Factors influencing young peoples choice of professional help for mental health concerns

Running Head: FACTORS INFLUENCING YOUNG PEOPLE‟S CHOICE OF

PROFESSIONAL HELP

Factors Influencing Young People’s Choice of Professional Help for Mental Health

Concerns

Sally R. Bradford

University of Canberra

2011

Submitted in partial fulfilment of the requirement for the degree of Bachelor of Science

in Psychology (Honours)

I declare work presented in this thesis is my own work and does not include materials

from published sources without proper acknowledgement.

Sally Bradford

ii

FACTORS INFLUENCING YOUNG PEOPLE‟S CHOICE OF PROFESSIONAL

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Abstract

It is well established that young people have high rates of mental health problems and

low rates of service utilisation. This study investigated whether young people have a

stronger preference for help online, face-to-face, over the phone, or not seeking help.

Further, this study tested whether an intention to seek help online could be predicted by

higher levels of self-stigma, self-reliance and shyness, and lower levels of emotional

competency and mental health literacy. A non-experimental cross-sectional survey

design was used. Participants were 231 students, aged 15–19 years, from three schools

across Canberra, ACT. Results indicated that participants had the strongest preference

for face-to-face help, followed by a preference not to seek help, help online, then help

over the phone. However, preferences did not match behavioural intentions, with

participant‟s highest intention to not seek help at all. In addition, the identified help-

seeking barriers were found to account for 14% of the variance in intentions to seek

help online, and 19% of the variance in an intention not to seek help. Results also

showed that gender differences within help-seeking preferences and the predictor

variables may not be as large as previously identified. The findings suggest that

organisations need to continue providing help face-to-face, whilst trying innovative

methods to promote and provide services online in an attempt to attract the large group

of young people still unwilling to seek help.

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Acknowledgements

Firstly, I‟d like to thank my supervisor Debra Rickwood for her wealth of

knowledge, encouragement, and unfailing support. I would also like to thank John

Leyshon, Martin Watson, Denis Dickinson, Bernard Walsh and the students of Radford

College, UC Senior Secondary College Lake Ginninderra and UC High School Kaleen

for allowing me into their schools and classrooms. Thank-you also to Lisa Kelly and

headspace ACT for providing a link to my survey on the headspace website. To all my

family and friends, thank-you for your support throughout the years, and this year in

particular. Finally, to the greatest supports in my life, my mum Jenny, and my partner

Jonesy. Mum, thank you for your unfailing financial and emotional support; I know that

I can always turn to you. Jones, you are my best friend and you make me laugh every

day, I love you and cannot thank you enough for all your support.

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Contents

Abstract ............................................................................................................................. ii

Acknowledgements ......................................................................................................... iii

Contents ........................................................................................................................... iv

List of Tables ................................................................................................................... vi

List of Figures ................................................................................................................. vii

List of Appendices ......................................................................................................... viii

Introduction 1

Factors Affecting Help-Seeking ................................................................................... 3

Gender. ..................................................................................................................... 4

Self-Stigma. .............................................................................................................. 4

Emotional Competence............................................................................................. 6

Mental Health Literacy. ............................................................................................ 7

Self-Reliance. ........................................................................................................... 8

Shyness. .................................................................................................................... 9

Overcoming Barriers .................................................................................................. 10

Face-to-Face Help................................................................................................... 10

Help Over the Phone. ............................................................................................. 11

Help Online. ........................................................................................................... 11

Preferences.................................................................................................................. 15

The Current Study ...................................................................................................... 16

Method ............................................................................................................................ 17

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Participants ................................................................................................................. 17

Measures ..................................................................................................................... 18

Help-Seeking Intentions. ........................................................................................ 18

Help-Seeking Preferences....................................................................................... 19

Self-Stigma. ............................................................................................................ 19

Emotional Competency. ......................................................................................... 20

Mental Health Literacy. .......................................................................................... 20

Self-Reliance. ......................................................................................................... 22

Shyness. .................................................................................................................. 22

Design and Procedure ................................................................................................. 22

Results ............................................................................................................................ 24

Preferences for Help Sources ..................................................................................... 25

Intentions to Use Each Help Source ........................................................................... 28

Gender Differences in the Predictor Variables ........................................................... 30

Correlations Between the Study Variables ................................................................. 31

Predictive Model of Help-Seeking Intentions ............................................................ 33

Discussion ....................................................................................................................... 36

Limitations of the Study ............................................................................................. 44

Future Research .......................................................................................................... 45

Conclusion .................................................................................................................. 46

References 47

Appendix ........................................................................................................................ 62

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List of Tables

Table 1 Psychometric Properties of the Study Variables 25

Table 2 Pairwise Contrasts of Help-Seeking Intentions by Help-Seeking

Source 30

Table 3 Summary of the Intercorrelations of the Study Variables 33

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List of Figures

Figure 1 Hypothesised mediated relationship of gender with help-seeking

intentions 17

Figure 2 Preference for each help source by gender 28

Figure 3 Intentions to use each help-seeking source 29

Figure 4 Hypothesised model predicting intentions to seek help online, face-to-

face and to not to seek help 34

Figure 5 Final path model predicting intentions to seek help online, face-to-face

and to not seek help 36

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List of Appendices

Appendix A Adolescent Help-Seeking Survey 62

Appendix B University of Canberra Committee for Ethics in Human Research

Letter of Ethical Approval 77

Appendix C ACT Department of Education and Training Letter of Ethical

Approval 74

Appendix D Letter of Invitation to Parents and Guardians 76

Appendix E Research Participant Information Sheet 78

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The reluctance of young people to seek help for their mental health problems is

well documented. Their lack of service use is concerning since the 16 to 24 year age

group has the highest prevalence rates of 12-month mental disorders (Australian Bureau

of Statistics [ABS], 2007). In addition, this time of life is an important developmental

period which may be adversely affected by these problems. A number of barriers to

help seeking have been identified, some of which may be overcome by providing

services through mediums other than the traditional face-to-face approach. What has

not been identified is whether young people actually prefer these alternate sources, such

as online or phone lines, and the characteristics of those young people who intend to use

each source. By understanding the characteristics of young people who are most likely

to use non face-to-face mediums, organisations may be able to address some of the help

seeking barriers, and tailor their services in order to provide more effective treatments.

The majority of young people aged 16 to 24 years are either dealing with mental

health problems themselves or know someone who is. Mental health problems are

pervasive with the 2007 Australian National Survey of Mental Health and Wellbeing

(NSMHWB) finding that 26.4% of Australians aged 16 to 24 will have a mental health

disorder in any 12-month period (ABS, 2007). In particular, affective disorders are

common with 6.3% of 16 to 24 year olds meeting the criteria for a mood disorder during

any 12-month period. Further, a study of mental disorders and their prevalence rates

among US citizens found that the median age of onset for any disorder was 14 years,

with 75% of all mental disorders having an age of onset by 24 years (Kessler et al.,

2005).

