recognize that this is not the case in many areas, the present focus is on underutilization of existing services. Using information from available research, we propose various strategies to encourage help-seeking among adolescents. Because most of these strategies have yet to be empirically validated, we conclude with suggestions for outcome evaluation.
To provide a framework, we point to three widely accepted stages of the help-seeking process: (a) problem recognition, (b) decision to seek help, and (c) service selection and utilization (Anderson, 1995; Goldsmith, Jackson, & Hough, 1988). Cauce and colleagues (2002), for example, used this framework to examine how culture and context permeate all three stages of this pathway. Particularly relevant to our discussion, they concluded that culturally competent practices are essential but irrelevant unless mental health providers can find ways to guide more minority adolescents to the available services. As mentioned, there has been a consistent trend that adolescents tend not to seek help from professional sources, but this is especially true for boys and those from minority groups (e.g., Cauce et al., 2002; Saunders, Resnick, Hoberman, & Blum, 1994; Sourander et al., 2001; Zwaanswijk et al., 2003, 2007). Thus, in this article, we focus on factors associated with the final stage of the model above, the selection and utilization (or lack thereof) of formal services. By identifying correlates in the research, potential targets to promote help-seeking can be identified. Some salient predictors associated with adolescents' willingness to seek formal psychological help include perceived trustworthiness and familiarity of the helper, developmental aspects of adolescence, perceived helpfulness of mental health services, and the availability of social support (Ciarrochi et al., 2002; Gulliver, Griffiths, & Christensen, 2010; Kuhl, Jarkon-Horlick, & Morrisey, 1997; Sheffield et al., 2004). Although not an exhaustive list, we highlight these particular factors because they are amenable to intervention, as will be discussed.
Building Trust, Familiarity, and Perceived Helpfulness
Sheffield et al. (2004) suggest that reducing barriers to help-seeking is important. Two significant barriers reported were preference to manage one's own problems and concern that professionals could not help, highlighting the need for adolescents to perceive mental health professionals as trustworthy and helpful. Although limited research exists on trust and adolescent help-seeking, adolescents are more likely to seek help from people they know and in places where they feel comfortable. This general preference for informal over formal help appears true across cultures (WHO & UNICEF, 2000), and may be influenced, in part, by specific cultural and community norms. Additionally, Sheffield et al. found many adolescents believe they should solve their own problems, which impedes professional help-seeking. Adolescents are at a critical stage of development when personal autonomy is highly valued. We need interventions sensitive to this particular developmental aspect. Mental health professionals must devise strategies to sell their services in a youth-friendly way that assures trust and confidentiality. Below are some potential strategies to address this barrier.
Training for mental health providers. When adolescents use mental health services, the providers' attitudes and their relationships with providers attract them to the service and lead them to return. Developing feelings of trust and respect between provder and client is essential to promote future help-seeking (Wilson & Deane, 2011, 2010). Training of mental health providers can target self-assessment of ones attitudes and respect for adolescents and provide specific communication strategies to increase engagement and view adolescents as active collaborators in the process.
Considering Developmental Aspects of Adolescence
Using peer promoters is a promising strategy for making mental health services youthfriendly. This involves training adolescents to reach their peers with information. Assuming a variety of social groups are represented, this also helps battle stigma that may surround help-seeking. Peer promoters have long been used to promote health programs such as HIV prevention (e.g., Cornish & Campbell, 2009). Mental health providers can use peers to disseminate information about specific psychosocial problems and services/support groups available.
Refitting service delivery. Consider ways to refit mental health services to be more adolescent-friendly. This might include adjusting the location of services to ensure maximum accessibility, having convenient operating hours based on typical adolescent schedules, and accepting walk-in clients to attract adolescents not likely to follow formal referral processes. School-based health clinics greatly improve access and visibility of mental health services to adolescent populations. As professionals, we can advocate for models such as these that integrate services. This promotes help-seeking by creating multiple entry points to formal help. Finally, consider modes of communication most prevalent among adolescents. Use social media, hotlines, websites, and other electronic methods to disseminate information, highlight available services, and modernize self-referral processes.
Fostering Perceived Helpfulness
Once students are attracted to mental health services and providers are seen as trustworthy and respectful, we must address the issue of perceived helpfulness. Survey results by Smith (2004) offer some points for intervention. Male adolescents, a group particularly resistant to seeking professional help, indicated that action-oriented services were most beneficial. They reported that traditional counseling methods (i.e., sitting and talking) were undesirable, and suggested action-oriented counseling methods such as games, exercise and sports, multimedia activities, volunteering, and hands-on activities such as art (Smith, 2004). Child therapists have long touted play therapy as the most developmentally sensitive approach for younger children. For adolescents, too, nontraditional counseling methods will likely promote help-seeking.
