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Early Intervention in Psychiatry 2015; 9: 228–233
doi:10.1111/eip.12101
Original Article Exploring functional concerns in help-seeking youth: a qualitative study Alice Cairns,1,3 Frances Dark,3 David Kavanagh2 and Steven McPhail1,4 Abstract Aim: This study aimed to explore the functional concerns of help-seeking young people 12–25 years of age.
1 School of Public Health and Social Work and 2School of Psychology and Counselling, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, and 3 Rehabilitation Clinical Academic Unit, Metro South Mental Health Service and 4 Centre for Functioning and Health Research, Metro South Health Service District, Queensland Health, Brisbane, Queensland, Australia
Corresponding author: Mrs Alice Cairns, Mobile Intensive Rehabilitation Team, 51 Wembley Road, Logan Central, Qld 4114, Australia. Email: alice.hodgson@ student.qut.edu.au Received 26 March 2013; accepted 22 September 2013
Method: Semistructured interviews with n = 10 young people seeking help from a youth mental health clinic were conducted. Data were transcribed verbatim and analysed using content analysis. Results were verified by member checking. Results: Participants identified reasons for seeking help, with the main themes being relationships, emotional management, risk-taking behaviour and difficulties with employment. There appeared to be a difference between the concerns of the older, post-school-age group and the younger participants. Conclusion: Young people are able to identify their functional concerns and
Key words: function, mental health, qualitative research, youth.
INTRODUCTION Adolescence and young adulthood is a critical developmental period where substantial neurobiological, hormonal, occupational and social changes are occurring.1–3 The transition for many includes completing education, commencing employment and experimenting with normal adult activities, such as developing intimate relationships and using alcohol.4 These changes allow individual opportunities for personal growth and accomplishment; however, they also increase the mental health vulnerability of young people, with most mental illnesses emerging during this time.4 The impact of mental illness during this period can substantially disrupt functional outcomes, 228
reasons for seeking help from mental health services. Understanding the concerns of these young people provides weight to the model of youth-specific mental health services. Future work examining concerns of 12–25 year olds should ensure adequate representation of the older group as their needs and concerns seem to differ from those of younger participants in this study. Postschool-age youth seem to be underrepresented in existing literature in this field. However, a limitation with this study is the small sample sizes once the cohort is divided by age. Future studies with a larger, more detailed examination of the needs and concerns of this population are warranted to inform service delivery advancements and clarify the difference in needs between the postschool and current school attendee groups.
particularly educational and vocational achievements, which impacts on identity formation, limiting opportunities and the establishment of adult roles.5 In 2003, mental disorders accounted for around 50% of the total disease burden for people aged 12–25 years in Australia.6 A large national survey conducted in 2009 described the main reasons for psychological distress and concern in 12–25 year olds as family conflict, substance use and mental health issues such as coping with stress and body image.7 This study was repeated in 2011; coping with stress and body image continued to be two of the top three issues reported, school or study problems increased as an area of concern.8 These studies did not report if there was a © 2013 Wiley Publishing Asia Pty Ltd
A. Cairns et al. difference in the concerns of the group who sought professional help as opposed to those that did not. There is currently limited evidence in scholarly literature derived directly from young people who are seeking help from professional services regarding their self-reported primary concerns or reasons for seeking help. Engagement in professional services has typically been low, with reported rates of help-seeking between 10% and 30% of young people who score in the clinical range for mental health problems.7,9,10 In Australia, there has been substantial fiscal and policy commitment and investment in promoting and supporting early intervention in mental health.11–13 The ultimate aim of these services is to reduce the disease burden of mental disorders for young people and their families by improving access to specialized, multidisciplinary services.12 Young people have indicated past negative helpseeking experiences as a barrier for future inclination for help-seeking, reporting they sought help in the past and they felt the help was not useful or that their problems were not taken seriously.1 Ensuring a match between the primary concerns of young people and the services offered is important to improve the rates of help-seeking. Understanding the concerns of youth seeking help will allow for evaluation of treatment approaches against service user needs and subsequent refinement of services. This process would support professionals to offer services that are validating the expectations of young people and are responsive to their developmental and psychosocial recovery needs. This investigation aims to explore the self-reported functional concerns of young people who are seeking help from youth-specific mental health services. METHODS Design In-depth semistructured face-to-face interviews with 10 participants were conducted. The interview addressed the aim by examining the current experiences of young people who are attending a youth mental health clinic. Participants, setting and recruitment Participants were youth (n = 10) seeking help from a non-government youth mental health centre (headspace). headspace provides services to youth between the ages of 12 and 25 years, with the aim of promoting and supporting early intervention © 2013 Wiley Publishing Asia Pty Ltd