Unfortunately, the high prevalence rates of mental illnesses do not result in high

rates of service utilisation, particularly for males. The 2007 NSMHWB found that only

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13.2% of males aged 16 to 24 years who identified as having a mental disorder had

sought professional help. The rates are considerably better, but still low for females of

the same age group with only 31.2% seeking help (Slade et al., 2009). These low rates

of service utilisation were also identified by Tanielian et al, (2009) who found that only

25.1% of American adolescents with depression were currently receiving treatment.

Similar concerning results have been found in New Zealand (Oakley Browne, Wells,

Scott, & McGee, 2006), and Canada (Cheung & Dewa, 2007).

In order to receive treatment and support for a mental health problem,

individuals must first seek out help. Help-seeking is the behaviour of actively

communicating with others in order to gain advice, information, treatment, or general

support for a particular problem (Rickwood, Deane, Wilson, & Ciarrochi, 2005). In this

sense, help-seeking is unlike other social interactions as it is intensely personal, often

requiring the help-seeker to disclose very personal thoughts and feelings. Help-seeking

can occur both formally, through professional sources, and informally through social

relationships, and requires a number of steps and responses (Rickwood, et al., 2005).

For example, the individual must first be aware that a problem exists, and realise they

may require outside intervention. They must then be able to express what the issue is to

a source that is both approachable and available.

Appropriate help-seeking behaviours are important protective factors as they are

likely to lead to professional and social supports which will reduce psychological

distress and ultimately improve mental well-being (Wilson, Deane, Ciarrochi, &

Rickwood, 2005). The low rate of adolescents who seek help is therefore concerning

for a number of reasons. Adolescence is a time of change as young people find their

way into new social roles. They are finishing school, gaining work and new financial

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autonomy, moving out of the family home, and beginning new relationships (Burns &

Field, 2002; Rickwood, White, & Eckersley, 2007). Since mental health problems have

been related to impaired peer relations, low self-esteem, low attention, and difficulties

in school (Strauss, Frame, & Forehand, 1987), even mild issues can cause social,

emotional, and cognitive changes during this pivotal developmental period (Rickwood,

et al., 2005; Sawyer, 2004). In addition to affecting the normal development of young

people, mental health problems have also been associated with increases in smoking and

substance abuse (ABS, 2007). The serious long term consequences that may emerge due

to untreated mental health problems makes it clear that we need to identify and

understand the barriers to help-seeking in order to improve rates of service utilisation.

Factors Affecting Help-Seeking

A wide range of factors have been investigated for their impact on help-seeking.

Particularly strong and consistent evidence has been found for the effects of gender,

self-stigma, emotional competency, mental health literacy, self-reliance and social

competencey. These factors have been identified as they aid or disrupt the skills and

phases required to complete the help seeking process (Srebnik, Cauce, & Baydar, 1996).

Levels of mental health literacy and self-reliance are important as the potential help

seeker must have some understanding of mental health problems in order to recognise

that a problem exists, and then decide that they require outside support (Rickwood,

Deane, & Wilson, 2007). In addition, they need to know who to turn too, what the

process will be (Gould et al., 2004), and believe that it will help (Prochaska &

DiClemente, 1982; Wilson, Deane, & Ciarrochi, 2005). Help-seekers also require

appropriate levels of emotional competency in order to describe their problem and

emotions to others (Rickwood, et al., 2005). Further, social competence and self-stigma

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are important as young people need to be confident enough to ask others for help

(Wilson & Deane, 2001) and, cannot be too concerned about the potential stigma they

may encounter by doing so (Hickie, Luscombe, Davenport, Burns, & Highet, 2007).

Gender. Women have regularly been identified as being more likely to self-

disclose (Valkenburg, Sumter, & Peter, 2011) and seek help for their mental health

problems than males (ABS, 2007; Angst et al., 2002; Rickwood, 1995). This is most

evident in the 16 to 24 years age group with females being almost two and a half times

more likely to seek help than males (ABS, 2007). The gender difference could be

attributed to the differences in prevalence rates of mental disorders, with approximately

30% of females within the 16 to 24 years group experiencing a 12-month mental health

problem, compared to 23% of males (Slade, et al., 2009). However, it may also be

associated with gender differences which have been identified in levels self-stigma

(Corrigan & Watson, 2007), emotional competency (Ciarrochi, Wilson, Deane, &

Rickwood, 2003), mental health literacy (Burns & Rapee, 2006), and self-reliance

(Rickwood, Deane, et al., 2007).

Self-Stigma. Stigma has been argued to be a strong factor affecting help seeking.

Stigma is a multidimensional construct which is affected by different influences and is

expressed through a range of behaviours (Jorm & Wright, 2008). Generally, stigma has

been defined as a process in which cue elicited stereotypes create attitudes of prejudice

and discrimination (Corrigan, 2004). Specifically, public stigma, personal stigma, and

most recently, self-stigma have been conceptualised as separate constructs. Public

stigma occurs when an individual believes others in the community hold stigmatising

attitudes about mental illnesses (Corrigan, 2004). Personal stigma transpires when an

individual holds those stigmatising views themself (Golberstein, Eisenberg, & Gollust,

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2009). Self-stigma occurs when an individual internalises their own negative attitudes,

and applies the corresponding stereotypes and prejudices to themself (Eisenberg, Downs,

Golberstein, & Zivin, 2009; Jorm, Barney, et al., 2006).

The empirical literature has shown inconsistencies in the relationship between

stigma and help-seeking, however, these inconsistencies may be a result of the varied

conceptualisations of the construct. Since self-stigma has been defined as separate

construct, a strong relationship with help-seeking behaviours has been identified

(Corrigan, 2004; Eisenberg, et al., 2009). Self-stigma has been suggested as a barrier to

help-seeking because of the strong beliefs people hold about the differences between

people with a mental illness („them‟) and those without („us‟) (Corrigan, 2004; Pinfold

et al., 2003). Corrigan suggests that people who hold these strong „us‟ and „them‟

beliefs will do everything in their power to stop from becoming one of „them‟ and

facing social disapproval. Consequently, these people refuse to seek help.

Self-stigma may be a particularly important factor for young people as they

have been identified as being extremely concerned about their problems becoming

public (Deane, Wilson, & Ciarrochi, 2001). This fear of others becoming aware of their

problems has been identified as a significant reason for students to refuse readily

available services such as their school counsellor. School counsellors‟ offices are often

in a very public place within the school and consequently many young people do not

utilise their services due a lack of confidentiality and anonymity (Rickwood, et al., 2005;

Ybarra & Suman, 2008). Further, students state that they are concerned that the

counsellor will discuss their issues with other teachers. The effects of self-stigma on

help-seeking behaviours may be even stronger for males, who have been identified as

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having significantly more stigmatising and prejudicial attitudes than females (Corrigan

& Watson, 2007; Schweitzer, Perkoulidis, Krome, Ludlow, & Ryan, 2005).

Emotional Competence. Emotional competency has been identified as a barrier

to help-seeking as potential help-seekers need to identify their feelings and be able to

describe them to others in order to successfully seek help (Rickwood, et al., 2005).