School-based professionals can foster perceived helpfulness of mental health services by offering a wide range of services, both educational and problem-oriented. As others have charged, school psychologists must be proactive in promoting their role as mental health service providers (Pluymert, 2002). Proactive approaches can battle negative perceptions by giving adolescents an opportunity to experience the benefits of mental health services in group settings. For example, programs designed to expand academic and personal skills, rather than address problem-related issues can be provided at various grade levels (Smith, 2004). To some extent, help-seeking is a learned behavior, and adolescents observe and internalize how adults around them cope with problems. Proactive mental health programs promote help-seeking as a local norm. Parent and community education programs are also important to influence the help-seeking messages adolescents receive (see Power et al., 2005, for family education strategies).
Lack of Social Support
Strategies to address multiple individual risk factors for help-seeking are beyond the scope of this article. However, results of Ciarrochi et al. (2002), Sheffield et al. (2004), and others suggest that social support is one crucial mediator for mental health helpseeking. Greater levels of social support predict greater willingness to seek help. This may be because family and friends serve an important role in helping adolescents recognize their symptoms and the need for help. They may also intervene on their behalf if an adolescent experiences significant distress. Interestingly, it appears that an adolescent's subjective feeling of social support is more important than objective measures (Costello, Pickens, & Fenton, 2001). All of this suggests that those who lack social support and/or struggle with interpersonal competence are at greater risk for falling through the cracks by failing to seek services. One logical response to this barrier is to conduct routine mental health screenings of all adolescents to identify atrisk youth. This will include those lacking interpersonal competence or social support networks that might otherwise go unnoticed. Although the majority of research conducted in this area focuses specifically on school-based suicide screenings, evidence supports school-wide screening programs as acceptable and effective in identifying at-risk students and increasing the likelihood of service utilization (e.g., Gould et al., 2009; Robinson et al., 2011).
Evaluating Help-Seeking Promotion Efforts
Although there is a substantial body of research on factors that influence adolescent help-seeking, there is not a substantial evidence base confirming interventions to promote help-seeking. Regardless of the strategies used, the overall goal of promotion efforts is clear: increasing formal help-seeking within one's school/organization. Logical outcome variables include (a) number of self-referrals to school-based mental health services and (b) number of students receiving initial services who voluntarily return for follow-up visits. If such referrals are tracked before and after specific promotion efforts are initiated, the effectiveness of those efforts can be assessed. If an increase is measured, consider and rule out alternative explanations for that finding to the greatest extent possible. For example, if there is an increase in self-referrals following promotion efforts, but a school- or community-wide traumatic event occurred simultaneously, increased referrals may be better explained by that event. Any other major changes to the system should be considered as well: start of a school year, addition of a new cohort of students due to school consolidations, or significant changes in administration/support-services staff.
Other evaluation methods can be used to determine what specific barriers exist for adolescents in your system. This can help a system determine what specific promotion strategies to implement first. For such formative evaluations, consider implementing student interviews, focus groups, or questionnaires that assess perceived barriers to help-seeking and identify mental health topics of interest. If you are interested in the effects of prior mental health experiences on the likelihood of future help-seeking, create evaluation questionnaires for clients to rate services. Such measures might include client perceptions of confidentiality, provider trust and respect, helpfulness of services, and attractiveness of counseling techniques.
Data trends suggest reluctance among adolescents to seek formal help for emotional and behavioral concerns, with many reporting that they prefer to handle problems on their own. Mental health professionals are charged with the task of increasing adolescents' willingness to seek psychological help, predominantly for those at-risk for mental health problems and those who lack social support from family and friends. This article suggests strategies to promote adolescent help-seeking, including routine mental health screenings to identify those at-risk and specific efforts to increase awareness of mental health issues and promote help-seeking. Although these strategies were developed using information from available research, we encourage researchers and practitioners alike to empirically examine whether they translate into greater adolescent help-seeking behaviors.
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Christy M. Walcott, PhD, NCSP, is an associate professor and director of the school psychology program at East Carolina University in Greenville, North Carolina. Ajlana Music, PhD, is a school psychologist at Pitt County School District in Greenville, North Carolina.