for young people through mental health, general health, vocational and substance use services.12 Prior to the interview commencing, potential participants were provided with verbal and written information about the study. To assess the maturity and capacity of the youth to consent to participation, they were asked to explain to the researcher their understanding of what will be expected of them, where the information will go, how their privacy will be protected and who they can contact if they have concerns about the interview or the project. The organization ethical review board gave approval to this recruitment process to ensure that young people seeking help without parental knowledge could still be represented in the sample. This investigation was approved by the Queensland University of Technology Human Research Ethics Committee and adhered to the Declaration of Helsinki. All participants provided written informed consent prior to participation in this investigation. Participation was voluntary and parental or guardian consent was not required. Procedure and semistructured interview A flyer advertising the research was placed in the waiting room at one of the headspace clinic locations. A member of the research team was available to answer questions relating to the research, provide information about the study and collect informed consent from participants. Semistructured one-toone interviews were conducted at the clinic at a time convenient for the participant. Recruitment of new participants ceased once data saturation occurred. Data saturation was considered to have occurred when two consecutive patient interviews did not add any additional categories or themes to the emerging framework. Interviews were audio recorded and transcribed. Interviews lasted approximately 30 minutes. The member of the research team conducting the interviews was an occupational therapist with 10 years experience working in mental health settings. In addition to the interview recording, demographic data were also collected for each participant. These demographic variables included age, gender, mental health diagnosis (if any), referral source to headspace (if any), occupational status (schooling and employment) and living situation (co-inhabitants). During the semistructured interview, participants were asked if they could identify areas in their life that they were having difficulty with, specific problems (functional concerns) they were experiencing and reasons for seeking help from headspace. The interviewer then asked follow-up questions to elicit 229
Functional concerns of help-seeking youth the nature of the impact of the functional concerns. Participants were also prompted to identify things that were going well in their life (to describe potential protective factors in their day-to-day life).
amendments or additions were made. The transcripts were analysed as the study progressed.
Data analysis
Demographics
Demographic information was tabulated to describe the sample (Table 1). Each interview was transcribed verbatim and then rechecked for accuracy by the interviewer (while listening to the recording). Interpretative phenomenological analysis14 was used to structure the research design and examine responses. This approach seeks to identify the lived experience of participants and the meanings that these experiences hold. Data were analysed by systematically identifying and grouping themes in the text.15 Member checking was used to confirm validity of analysis.16 Each participant was given an opportunity to view, amend or add additional detail to the themes from their interview via email. However, no feedback was received, and therefore, no
The characteristics of the 10 individual participants are detailed in Table 1; six were female. The age range was 14–25 years. Two (20%) participants did not live at home; despite half of the participant cohort being older than 21 years. One participant identified as neither working nor studying, and half of the group was engaged in full-time study at high school.
RESULTS
Themes Data reached saturation by eight interviews with the final two interviews not adding any additional categories or themes to the emerging framework (Table 2). Four prominent interrelated themes were identified including:
TABLE 1. Participant demographics ordered by age Participant
Age
Gender
Diagnosis
Referral source
Occupational status
9 10 5 3 2
14 14 14 16 17
M F F F M
None Depression and anxiety None Depression and anxiety None
Friend School Police GP Self
7 1 6 4 8
21 21 24 25 25
M M F F F
None Depression PTSD Depression None
Probation officer Friend Friend Public mental health Parent
Living situation
Student F/T Student F/T Student F/T Student F/T Student F/T Employed P/T Employed P/T Unemployed Employed F/T Volunteer work P/T Student P/T
Parents Parents Parents Parents Parents Parents Partner and friends Live in carer Parents Parents
GP, general practitioner; PTSD, post-traumatic stress disorder.