Emotional competence has been defined as the “…ability to perceive emotions, and the

ability to manage self-relevant emotions and to manage others‟ emotions in a socially

acceptable way…” (Ciarrochi & Deane, 2001, p. 234). There are two opinions in how

emotional competence affects help-seeking. Firstly, people low in emotional

competence could have the highest intentions to seek help because they feel less capable

of coping. Conversely, people low in emotional competence may have lower levels of

help-seeking as they have fewer social supports, fewer positive past help-seeking

experiences, and are more embarrassed than those higher in emotional competence

(Ciarrochi, Heaven, & Supavadeeprasit, 2008; Rickwood, et al., 2005). The latter is

supported within the literature with Ciarrochi and Deane (2001) finding that managing

self-relevant emotions was related to a willingness to seek help for suicidal ideation.

This was further supported in Ciarrochi et al. (2003), where higher emotional

competence was found to be associated with higher intentions to seek help in young

people aged 14 to 16 years.

Emotional competence has been found to be generally higher in females

(Ciarrochi & Deane, 2001; Ciarrochi, et al., 2003) and connected to self-stigma. For

example, Ciarrochi, Chan, and Bajgar (2001) found that females had greater skill at

perceiving emotions, regulating others‟ emotions, and utilising emotions, than males.

Further, females appear to be more willing to use emotional labels (Burns & Rapee,

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2006). Females have also been identified as believing that emotional outlets such as

laughing, crying, and shouting are of greater benefit for emotional problems, than males

believe they are (Angst, et al., 2002). As low emotional competency has also been

associated with a fear of embarrassment (Rickwood, et al., 2005), it is likely that low

emotional competency would be related to higher levels of self-stigma.

Mental Health Literacy. Mental health literacy has been identified as an

important factor in help seeking. „Mental health literacy‟ refers to the “knowledge and

beliefs about mental disorders which aid their recognition, management or prevention”

(Jorm et al., 1997). It encompasses the ability to “recognise specific disorders, knowing

how to seek mental health information, knowledge of the risk factors and causes of self-

treatments and of professional help available, and attitudes that promote recognition and

appropriate help-seeking” (Jorm, et al., 1997). Mental health literacy is important as

the information and knowledge that individuals have on mental health problems can

have a significant impact on the way that they identify and come to terms with their

symptoms (Burns & Rapee, 2006), seek help and stay in control of their treatment

(Rickwood, Deane, et al., 2007), and cope with the changes in their life (Jorm, Barney,

et al., 2006; Korp, 2006).

Mental health literacy tends to be higher in females and has been associated with

lower levels of self-stigma. For example, females have been found to have greater

awareness of available help sources such as beyondblue (Jorm, 2009). Males have also

been identified as being less likely to correctly recognise symptoms of psychosis

(Cotton, Wright, Harris, Jorm, & McGorry, 2006). This was most pronounced for

males aged 18 to 25 years. The connection between mental health literacy and self-

stigma has emerged due to the argument that increasing individual knowledge around

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mental health problems will decrease feelings of stigma and increase help seeking

behaviours (Burns, Durkin, & Nicholas, 2009; Jorm, Barney, et al., 2006; Wilson &

Deane, 2001).

Self-Reliance. Higher levels of self-reliance have been identified as a barrier to

help seeking due to the belief that one should be able to cope with their problems alone

(Wilson, Deane, & Ciarrochi, 2005). As teenagers progress through their adolescent

years there is a natural transition from relying on parents, to self-reliance and autonomy

(Rickwood, Deane, et al., 2007; Steinberg & Silverberg, 1986; Wilson, Deane, &

Ciarrochi, 2005). Therefore, as young people move through this developmental period

they are likely to increase their belief that they should be able to cope alone, and

consequently are less likely to seek help. For example, in a study conducted by Gould

et al. (2004), 33.1% of participants stated they did not seek help as they wanted to solve

their problems themselves. Similar beliefs were identified by Wilson, Deane and

Ciarrochi (2005), who found that adolescents admired others‟ abilities to cope without

counselling, and felt that counselling should be used as a last resort. Further, Ortega

and Alegria (2002) found that adolescents with significant mental health problems who

held self-reliant attitudes, were 54% to 58% less likely to use services than adolescents

without self-reliant attitudes.

Empirical research has not directly identified an overall gender difference in

self-reliance, however, males have been shown to be significantly more likely to hold

the belief that depression should be dealt with alone (Jorm, Kelly, et al., 2006). This

gender difference may be attributed to the socially developed belief that help seeking is

un-masculine and reflects personal weakness (Jorm, Kelly, et al., 2006). Further, self-

reliance may also be associated with self-stigma, with highly self-reliant 14 to 16 year

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olds holding negative views about depression (Jorm, Kelly, et al., 2006). Additional

evidence for the relationship between self-stigma and self-reliance was provided by

Ortega and Alegria (2002) who found that highly self-reliant Peurto Rican adults were

much less comfortable with their family or others knowing they were seeking treatment.

Shyness. Shyness is an aspect of social competence that has been identified as a

contributing factor in help-seeking (Rickwood, et al., 2005). Cognitively, shyness is the

“discomfort or inhibition in interpersonal situations that interferes with pursuing

ones...goals” (Henderson & Zimbardo, 1998, p. 497). Shy people are often withdrawn,

fearful, and hesitant to interact because they see themselves as awkward, unfriendly and

incompetent (Greenberger, Josselson, Knerr, & Knerr, 1974; Henderson & Zimbardo,

1998; Shiner & Caspi, 2003). These negative views cause shy people to have excessive

self-focus and a preoccupation with others‟ evaluations, and possible rejection of them

(Bruch, Gorsky, Collins, & Berger, 1989; Bruch, Hamer, & Heimberg, 1995; Rivet

Amico, Bruch, Haase, & Sturmer, 2004). This is particularly the case in unpredictable

or unknown situations, such as asking people for help (Carducci, 1999; Greenberger, et

al., 1974; Zimbardo, 1977). In-fact, one study found that the most commonly reported

triggers for shyness by American university students were „strangers‟ and „those in

authority‟ (Zimbardo, 1977, p. 36).

Gender differences do not appear to exist in levels of shyness, and the

relationship between self-stigma and shyness is questionable due to limited empirical

evidence. Unlike the other barriers associated with help-seeking, gender differences

have not been identified in levels of shyness (Bruch, et al., 1989; Crozier, 2005; Miller,

1995). Although the relationship between self-stigma and shyness is yet to be

empirically tested, it is likely that shyness is related to greater concerns of self-stigma as

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shy people tend to be overly concerned with others‟ evaluations of them (Bruch, et al.,

1989).

Overcoming Barriers

By understanding what influences certain groups of people to seek help,

organisations may be able to match appropriate supports to the appropriate group rather

than providing a homogenous service to the entire heterogeneous population, with the

assumption that “one size fits all” (Kelly, Jorm, & Wright, 2007). Matching appropriate

services to the groups of young people who are most likely to benefit from them may

result in higher help-seeking behaviours and reduced distress (Deane, et al., 2001).

Many studies have found that adolescents are most willing to seek help from

informal sources such as their family and friends (Rickwood, et al., 2005; Ryan,

Shochet, & Stallman, 2010; Wilson, Deane, Ciarrochi, et al., 2005), however peers may

not be the most appropriate source of help. For example, Gould et al. (2004) found that

students who had contact with a suicidal peer were significantly more likely to be

depressed, have a substance abuse problem, or be seriously suicidal themselves, than an

adolescent not in contact with a suicidal peer. In addition, Rickwood (1995) found that

participants who shared their problems with family or friends did not experience a

reduction in psychological distress. It was argued that sharing a problem with non-

professionals where the conversation focuses on all the possible negative ramifications

may, in-fact, increase distress. For these reasons it is suggested that professionals are

the most appropriate source of help for young people with a mental health problem.

Face-to-Face Help. Traditional approaches to mental health care rely on face-

to-face service delivery. This approach has a number of benefits. For example, face-to-

face help is likely to benefit those help-seekers who rely on the reassuring non-verbal

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and visual cues that are fundamental to the traditional counselling process (Reynolds Jr,

Stiles, & Grohol, 2006; Rochlen, Zack, & Speyer, 2004; Ybarra & Suman, 2008). Face-

to-face help may also be preferred by those people who lack human contact in their

usual day-to-day activities. Further, face-to-face help is likely to be preferred by those

who are concerned about the quality of online or phone line information, or the

credentials of those therapists providing it (Barak, Klein, & Proudfoot, 2009; Eysenbach,

Powell, Kuss, & Sa, 2002; Kiley, 2002). However, the barriers of self-stigma,

emotional competency, mental health literacy, self-reliance, and shyness may be

maximally evident when utilising face-to-face approaches.

Help Over the Phone. Crisis lines and counselling over the phone may be

beneficial for those help-seekers who prefer to talk through their problems with another

human being, whilst remaining anonymous. Like face-to-face help, phone lines allow

for verbal cues, however, non-verbal body language cannot be observed. The lack of

non-verbals may then contribute to an incomplete understanding of the situation by

either party (S. A. King, Engi, & Poulos, 1998; Oravec, 2000). Whilst phone lines are

more anonymous than face-to-face services, this is not to the extent of online services as

others may overhear the conversation or see the phone bills (Oravec, 2000). Phone

lines are however, likely to be more cost effective and easier to access than face-to-face

therapy (J. Wright, 2002).

Help Online. Online therapy offers a number of unique benefits which may

address some of the identified help-seeking barriers. A significant benefit is the

potential to reach more males. Studies have shown that the „gender divide‟ apparent in

other sources of help is reduced in online sources, with males accessing help (Gould,

Munfakh, Lubell, Kleinman, & Parker, 2002), and self-disclosing at similar levels to

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females (Valkenburg, et al., 2011). As well as potentially reaching more males, the

internet also allows users to remain anonymous, search for information on mental

disorders and treatments, express their emotions in their own time, and solve their own

problems.

Online therapy is difficult to define due to the internet‟s capacity to use many

mediums (Barak, et al., 2009). Richlen, Zack and Speyer (2004), have defined online

therapy as “any type of professional therapeutic interaction that makes use of the

internet to connect to qualified mental health professionals”. Whilst covering some

aspects of online therapy, this definition fails to include other available mediums such

as self-guided automated web sites. Online therapy can occur either asynchronously or

synchronously, through guided or self-guided options, be public or private, and occur in

either individual or group circumstances (Barak & Bloch, 2006; Barak, et al., 2009;

Luce, Winzelberg, Zabinski, & Osborne, 2003; Oravec, 2000). The automatic feedback

provided by self-guided therapy websites can vary by being either personal, normative

or ipsative (changes since the last assessment) (de Vries & Brug, 1999). Asynchronous

means that the communication does not occur in „real-time‟ but when it suits both

parties, such as via email (Rochlen, et al., 2004). Communication that occurs

synchronously is in „real time‟ using mediums such as chat rooms or instant messaging.

Guided counselling occurs when there is a counsellor guiding the help-seeker through

some type of therapy, whereas self-guided therapy occurs when the help-seeker is using

an automated website or computer program which simulates human communication

(Sofka, 1997). There are currently a number of sites which offer self-guided therapy

options by combining health information and interactive learning or counselling

activities (Kerr, Murray, Stevenson, Gore, & Nazareth, 2006). Some examples of sites

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already available include; „www.blackdoginstitute.com‟ (Barnes et al., 2009),

„www.moodgym.org‟ (Christensen, Griffiths, & Jorm, 2004),

„www.gamblingtherapy.org‟ (Anthony, 2005), and „http://au.reachout.com‟ (Burns,

Ellis, Mackenzie, & Stephens-Reicher, 2009). The „Beacon‟ website run by the

Australian National University is also a useful portal which provides links to alternative

self-help programs and their empirical evidence.

As confidentiality is a great concern for young people, the internet is likely to be

advantageous as it allows users to receive help whilst remaining completely anonymous

to services (Oh, Jorm, & Wright, 2009; Oravec, 2000; Ryan, et al., 2010), families

and/or friends (R. King et al., 2006). Remaining anonymous may increase the

likelihood that young people will ask questions they are too embarrassed to ask others,

and at a pace they can set themselves (Korp, 2006). For example, in an online

intervention on body image, many participants stated they felt that they were able to be

more honest as they were less concerned about the judgement of others (Zabinski et al.,

2001). The anonymity of the internet is also likely to reduce young people‟s fears

around stigma, particularly when they are dealing with highly stigmatised issues such as

suicide (Ybarra & Suman, 2008). Therefore, online therapy may be particularly useful

for those young people high in self-stigma and shyness, as their fears around other‟s

judgements of them may be reduced.

Online services allows adolescents to increase their autonomy from parents and

be more self-reliant by providing an easily accessible point to start the help-seeking

process (Luce, et al., 2003; Oravec, 2000; Rickwood, Deane, et al., 2007; Rochlen, et al.,

2004; J. Wright, 2002). Whilst some young people may not have links to traditional

sources of help such as school, work, or doctors, most will have some access to the

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internet (Becker, Mayer, Nagenborg, El-Faddagh, & Schmidt, 2004; Rickwood, Deane,

et al., 2007). For example, a study conducted by Blanchard, Metcalf, Degney, Herman

and Burns (2008), found that 43% of 13 to 25 year olds had access to the internet at

home, 30.2% had access through a local library, and 17.7% had access at school.

Another study found that of participants connected with „headspace‟; an Australian

service providing mental health support and information to young people (headspace,

2011), only 5% were not current internet users (McGorry et al., 2007).

Online therapy may be beneficial to young people who have limited mental

health literacy. The internet allows for almost unlimited amounts of additional

information such as fact sheets on illnesses to be transferred and accessed between

parties (Kerr, et al., 2006; Oravec, 2000; Rochlen, et al., 2004). The ability to access

this information readily allows help-seekers to research what their symptoms mean, and

what treatments are available.