TABLE 2. The emerging framework of four overarching themes, and categories within each theme Theme 1: Relationships
Theme 2: Managing feelings and emotions
Family conflict – being understood, trusting parents (n = 5) Positive peer relationships (n = 3) Negative peer relationships – bullying and disengagement (n = 2) Romantic relationships (n = 3) – –
Depression (n = 4) Impact on relationships (n = 4) Impact on school work (n = 1)
– – –
Impact on keeping employment (n = 3) Poor sleep patterns (n = 1) Body image (n = 1)
230
Theme 3: Risk-taking behaviours
Theme 4: Employment
Anger (n = 1)
Alcohol (n = 2)
Anxiety (n = 2) Self-harm (n = 1)
Unsafe partying (n = 2) Illegal activity for thrill-seeking (n = 2) Illicit drug use (n = 2) Truancy (n = 1) Impact on work, school, hobbies and legal requirements (probation) (n = 2) – – –
Motivation to work (n = 2) Finding work (n = 5) Keeping employment (n = 2) Finances (n = 3) Housing (n = 2) –
– – –
© 2013 Wiley Publishing Asia Pty Ltd
A. Cairns et al. 1 2 3 4
Relationships Emotional management Risk-taking behaviours Employment
Relationships Six of the ten participants identified difficulties with relationships. All the participants under 21 years of age identified this issue. The main concern of five of these six participants was conflict within the family unit, mostly arising from feelings of disengagement from parents or being in conflict with them. All of the female participants under 17 years of age (n = 3) reported this issue. The link between me and my mum and me and my dad has disintegrated. (p10, female, age 14) I feel I can’t really trust my mum on things. And so I don’t really talk to her about anything that I find important because I found that it doesn’t really matter to them. (p3, female, age 16) When one 14-year-old female participant (p5) was asked if she feels she has skills to work through these issues, she replied, No! I have no skill. Difficulties with relationships with friends presented as less of a current concern to the young people and the peer group was often described as a protective factor by the young person despite previous experience that appeared negative. If I had stayed at my old school, I would have just ruined my life. I would have kept going on with the things that I use to do because I hung out with people that were such a bad influence on me but now that I am at a new school they are a good influence on me and stop me from doing bad things. (p10, female, age 14) Four participants identified relationship skills as the primary purpose for seeking help. Emotional management Difficulty with responding to feelings and emotions was a major theme and appeared to be a prominent factor affecting other aspects of life such as relationships, school and work. My anger gets me into a lot of fights and gets me in trouble with the police . . . you know I’ve just got bad temper issues and it affects my relationship with my partner. She is just scared of my anger . . . my voice scares her and when I do get angry my © 2013 Wiley Publishing Asia Pty Ltd
whole body tenses up and she gets scared of that and I don’t like scaring her. (p1, male, age 21) I get anxiety, I get shakes, nauseous, light headed, scared like I want to either run or fight. (p2, male, age 17) [If I felt more relaxed] I would be able do better academically, would be able to excel more like I wouldn’t have to worry socially. (p9, male, age 14) One participant talked about the serious consequence of difficulties managing experiences and emotions. When I was little I was bullied and teased . . . that impacted on me a lot and people were very racist, they would make up names with my names and tease me . . . I would cry then they would laugh at me. I started self harming when I was in year six. (p10, female, age 14)
Risk-taking behaviour Participants reported their risk-taking behaviour as a reason for seeking help. These behaviours centred on alcohol use and engaging in illegal activity for thrill-seeking. I want to do the right things but they seem to be pretty boring I guess. That’s why I tend to break the law a little bit. (p5, female, age 14) For one 21-year-old man (p7), his alcohol use was his primary concern as it impacted on his ability to participate in hobbies, maintain employment and remain out of jail. [I have difficulty] with not wanting to stop drinking . . . I was almost late for probation today because I went out drinking last night and I won’t have the money to buy some things for my car. I bought a carton of beer on Monday and I had to buy another carton on Tuesday night ‘cause it was going to be all gone. (p7, male, age 21)
Employment Some participants talked about difficulties with employment as a consequence of some of their other concerns such as risk-taking behaviours and anger. Of the four participants whose primary reason for seeking help related to employment, three were older than 21 years. The descriptions of these concerns had two sub-foci; one was obtaining (any) gainful employment and the other was obtaining desired employment. Complaints included not being able to secure full-time work (rather than 231
Functional concerns of help-seeking youth part-time or casual work), work in a convenient location or dissatisfaction with their current field of employment. I’m applying for jobs and just not hearing back from them at all or I haven’t got the experience even though I have different certificates of qualifications it doesn’t really matter you have to have the experience. It’s really tough . . . I’m going out doing the training to get the qualifications but they are just not interested. (p4, female, age 25) Well I have had some part time jobs before . . . I’ve been looking but everything has been filled. It’s especially hard because I’m only a junior. (p5, female, age 14) Difficulties with employment led onto a discussion around housing and finances. One 25-year-old woman reported she was still living at home, not out of choice but because she could not afford to move without a job. DISCUSSION This study explored the primary concerns of young people who were seeking help for psychological issues. To this end, four main themes were identified, which have provided insight into the problems young people are seeking help for. Although youthspecific mental health services are targeting young people, aged 12–25 years,12 findings from this study have highlighted that there may be differences between some of the concerns of the under 21 years group and the young adult (21–25 years) group. For example, the younger group may be primarily concerned with family conflict, whereas slightly older clients may be less concerned with this issue (despite potentially still living with their parents). On the contrary, a prominent reason for seeking help among the older participants in this study were issues related to employment, which they reported to subsequently impact their self-esteem, finances, leisure and housing goals. Interpersonal relationships with peers were not a frequently reported concern, with only two participants reporting this to be a problem. This is in contrast to previous research, which has reported peer relationships to be a driver for help-seeking.17 Other prominent themes identified in this study were less sensitive to age. Participants of all ages included in this study reported difficulty managing and responding to feelings and emotions in a healthy way. The issues reported by these participants varied from more traditional mental health concerns such as anxiety, depression and self-harm, 232
to the impact their behaviour was having on their relationships and school work. Difficulty with emotional management was an issue for every participant and appeared to underlie many of the practical concerns raised. The impact of psychological distress was often reported by participants to manifest in risk-taking behaviour. Although these themes are interrelated, risk-taking behaviour was described by participants in both the context of managing uncomfortable emotions (anger, hurt, frustration) and also for the thrill of the activity itself. Findings from this study are consistent with prior related research. A large national survey examining the issues of concern for young Australians (11–24 years)7 highlighted family conflict in the top four areas of concern. This 2009 survey did not report if there was a difference with this issue between age groups, and with only 2.1% of respondents being over 20 years old, the views of the older group may have been masked. The results from the 2011 survey reported that concerns with family conflict decreased with age; however, the representation of respondents over 20 years old was not improved.8 These surveys also identified young Australians as being concerned with mental health problems, including stress and depression,7,8 and indicated that the older cohort (20–24 years old) were more concerned about coping with stress and depression. This is in contrast to our results which indicated that difficulties with managing emotions was not age specific and could be an indication of the difference in help-seeking youth versus general population. High rates of psychological distress have been reported in Australian youth,18 with girls generally reporting greater psychological distress than boys. Risk-taking behaviour has been reported in previous studies as being both a concern for young people7 and as a natural part of the process of maturation to adulthood where risk taking holds a function for the young people who participate.19 Other studies have identified engagement in positive vocational experiences as a fundamental component in maintaining positive psychological health.20,21 Understanding the concerns of these young people provides weight to the model of youthspecific mental health services where access to psychological therapies including cognitive behaviour therapy is standard treatment.22 A salient observation from this investigation was the employment concerns of post-school-age youth. Unemployment is likely to compound negative psychological and health issues and has been associated with increased substance misuse.23,24 Vocational support is one of the core services headspace centres are funded to deliver. This investigation would suggest a © 2013 Wiley Publishing Asia Pty Ltd
A. Cairns et al. positive match between the self-identified needs of the post-school-age cohort and the services offered. Strengths, limitations and future research There are several strengths and limitations of this research, as well as some important future research directions. A strength of this study was the in-depth nature of the interviews that allowed detailed examination of the concerns for these help-seeking young people, thus subsequently addressing the research aim. A key limitation of this investigation was the recruitment of participants from one centre in one location. Other young people who are accessing help from different organizations may have different opinions and experiences. It is possible that the prevalence of the reported difficulties (and selfawareness of participants in identifying these difficulties) is due to the help-seeking nature of these participants. Other broader youth populations may not have had the self-awareness to articulate these difficulties, or may have identified other concerns in their lives. A further limitation was the self-selecting nature of recruitment, which may have contributed to different experiences and levels of engagement with the researcher. A larger, more detailed examination of the needs and concerns of the help-seeking young adult age group (18–25 years) is warranted to inform future service delivery advancements. Future work examining concerns of 12–25 year olds should ensure adequate representation of the older group, or consider post-school-age youth as a separate population as their needs and concerns seemed to differ from younger participants, and post-school-age youth seem to be underrepresented in existing literature in this field.
ACKNOWLEDGEMENTS We would like to thank the staff and clients of the Southport headspace centre. Their support and participation is greatly appreciated.
REFERENCES 1. Rickwood DJ, Deane FP, Wilson CJ, Ciarrochi J. Young people’s help-seeking for mental health problems. Aust e-J Adv Ment Health 2005; 4 (3 Suppl.). 2. Luna B, Sweeney JA. Studies of brain and cognitive maturation through childhood and adolescence: a strategy for testing neurodeveolpmental hypothesis. Schizophr Bull 2001; 27: 443–55.