Further, online therapy may help young people who are shy and/or, low in

emotional competence by providing help-seekers with a „zone of reflection‟, where they

can take the time to decide what they would like to say (Lange et al., 2003; Rochlen, et

al., 2004; Wolak, Mitchell, & Finkelhor, 2002). In addition, online therapy often allows

help-seekers to progress at their own pace (Proudfoot et al., 2007). Having this time to

respond appropriately, and controlling the pace, may make online therapy less

confronting to young people than the more traditional face-to-face or phone line

services (Henderson & Zimbardo, 1998).

As well as having the potential to overcome a number of help-seeking barriers,

most importantly, online therapy has been shown to be effective. To date, trials have

found positive results for interventions focusing on body image and dissatisfaction

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(Heinicke, Paxton, McLean, & Wertheim, 2007; Luce, et al., 2003; Zabinski, Wilfley,

Calfas, Winzelberg, & Taylor, 2004; Zabinski, et al., 2001), and reducing symptoms in

post-traumatic stress disorder (Lange, et al., 2003) and depression (Christensen, et al.,

2004). There have also been encouraging results in interventions aimed at reducing

alcohol and cannabis use (Bewick, Trusler, Mulhern, Barkham, & Hill, 2008; Newton,

Teesson, Vogl, & Andrews, 2009).

Preferences

Due to the low numbers of young people who seek professional help for their

mental health problems, organisations have been trying to understand and overcome the

barriers to young people accessing their services. One of the recent ways they have

been attempting to reach young people is by providing help online. The change in

service delivery has occurred under the assumption that young people would prefer to

access services over the internet. Although research has shown that providing therapy

and counselling online has had positive outcomes (Cook & Doyle, 2002; Heinicke, et al.,

2007), a review of the literature has found no study demonstrating that young people

actually prefer this source of help over that of face-to-face or phone line services. It

seems that the belief that young people hold this preference is, to date, an assumption.

One of the few studies examining this area asked young people if they would use a self-

guided online program or book if it existed (Farrand, Perry, Lee, & Parker, 2006).

Participants could however, only answer yes or no, and although 73% stated they may

use a self-guided option if it existed, this did not indicate that it was actually their

preferred help source. Further, whilst studies by Burns, Davenport, Durkin, Luscombe

and Hickie (2010) and Gould et al. (2002) found that approximately one fifth of

adolescents aged 12-17 had used the internet in the past for a mental health or substance

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abuse problem, neither of these studies indicated whether the internet was preferred by

these young people or if it was used because they lacked an alternative. Consequently,

at this point in time it is an untested assumption that young people actually prefer online

mental health care over the more traditional forms of delivery.

The Current Study

The aim of this study was to assess whether young people do have a preference

for online therapy over other more traditional types of services, what their actual help-

seeking intentions are, and the factors which contribute to this intention. Based on

previous research indicating the differences between males and females on how they

deal with emotional problems, it was firstly hypothesised that overall girls would have a

higher intention to seek help and would be more likely to prefer face-to-face or phone

line services, whilst boys would have a lower intention to seek help and would have a

greater preference for the more anonymous online help. In addition, it was

hypothesised that intentions to seek help online would be directly related to higher

levels of potential self-stigma. Thirdly, it was hypothesised that higher levels of

potential self-stigma would be related to higher levels of self-reliance and shyness, and

lower levels of mental health literacy and emotional competency. Finally, it was

hypothesised that boy‟s greater intention to seek help online would be explained by

their lower levels of mental health literacy and emotional competency, and higher levels

of self-reliance. Gender differences in shyness were not anticipated. Figure 1 shows the

hypothesised relationship between gender, emotional competency, mental health

literacy, self-reliance, shyness, self-stigma and help-seeking intentions.

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Figure 1. Hypothesised mediated relationship of gender with help-seeking intentions.

Method

Participants

Participants were 231 students attending three schools in Canberra during April

and May, 2011. There were 139 females (60.2%) and 92 males (39.8%) with ages

ranging from 15 to 19 years ( ). The students were evenly spread

between public and private schools with 69 of the participants attending the University

of Canberra Secondary School Lake Ginninderra (UCSSLG) and 31 attending the

University of Canberra Kaleen High (UC Kaleen), giving a total 43.3% of participants

from public schools. The remaining 131 participants (56.7%) were attending Radford

College which is an independent Anglican college. Across the three schools there were

59 students in year ten (25.5%), 94 in year eleven (40.7%), and 78 in year twelve

(33.8%).

Gender

Emotional Competence

Self-Reliance

Shyness

Self-Stigma

Mental Health Literacy

Seek Help Online

Seek Help Face-to-Face

Seek Help over the Phone

Would Not Seek Help

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Measures

Participants were asked to complete a series of self-report measures combined

into a questionnaire labelled the “Adolescent Help Seeking Questionnaire” (see

Appendix A). This firstly asked demographic questions such as age, gender and the

school attended, and then assessed help-seeking intentions, help-seeking preferences,

self-stigma, shyness, self-reliance, emotional competency, and mental health literacy.

Help-Seeking Intentions. The „General Help Seeking Questionnaire‟ (GHSQ)

(Rickwood, et al., 2005; Wilson, Deane, Ciarrochi, et al., 2005) was adapted to assess

intentions to use each source of help. Participants were asked to read a vignette

describing depression, which was adapted from Jorm and Wright (2008) so that

participants imagined themselves feeling depressed. Depression was chosen as the

mental health problem as this is the most commonly experienced mental health problem

for this age group (ABS, 2007). Participants were then asked to identify how likely it is

that they would seek help from each of the sources if they were feeling as the vignette

described.

The various sources of help were chosen to reflect variation in type of

communication and level of anonymity comprising of online, phone line, face-to-face

and no help. The online options were split into self-guided “...from a website” and

guided options, with the guided options also being split into an asynchronous source

“…email with a professional”, and a synchronous source “… instant chat with a

professional”. The various face-to-face options were as follows: “Youth worker”,

“Private psychologist”, “School counsellor”, “Other counsellor”, and “Health

Practitioner/GP”. For each of the options participants were asked to rate how likely it

is they would use that source from 1 (Extremely Unlikely) through to 7 (Extremely

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Likely). The responses for each of the categories were averaged to obtain a total help-

seeking intention for each of the four categories of phone, online, face-to-face, and no

one.

In previous studies the GHSQ has been used by averaging all the help-seeking

options in order to create a single score of help-seeking intentions. When the measure

was used in this way, a Cronbachs‟ alpha of .70 and a three week test-retest validity

of .86 for non-suicidal issues was identified in a sample of Australian adolescents

(Wilson, Deane, Ciarrochi, et al., 2005). The measure was also shown to be valid with

positive and significant correlations between scores on the intention to seek help and

actual help-seeking behaviours.

Help-Seeking Preferences. To assess help-seeking preferences, participants

were asked to choose overall whether they would prefer to have help: “over the phone”,

“online” “face-to-face”, or “I would not seek help”. An open-ended question also asked

why they would prefer that type of help source.

Self-Stigma. Self-stigma was assessed using the „Self-Stigma of Depression

Scale‟ (SSDS) (Barney, Griffiths, Christensen, & Jorm, 2010). Participants were asked

to imagine they had the problem stated in the depression vignette when answering each

item. The scale is composed of 16 items which assess four factors of Shame, Self-

Blame, Help-Seeking Inhibition and Social Inadequacy. An example item is, “I would

see myself as weak if I took antidepressants”. The items are rated on a 5-point Likert

scale ranging from 1 (Strongly Disagree) through to 5 (Strongly Agree). Item C3 was

reverse scored and then all items averaged to obtain a total self-stigma score, with

higher scores indicating higher self-stigma.

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The scale is yet to be tested on adolescents, however, it has been shown to have

high internal consistency with a Cronbach‟s alpha of .87 for the total SSDS, .83 for

Shame, .78 for Self-Blame, .79 for Help-Seeking Inhibitions, and .79 for Social

Inadequacy in Australian adults (Barney, et al., 2010). Initial uses of the test have also

shown good test-retest reliability with no significant differences in scores at a two

month follow up (Barney, et al., 2010).

Emotional Competency. An adapted version of the „Toronto Alexithymia

Scale‟ (TAS-20) (Bagby, Parker, & Taylor, 1994) was used to measure emotional

competency. The adapted version of the scale has 12 items and has previously been

used with Australian adolescents (Heaven, Ciarrochi, & Hurrell, 2010). The scale

assesses difficulty in identifying feelings (“I have feelings that I can‟t quite identify”)

and difficulty in describing feelings (“It is difficult for me to find the right words for my

feelings”), however, factor analysis indicates a single dimension exists (Heaven, et al.,

2010). Items are responded to on a 5-point Likert scale from 1 (Strongly Agree)

through to 5 (Strongly Disagree). Item F4 is reverse scored and then all items averaged

to obtain a total emotional competency score with higher scores indicating higher

emotional competency.

The scale has good internal consistency in Australian adolescent populations

with a Cronbach‟s alpha of .87 (Heaven, et al., 2010). Criterion validity was also found

with positive correlations between emotional competency and social support, negative

affect, and positive affect (Heaven, et al., 2010).

Mental Health Literacy. Mental health literacy was assessed by adapting

methods used in previous studies where participants were asked to respond to vignettes

(Burns & Rapee, 2006; Cotton, et al., 2006; Farrer, Leach, Griffiths, Christensen, &

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Jorm, 2008). In the current study, three vignettes were chosen describing someone with

Social Phobia/Anxiety, Schizophrenia, and Depression with Substance Misuse as these

are have been used in previous studies assessing mental health literacy (Burns & Rapee,

2006; Jorm & Wright, 2008). The vignettes were adapted from those used by Burns and

Rapee (2006) and Jorm and Wright (2008) by changing the names and identifying terms

so that they were not gender specific. For each vignette, participants were asked to

indicate how worried they would be, from 1 (Not at all Worried) through to 4

(Extremely Worried) about the emotional well-being of the person described in the

vignette if that person were their friend. Participants were also asked what they thought

was the matter and whether they thought the person needs help for their problem.

To compute a score for mental health literacy, zero points were awarded if the

participant was not at all worried, one point was awarded if they were a little bit

worried, and two points awarded if they were either quite worried or extremely worried.

Points were also awarded for a correct or partly correct diagnosis for each vignette.

Diagnoses were considered partly correct if they only stated half of the disorder. For

example a diagnosis of “Phobia” or “Depression” received one point, where “Social

Phobia” or “Depression with Substance Misuse” received two points. Points were also

awarded based on the belief that the disorder required help, where answers of „no‟

received zero, „maybe‟ received one, and „yes‟ received two. Scores for the three

questions of how worried they were, diagnosis, and belief that it required help were

summed to give a score out of six. The total scores for the three vignettes were

averaged to obtain a total mental health literacy score out of six, with higher scores

indicating better mental health literacy.

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Self-Reliance. Self-reliance was assessed using the self-reliance subscale of the

„Psychosocial Maturity Inventory Form D‟, for the 11th

grade (Greenberger, et al., 1974).

The scale is composed of 10 items rated on a 4-point scale from 1 (Strongly Agree) to 4

(Strongly Disagree) with all items averaged to attain a total self-reliance score. Higher

scores indicate higher self-reliance. An example item is “In a group I prefer to let other

people make the decisions”.

The scale has good internal consistency with an alpha of .82 in American

adolescent populations, and has also been found to have concurrent validity with teacher

ratings of self-reliance (Greenberger, et al., 1974).

Shyness. Shyness was assessed using the „Revised Cheek and Buss Shyness

Scale‟ (CBSS-R) (Crozier, 2005). The scale has 14 items asking participants to respond

to statements such as “I feel tense when I am with people I don‟t know well”.

Participants were asked to rate how characteristic each statement is of them on a 5-point

scale ranging from 1 (Very Unlike Me) through to 5 (Very Like Me). Items D3, D6, D9

and D12 were reverse scored and then all items averaged to obtain a total shyness score

with higher scores indicating higher levels of shyness.

The scale has high internal consistency with a Cronbach alpha of .86 in

American university students. There is limited evidence for the test-retest reliability of

the CBSS-R, however, a 90 day test-retest reliability of .74 was found for a 9 item

version of the test (Cheek & Buss, 1981).

Design and Procedure

The research was approved by the University of Canberra (UC) Committee for

Ethics in Human Research (Project No. CEHR 11-55), and the ACT Department of

Education and Training (Ref No. 2011/00468-3) (see Appendix B and C). It was also

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peer reviewed by two UC psychology lecturers. In order to obtain participants from a

wide socioeconomic range, letters of interest in participating in the research were sent to

principals of a public high school and college, and a private college in Canberra. The

participating school principals gave approval for the students in their schools to

participate.

A non-experimental cross-sectional survey design was employed for the study.

A convenience sampling technique was used where all students at school on the day of

testing in years 10 at UC Kaleen, and years 10, 11 and 12 at Radford College were

given the option to participate. At UCSSLG all students who were enrolled in

Psychology or Sociology and were at school on the day of testing were given the

opportunity to participate. Letters were sent to all students‟ parents informing them of

the study and providing them with the option to have their child „opt out‟ if they did not

want them to participate (see Appendix D). If the letter was not returned consent was

assumed. Students at UC Kaleen and UCSSLG completed the survey in class time

using either the pen and paper formats, or online through a web-link. Students at

Radford College were emailed a link to the survey and completed it in their own time. A

sample size of between 200-300 students was aimed for, which would allow for any

medium sized effects to be detected at a power of .80, for five predictors in a multiple

regression analysis (Cohen, 1992). Out of a total 302 students who were informed of

the study, 231 completed it, resulting in a return rate of 76.49%.

Participation in the study involved completing the „Adolescent Help-Seeking

Questionnaire‟ which took between 20 and 30 minutes. The first page of the survey

informed participants about the study and made it clear that responses were confidential

and that participation was voluntary. It also provided details on where to go for more

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information, where to go to make a complaint about the research, and where to obtain a

summary of the final results (see Appendix E). Consent was assumed if they survey was

completed.