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3. Walker EF, Sabuwalla Z, Huot R. Pubertal neuromaturation, stress sensitivity, and psychopathology. Dev Psychopathol 2004; 16: 807–24. 4. Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet 2007; 369 (9569): 1302–13. 5. Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I: educational attainment. Am J Psychiatry 1995; 152: 1026–32. 6. Australian Institute of Health and Welfare. Young Australians: their health and wellbeing. Canberra: AIHW, 2007. 7. Hampshire A, Di Nicola K. What’s worrying young Australians and where do they go for advice and support? Policy and practice implications for thier well-being. Early Interv Psychiatry 2011; 5 (Suppl. 1): 12–16. 8. Mission Australia. National survey of young Australians 2011: Key and emerging issues: Mission Australia. 2011. 9. Catania LS, Hetrick S, Newman LK, Purcell R. Prevention and early intervention for mental health problems in 0–25 year olds: are there evidence-based models of care? Adv Ment Health 2011; 10: 6–19. 10. Oliver MI, Pearson N, Coe N, Gunnell D. Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. Br J Psychiatry 2005; 186: 297–301. 11. Queensland Government. Queensland Plan for Mental Health 2007–2017. Brisbane: Queensland Government, 2008. 12. McGorry P, Tanti C, Stokes R et al. headspace: Australia’s National Youth Mental Health Foundation – where young minds come first. Med J Aust 2007; 187: S68. 13. Australian Health Ministers. Fourth National Mental Health Plan: An agenda for collaborative government action in mental health 2009–2014. Canberra: Commonwealth Department of Health and Aging, 2009. 14. Smith JA, Osborn M. Interpretative phenomenolgical analysis. In: Smith JA, ed. Qualitative Psychology: A Practical Guide to Research Methods, 2nd edn. London: Sage Publications Ltd, 2008; 53–80. 15. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311: 42–5. 16. Patton MQ. Qualitative Research & Evaluation Methods, 3rd edn. Thousand Oaks, CA: Sage Publications, Inc., 2002. 17. Boldero J, Fallon B. Adolescent help-seeking: what do they get help for and from whom? J Adolesc 1995; 18: 193–209. 18. Rickwood DJ, d’Espaignet ET. Psychological distress among older adolescents and young adults in Australia. Aust N Z J Public Health 1996; 20: 83–6. 19. Ellis BJ, Del Giudice M, Dishion TJ et al. The evolutionary basis of risky adolescent behavior: implications for science, policy, and practice. Dev Psychol 2012; 48: 598–623. 20. Blustein DL. The role of work in psychological health and well-being – a conceptual, historical, and public policy perspective [Review]. Am Psychol 2008; 63: 228–40.. 21. Graetz B. Health consequences of employment and unemployment. In: Gregory RG, Karmel T, eds. Youth in the Eighties Papers from the Australian Longitudinal Survey Resarch Project. Canberra: Centre for Economic Policy Research, 1992; 352–71. 22. McGorry P. The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust 2007; 187 (7 Suppl.): S53–6. 23. Killackey E. Something for everyone: employment interventions in psychotic illness. Acta Neuropsychiatr 2008; 20: 277–9. 24. Morrell SL, Taylor RJ, Kerr CB. Unemployment and young people’s health. Med J Aust 1998; 168: 236–40.
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Early Intervention in Psychiatry 2015; 9: 228–233
doi:10.1111/eip.12101
Original Article Exploring functional concerns in help-seeking youth: a qualitative study Alice Cairns,1,3 Frances Dark,3 David Kavanagh2 and Steven McPhail1,4 Abstract Aim: This study aimed to explore the functional concerns of help-seeking young people 12–25 years of age.
1 School of Public Health and Social Work and 2School of Psychology and Counselling, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, and 3 Rehabilitation Clinical Academic Unit, Metro South Mental Health Service and 4 Centre for Functioning and Health Research, Metro South Health Service District, Queensland Health, Brisbane, Queensland, Australia
Corresponding author: Mrs Alice Cairns, Mobile Intensive Rehabilitation Team, 51 Wembley Road, Logan Central, Qld 4114, Australia. Email: alice.hodgson@ student.qut.edu.au Received 26 March 2013; accepted 22 September 2013
Method: Semistructured interviews with n = 10 young people seeking help from a youth mental health clinic were conducted. Data were transcribed verbatim and analysed using content analysis. Results were verified by member checking. Results: Participants identified reasons for seeking help, with the main themes being relationships, emotional management, risk-taking behaviour and difficulties with employment. There appeared to be a difference between the concerns of the older, post-school-age group and the younger participants. Conclusion: Young people are able to identify their functional concerns and
Key words: function, mental health, qualitative research, youth.
INTRODUCTION Adolescence and young adulthood is a critical developmental period where substantial neurobiological, hormonal, occupational and social changes are occurring.1–3 The transition for many includes completing education, commencing employment and experimenting with normal adult activities, such as developing intimate relationships and using alcohol.4 These changes allow individual opportunities for personal growth and accomplishment; however, they also increase the mental health vulnerability of young people, with most mental illnesses emerging during this time.4 The impact of mental illness during this period can substantially disrupt functional outcomes, 228
reasons for seeking help from mental health services. Understanding the concerns of these young people provides weight to the model of youth-specific mental health services. Future work examining concerns of 12–25 year olds should ensure adequate representation of the older group as their needs and concerns seem to differ from those of younger participants in this study. Postschool-age youth seem to be underrepresented in existing literature in this field. However, a limitation with this study is the small sample sizes once the cohort is divided by age. Future studies with a larger, more detailed examination of the needs and concerns of this population are warranted to inform service delivery advancements and clarify the difference in needs between the postschool and current school attendee groups.