Results

Data were analysed using PASW Statistics 18 with alpha set at .05 unless

otherwise specified. All data were first carefully screened. There was less than 5%

missing data over all items, indicating the data can be assumed „missing at random‟

(Tabachnick & Fidell, 2007), listwise deletion was therefore used. The psychometric

properties of each variable used in the study are presented in Table 1. This reveals that

all scales attained adequate internal consistency according to Cronbach‟s alpha. The

lowest alpha scores were for the subscales of the self-stigma measure. Skewness scores

showed no major deviations from normality.

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Table 1

Psychometric Properties of the Study Variables

Range

Variable No. of Items M SD α Potential Actual Skew Kurt

Help Seeking Sources

Online 3 3.01 1.49 .81 1-7 1.00-6.33 .36 -.90

Face-to-face 4 3.46 1.51 .86 1-7 1.00-6.80 -.01 -1.02

Phone 2 2.25 1.35 .88 1-7 1.00-7.00 1.22 1.32

No Help 1 3.95 1.99 1-7 1.00-7.00 .02 1.22

Self-Stigma 16 3.05 .67 .84 1-5 1.63-4.75 -.32 .12

Shame 4 3.12 .80 .71 1-5 1.00-4.75 -.54 .08

Self-Blame 4 3.71 .67 .63 1-5 1.50-5.00 -.49 .65

Help-Seeking Inhibitions

4 3.31 .82 .65 1-5 1.25-5.00 -.25 -.42

Social Inadequacy

4 3.52 .73 .60 1-5 1.25-5.00 -.40 .15

Emotional Competency

12 3.18 .77 .87 1-5 1.42-5.00 .04 .60


9 4.50 .84 .61 0-6 1.17-6.00 -1.20 2.71

Self-Reliance 10 3.00 .46 .81 1-4 1.30-4.00 -.37 .25

Shyness 14 2.82 .67 .85 1-5 1.57-4.54 .25 .81

Note. Standard Error for all variables is .16.

Preferences for Help Sources

When participants were forced to choose between the options of online, face-to-

face, phone line, or no help it was clear that face-to-face help was the preferred option

for both genders. Overall, 58.9% of participants preferred face-to-face help, 23.8%

stated they would not seek help, 16% preferred online help, and 1.3% stated they would

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seek help over the phone. There were 35% of participants who supplied a qualitative

response as to why a certain help source was their preferred option. The commonly

stated reasons for face-to-face help were because it is more personal, body language can

be assessed, it is a trusting environment, the help-seeker knows who they are talking to

and the service provider‟s qualifications, and there is customised feedback. The reasons

for not wanting to seek help were because the potential help seekers were too scared or

did not like talking about themselves. The participants who preferred online sources

stated that they preferred the anonymity of the internet, that information was easily

accessible, and that there are often people in chat rooms who have been through the

same thing. One insightful participant noted:

“I tried to use to internet last year but could not find anything useful so I just

talked to trusted adults and friends, I tried the internet because it seemed

better, less personal, less intrusive. But I was unsuccessful because I didn't

really know what I was looking for. I find it hard talking to people I don't

really know, the fear of judgement or gossip is large. The internet is a lot

faster, easier, less organisation, and less pressure.”

In order to determine whether gender or grade affected the preferences for

sources of help, a Pearson‟s Chi-square test of contingencies was used. As only three

participants chose „Over the phone’ as their desired preference, these scores were

recoded as missing so as not to violate the assumption that each cell has an expected

frequency of at least five. This resulted in a sample size of 228 for this analysis. The

assumption of minimum cell frequencies was also violated when the cells were further

split by school grade so the analysis was run only comparing the preferences between

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genders. The Chi-square test was statistically significant, ( )

, with a small to medium effect size, Cramer‟s

To determine where the significant difference in preferences lay, separate

Chi-square tests were used. The association between gender and help-seeking

preference was small but statistically significant when comparing preferences for online

and face-to-face help, ( ) Cramer‟s . Odds

ratios revealed that males were 1.66 times more likely to prefer online sources over

face-to-face sources than females. There was also a significant, small to moderate

association between gender and the help-seeking preferences of face-to-face help and

not seeking help, ( ) Cramer‟s . Odds ratios

showed that females were 1.58 times more likely to prefer help face-to-face than not

seek help, compared to males. The association between gender and the preferences of

online help and not seeking help were non-significant, ( ) ,

indicating that males and females were just as likely to have a preference for either of

these sources. The preferences by gender are shown in Figure 2.

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Figure 2. Preference for each help source by gender.

Intentions to Use Each Help Source

To examine the gender and grade differences in intentions to seek help by each

help source a 2 (gender) x 3(grade) x 4 (help seeking preference) mixed analysis of

variance with a repeated measure on the last factor was performed. A visual inspection

of each distribution‟s histograms, Q-plots and bar graphs indicated that all distributions

were relatively normal. In addition, the skewness and kurtosis scores of each

distribution were close to zero. Homogeneity of variance was met as Levene‟s test was

non-significant and the Fmax statistic was smaller than the recommended maximum of

10 (Tabachnick & Fidell, 2007). Homogeneity of intercorrelations was met as Box‟s M

was non-significant. Mauchly‟s test indicated that the sphericity assumption was

violated, consequently the Huynh-Feldt correction was employed (Tabachnick & Fidell,

2007).

0

10

20

30

40

50

60

70

80

Online Face-to-Face Phone I would notseek help

Pe

rce

nt

Help Source

Male

Female

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The only statistically significant effect revealed by the analysis was a large main

effect for help-seeking intentions, ( ) , partial . A

series of pairwise comparisons using a Bonferroni adjustment found that the intention to

use each help-seeking source was significantly different from the intention to use any

other source. Figure 3 shows that the highest intention was to not seek help, followed

by seeking help face-to-face, then online help, with phone help being the least likely

source of help. Table 2 displays the significance values for each contrast. Means and

standard deviations of each help-seeking source are presented in Table 1. There were

no significant effects for gender ( ) ; grade, ( )

, or the gender by grade interaction, ( ) .

Figure 3. Intentions to use each help-seeking source.

Note. Error bars represent 95% confidence intervals.

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Table 2 Pairwise Contrasts of Help-Seeking Intentions by Help-Seeking Source

Mean Difference

95% Confidence Interval

Help Seeking Source p Lower Bound

Upper Bound

I would not seek help

Face-to-Face

.56 .037* .02 1.09

Online .98 .000** .49 1.45

Phone 1.69 .000** 1.20 2.18

Face-to-Face

Online .41 .003* .10 .72

Phone 1.13 .000** .86 1.41

Online Phone .72 .000** .46 .99

Note. *p < .05. **p < .01.

Gender Differences in the Predictor Variables

Independent sample t tests were used to compare the average scores between

males and females for each predictor variable. Normality was assumed after inspecting

histograms, Q-plots and skewness scores. Levene‟s test was significant for the self-

reliance and shyness variables, and therefore equal variances could not be assumed.