particularly educational and vocational achievements, which impacts on identity formation, limiting opportunities and the establishment of adult roles.5 In 2003, mental disorders accounted for around 50% of the total disease burden for people aged 12–25 years in Australia.6 A large national survey conducted in 2009 described the main reasons for psychological distress and concern in 12–25 year olds as family conflict, substance use and mental health issues such as coping with stress and body image.7 This study was repeated in 2011; coping with stress and body image continued to be two of the top three issues reported, school or study problems increased as an area of concern.8 These studies did not report if there was a © 2013 Wiley Publishing Asia Pty Ltd
A. Cairns et al. difference in the concerns of the group who sought professional help as opposed to those that did not. There is currently limited evidence in scholarly literature derived directly from young people who are seeking help from professional services regarding their self-reported primary concerns or reasons for seeking help. Engagement in professional services has typically been low, with reported rates of help-seeking between 10% and 30% of young people who score in the clinical range for mental health problems.7,9,10 In Australia, there has been substantial fiscal and policy commitment and investment in promoting and supporting early intervention in mental health.11–13 The ultimate aim of these services is to reduce the disease burden of mental disorders for young people and their families by improving access to specialized, multidisciplinary services.12 Young people have indicated past negative helpseeking experiences as a barrier for future inclination for help-seeking, reporting they sought help in the past and they felt the help was not useful or that their problems were not taken seriously.1 Ensuring a match between the primary concerns of young people and the services offered is important to improve the rates of help-seeking. Understanding the concerns of youth seeking help will allow for evaluation of treatment approaches against service user needs and subsequent refinement of services. This process would support professionals to offer services that are validating the expectations of young people and are responsive to their developmental and psychosocial recovery needs. This investigation aims to explore the self-reported functional concerns of young people who are seeking help from youth-specific mental health services. METHODS Design In-depth semistructured face-to-face interviews with 10 participants were conducted. The interview addressed the aim by examining the current experiences of young people who are attending a youth mental health clinic. Participants, setting and recruitment Participants were youth (n = 10) seeking help from a non-government youth mental health centre (headspace). headspace provides services to youth between the ages of 12 and 25 years, with the aim of promoting and supporting early intervention © 2013 Wiley Publishing Asia Pty Ltd
for young people through mental health, general health, vocational and substance use services.12 Prior to the interview commencing, potential participants were provided with verbal and written information about the study. To assess the maturity and capacity of the youth to consent to participation, they were asked to explain to the researcher their understanding of what will be expected of them, where the information will go, how their privacy will be protected and who they can contact if they have concerns about the interview or the project. The organization ethical review board gave approval to this recruitment process to ensure that young people seeking help without parental knowledge could still be represented in the sample. This investigation was approved by the Queensland University of Technology Human Research Ethics Committee and adhered to the Declaration of Helsinki. All participants provided written informed consent prior to participation in this investigation. Participation was voluntary and parental or guardian consent was not required. Procedure and semistructured interview A flyer advertising the research was placed in the waiting room at one of the headspace clinic locations. A member of the research team was available to answer questions relating to the research, provide information about the study and collect informed consent from participants. Semistructured one-toone interviews were conducted at the clinic at a time convenient for the participant. Recruitment of new participants ceased once data saturation occurred. Data saturation was considered to have occurred when two consecutive patient interviews did not add any additional categories or themes to the emerging framework. Interviews were audio recorded and transcribed. Interviews lasted approximately 30 minutes. The member of the research team conducting the interviews was an occupational therapist with 10 years experience working in mental health settings. In addition to the interview recording, demographic data were also collected for each participant. These demographic variables included age, gender, mental health diagnosis (if any), referral source to headspace (if any), occupational status (schooling and employment) and living situation (co-inhabitants). During the semistructured interview, participants were asked if they could identify areas in their life that they were having difficulty with, specific problems (functional concerns) they were experiencing and reasons for seeking help from headspace. The interviewer then asked follow-up questions to elicit 229
Functional concerns of help-seeking youth the nature of the impact of the functional concerns. Participants were also prompted to identify things that were going well in their life (to describe potential protective factors in their day-to-day life).
amendments or additions were made. The transcripts were analysed as the study progressed.
Data analysis
Demographics
Demographic information was tabulated to describe the sample (Table 1). Each interview was transcribed verbatim and then rechecked for accuracy by the interviewer (while listening to the recording). Interpretative phenomenological analysis14 was used to structure the research design and examine responses. This approach seeks to identify the lived experience of participants and the meanings that these experiences hold. Data were analysed by systematically identifying and grouping themes in the text.15 Member checking was used to confirm validity of analysis.16 Each participant was given an opportunity to view, amend or add additional detail to the themes from their interview via email. However, no feedback was received, and therefore, no
The characteristics of the 10 individual participants are detailed in Table 1; six were female. The age range was 14–25 years. Two (20%) participants did not live at home; despite half of the participant cohort being older than 21 years. One participant identified as neither working nor studying, and half of the group was engaged in full-time study at high school.
RESULTS
Themes Data reached saturation by eight interviews with the final two interviews not adding any additional categories or themes to the emerging framework (Table 2). Four prominent interrelated themes were identified including:
TABLE 1. Participant demographics ordered by age Participant
Age
Gender
Diagnosis
Referral source
Occupational status
9 10 5 3 2
14 14 14 16 17
M F F F M
None Depression and anxiety None Depression and anxiety None
Friend School Police GP Self
7 1 6 4 8
21 21 24 25 25
M M F F F
None Depression PTSD Depression None
Probation officer Friend Friend Public mental health Parent
Living situation
Student F/T Student F/T Student F/T Student F/T Student F/T Employed P/T Employed P/T Unemployed Employed F/T Volunteer work P/T Student P/T
Parents Parents Parents Parents Parents Parents Partner and friends Live in carer Parents Parents
GP, general practitioner; PTSD, post-traumatic stress disorder.
TABLE 2. The emerging framework of four overarching themes, and categories within each theme Theme 1: Relationships
Theme 2: Managing feelings and emotions
Family conflict – being understood, trusting parents (n = 5) Positive peer relationships (n = 3) Negative peer relationships – bullying and disengagement (n = 2) Romantic relationships (n = 3) – –
Depression (n = 4) Impact on relationships (n = 4) Impact on school work (n = 1)
– – –
Impact on keeping employment (n = 3) Poor sleep patterns (n = 1) Body image (n = 1)
230
Theme 3: Risk-taking behaviours
Theme 4: Employment
Anger (n = 1)
Alcohol (n = 2)
Anxiety (n = 2) Self-harm (n = 1)
Unsafe partying (n = 2) Illegal activity for thrill-seeking (n = 2) Illicit drug use (n = 2) Truancy (n = 1) Impact on work, school, hobbies and legal requirements (probation) (n = 2) – – –
Motivation to work (n = 2) Finding work (n = 5) Keeping employment (n = 2) Finances (n = 3) Housing (n = 2) –
– – –
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A. Cairns et al. 1 2 3 4
Relationships Emotional management Risk-taking behaviours Employment
Relationships Six of the ten participants identified difficulties with relationships. All the participants under 21 years of age identified this issue. The main concern of five of these six participants was conflict within the family unit, mostly arising from feelings of disengagement from parents or being in conflict with them. All of the female participants under 17 years of age (n = 3) reported this issue. The link between me and my mum and me and my dad has disintegrated. (p10, female, age 14) I feel I can’t really trust my mum on things. And so I don’t really talk to her about anything that I find important because I found that it doesn’t really matter to them. (p3, female, age 16) When one 14-year-old female participant (p5) was asked if she feels she has skills to work through these issues, she replied, No! I have no skill. Difficulties with relationships with friends presented as less of a current concern to the young people and the peer group was often described as a protective factor by the young person despite previous experience that appeared negative. If I had stayed at my old school, I would have just ruined my life. I would have kept going on with the things that I use to do because I hung out with people that were such a bad influence on me but now that I am at a new school they are a good influence on me and stop me from doing bad things. (p10, female, age 14) Four participants identified relationship skills as the primary purpose for seeking help. Emotional management Difficulty with responding to feelings and emotions was a major theme and appeared to be a prominent factor affecting other aspects of life such as relationships, school and work. My anger gets me into a lot of fights and gets me in trouble with the police . . . you know I’ve just got bad temper issues and it affects my relationship with my partner. She is just scared of my anger . . . my voice scares her and when I do get angry my © 2013 Wiley Publishing Asia Pty Ltd
whole body tenses up and she gets scared of that and I don’t like scaring her. (p1, male, age 21) I get anxiety, I get shakes, nauseous, light headed, scared like I want to either run or fight. (p2, male, age 17) [If I felt more relaxed] I would be able do better academically, would be able to excel more like I wouldn’t have to worry socially. (p9, male, age 14) One participant talked about the serious consequence of difficulties managing experiences and emotions. When I was little I was bullied and teased . . . that impacted on me a lot and people were very racist, they would make up names with my names and tease me . . . I would cry then they would laugh at me. I started self harming when I was in year six. (p10, female, age 14)
Risk-taking behaviour Participants reported their risk-taking behaviour as a reason for seeking help. These behaviours centred on alcohol use and engaging in illegal activity for thrill-seeking. I want to do the right things but they seem to be pretty boring I guess. That’s why I tend to break the law a little bit. (p5, female, age 14) For one 21-year-old man (p7), his alcohol use was his primary concern as it impacted on his ability to participate in hobbies, maintain employment and remain out of jail. [I have difficulty] with not wanting to stop drinking . . . I was almost late for probation today because I went out drinking last night and I won’t have the money to buy some things for my car. I bought a carton of beer on Monday and I had to buy another carton on Tuesday night ‘cause it was going to be all gone. (p7, male, age 21)
Employment Some participants talked about difficulties with employment as a consequence of some of their other concerns such as risk-taking behaviours and anger. Of the four participants whose primary reason for seeking help related to employment, three were older than 21 years. The descriptions of these concerns had two sub-foci; one was obtaining (any) gainful employment and the other was obtaining desired employment. Complaints included not being able to secure full-time work (rather than 231
Functional concerns of help-seeking youth part-time or casual work), work in a convenient location or dissatisfaction with their current field of employment. I’m applying for jobs and just not hearing back from them at all or I haven’t got the experience even though I have different certificates of qualifications it doesn’t really matter you have to have the experience. It’s really tough . . . I’m going out doing the training to get the qualifications but they are just not interested. (p4, female, age 25) Well I have had some part time jobs before . . . I’ve been looking but everything has been filled. It’s especially hard because I’m only a junior. (p5, female, age 14) Difficulties with employment led onto a discussion around housing and finances. One 25-year-old woman reported she was still living at home, not out of choice but because she could not afford to move without a job. DISCUSSION This study explored the primary concerns of young people who were seeking help for psychological issues. To this end, four main themes were identified, which have provided insight into the problems young people are seeking help for. Although youthspecific mental health services are targeting young people, aged 12–25 years,12 findings from this study have highlighted that there may be differences between some of the concerns of the under 21 years group and the young adult (21–25 years) group. For example, the younger group may be primarily concerned with family conflict, whereas slightly older clients may be less concerned with this issue (despite potentially still living with their parents). On the contrary, a prominent reason for seeking help among the older participants in this study were issues related to employment, which they reported to subsequently impact their self-esteem, finances, leisure and housing goals. Interpersonal relationships with peers were not a frequently reported concern, with only two participants reporting this to be a problem. This is in contrast to previous research, which has reported peer relationships to be a driver for help-seeking.17 Other prominent themes identified in this study were less sensitive to age. Participants of all ages included in this study reported difficulty managing and responding to feelings and emotions in a healthy way. The issues reported by these participants varied from more traditional mental health concerns such as anxiety, depression and self-harm, 232
to the impact their behaviour was having on their relationships and school work. Difficulty with emotional management was an issue for every participant and appeared to underlie many of the practical concerns raised. The impact of psychological distress was often reported by participants to manifest in risk-taking behaviour. Although these themes are interrelated, risk-taking behaviour was described by participants in both the context of managing uncomfortable emotions (anger, hurt, frustration) and also for the thrill of the activity itself. Findings from this study are consistent with prior related research. A large national survey examining the issues of concern for young Australians (11–24 years)7 highlighted family conflict in the top four areas of concern. This 2009 survey did not report if there was a difference with this issue between age groups, and with only 2.1% of respondents being over 20 years old, the views of the older group may have been masked. The results from the 2011 survey reported that concerns with family conflict decreased with age; however, the representation of respondents over 20 years old was not improved.8 These surveys also identified young Australians as being concerned with mental health problems, including stress and depression,7,8 and indicated that the older cohort (20–24 years old) were more concerned about coping with stress and depression. This is in contrast to our results which indicated that difficulties with managing emotions was not age specific and could be an indication of the difference in help-seeking youth versus general population. High rates of psychological distress have been reported in Australian youth,18 with girls generally reporting greater psychological distress than boys. Risk-taking behaviour has been reported in previous studies as being both a concern for young people7 and as a natural part of the process of maturation to adulthood where risk taking holds a function for the young people who participate.19 Other studies have identified engagement in positive vocational experiences as a fundamental component in maintaining positive psychological health.20,21 Understanding the concerns of these young people provides weight to the model of youthspecific mental health services where access to psychological therapies including cognitive behaviour therapy is standard treatment.22 A salient observation from this investigation was the employment concerns of post-school-age youth. Unemployment is likely to compound negative psychological and health issues and has been associated with increased substance misuse.23,24 Vocational support is one of the core services headspace centres are funded to deliver. This investigation would suggest a © 2013 Wiley Publishing Asia Pty Ltd
A. Cairns et al. positive match between the self-identified needs of the post-school-age cohort and the services offered. Strengths, limitations and future research There are several strengths and limitations of this research, as well as some important future research directions. A strength of this study was the in-depth nature of the interviews that allowed detailed examination of the concerns for these help-seeking young people, thus subsequently addressing the research aim. A key limitation of this investigation was the recruitment of participants from one centre in one location. Other young people who are accessing help from different organizations may have different opinions and experiences. It is possible that the prevalence of the reported difficulties (and selfawareness of participants in identifying these difficulties) is due to the help-seeking nature of these participants. Other broader youth populations may not have had the self-awareness to articulate these difficulties, or may have identified other concerns in their lives. A further limitation was the self-selecting nature of recruitment, which may have contributed to different experiences and levels of engagement with the researcher. A larger, more detailed examination of the needs and concerns of the help-seeking young adult age group (18–25 years) is warranted to inform future service delivery advancements. Future work examining concerns of 12–25 year olds should ensure adequate representation of the older group, or consider post-school-age youth as a separate population as their needs and concerns seemed to differ from younger participants, and post-school-age youth seem to be underrepresented in existing literature in this field.
ACKNOWLEDGEMENTS We would like to thank the staff and clients of the Southport headspace centre. Their support and participation is greatly appreciated.
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