Equal variance could be assumed in the remaining variables. The t test indicated a

moderate, statistically significant difference between males and females for self-stigma,

( ) with males ( ) scoring lower

than females ( ). There was also a statistically significant, moderate

to large difference in scores for mental health literacy, with females (

) scoring higher than males ( ), ( )

The t tests for shyness, ( ) self-reliance, ( )

and emotional competency, ( ) were all non-

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significant showing no difference in scores between males and females for these

variables.

Correlations Between the Study Variables

To assess the size and direction of the linear relationships between the study

variables, bivariate Pearson‟s product-movement correlation coefficients (r) were

computed and are presented in Table 3. The assumptions of normality, linearity and

homoscedasticity were assessed, and found to be supported. Specifically, a visual

inspection of the histograms, Q plots, and skewness scores for each variable confirmed

that all variables were normally distributed. Similarly, visually inspecting scatterplots

of each variable against the other variables confirmed that the relationships were linear

and homoscedastic.

In terms of intercorrelations among the help-seeking variables, the three help-

seeking sources of online, face-to-face and phone help were all moderately

intercorrelated. The relationships showed that as the likelihood of using a particular help

source increased, the likelihood of using either of the other two sources also increased.

There were weak to moderate negative correlations between each of the three sources of

online, phone and face-to-face help with not seeking help. As the likelihood of using

any of the three sources increased, the likelihood of not seeking help decreased.

The help-seeking variables were generally not significantly related to their

predictors in the ways that were hypothesised. Both online, and face-to-face, intentions

were only weakly related to mental health literacy, with higher mental health literacy

related to an increased intention to use each source. Neither online nor face-to-face

intentions were significantly related to any other predictor variable. Help-seeking

intentions to use phone lines were not significantly related to any of the predictor

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variables. Only an intention to not seek help showed significant associations with most

of the predictors, but the relationships were weak. An increased intention to not seek

help was weakly related to increased self-stigma and shyness, and decreased emotional

competency and self-reliance. There was no significant association between an

intention to not seek help and mental health literacy.

Examination of intercorrelations among the predictor variables revealed that

self-stigma was related to most of the other predictor variables in the hypothesised

directions, although the relationships were relatively weak. With increasing levels in

self-stigma, levels of emotional competency and mental health literacy decreased and

shyness levels increased. Unexpectedly, however, self-stigma scores increased as self-

reliance scores decreased. There were also significant relationships between emotional

competency scores with self-reliance and shyness. As emotional competency scores

increased self-reliance ratings also increased and shyness levels decreased. Further,

higher levels of mental health literacy were related to higher levels of self-reliance and

higher self-reliance was related to lower levels of shyness. There were non-significant

relationships between mental health literacy and emotional competency, and mental

health literacy and shyness.

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Table 3

Summary of the Intercorrelations of the Study Variables

Measure 1 2 3 4 5 6 7 8 9

1. Online - .38** .47** -.14* .10 .12 .13* -.02 .01

2. Face-to face - .45** -.40** -.01 .03 .21** .07 -.07

3. Phone - -.25** .03 .02 .07 -.04 -.03

4. No Help - .20** -.22** -.12 -.18** .15*

5. Self-Stigma - -.26** -.16* -.18** .21**

6. Emotional Competency

- .08 .44** -.27**

7. Mental Health Literacy - .19* .04

8. Self-Reliance - -.43**

9. Shyness -

Note. N = 230. *p < .05. **p < .01.

Predictive Model of Help-Seeking Intentions

A path analysis was conducted to test the goodness of fit of the data to the initial

hypothesised model (Presented in Figure 1), predicting intentions to use each of the

help-seeking sources. However, as shown in Figure 4, the tested path analysis did not

include phone help as this preference was negligible. Note that a multiple regression

analysis was not conducted due to the lack of significant bivariate correlations between

the dependent variables and the predictor variables. Consequently, the multivariate

regression analysis would provide no useful information. Rather, the path analysis was

conducted to reveal the indirect effects and enable prediction of multiple dependant

variables. The path analysis was performed using AMOS 18 (Arbuckle, 1983-2005) to

enable the simultaneous estimation of multiple dependent relationships. The sample

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size of 231 met the minimum requirement of 200 in order to ensure high statistical

power (Kline, 1998). Testing for multivariate outliers, normality and homogeneity of

variance did not reveal any serious violation of assumptions.

The hypothesised model presented in Figure 4 did not fit the data, χ2

= 233.861,

df = 26, p < .001, GFI = .807, AGFI = .666, TLI = -.077, RMSEA = .186. This model

explained less than 1% of the variance in intentions to use face-to-face help, 1% of the

variance in online help and 3% of the variance in intentions to seek no help.

Figure 4. Hypothesised model predicting intentions to seek help online, face-to-face and to not seek help.

The model was subsequently modified by dropping non-significant paths and the

examination of modification indices was used to obtain a better fitting model. Further,

at each stage of model respecification, the best-fitting model was assessed using the

Akiake Information Criterion (AIC) and more stringent Consistent Akiake Information

Criterion (CAIC), which Williams and Holahan (1994) suggest are the best indicators of

model-parsimony. Based on the recommendation of Holmes-Smith, Coote, and

Gender

Emotional Competence

Self-Reliance

Shyness

Self-Stigma


Seek Help Online

Seek Help Face-to-Face

Would Not Seek Help

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Cunningham (2004) that the model with the smallest AIC/CIAC is the best fitting model,

Figure 5 illustrates the model which was shown to best fit the data, χ2

= 36.236, df = 24,

p = .052, GFI = .966, AGFI = .937, TLI = .931, RMSEA = .047, AIC = 78.236, CAIC =

171.526, along with standardised parameter estimates. All paths presented were

significant at p < .05. This model explained 5% of the variance in intentions to use face-

to-face help, 14% of the variance in online help and 19% of the variance in intentions to

seek no help. All the parameters attaining significance in this multivariate model were

consistent with their bivariate correlations.

In the multivariate model, the only direct predictor of online intentions was a

moderately strong intention for face-to-face help. The only direct predictor of face-to-

face help-seeking intentions was a weak relationship with mental health literacy.

Intention to not seek help was directly predicted by a moderately strong negative

relationship with intentions to seek face-to-face help and a weaker association with self-

stigma. In turn, greater self-stigma was predicted by relatively weak relationships with

emotional competence (less competence), gender (being female) and higher shyness.

Mental health literacy was only predicted by gender, with girls having greater literacy.

Self-reliance was not directly or indirectly related to any of the help-seeking

intentions, but was shown to be predicted by mental health literacy, emotional

competence and shyness. Emotional competence was only indirectly related to help-

seeking intentions through self-stigma, and was predicted by shyness. As noted, gender

was indirectly related to help-seeking intentions via girls having greater mental health

literacy and higher levels of self-stigma.

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Figure 5. Final path model predicting intentions to seek help online, face-to-face and to not seek help.

Discussion

The aim of this study was to determine whether young people do have a

preference for online therapy over the more traditional service types, what their actual

help-seeking intentions are, and the factors which contribute to these intentions.

Overall, it appears that young people still hold a majority preference for help face-to-

face, however, the highest intention was to not seek help at all, and this was also a

strong preference. Contrary to the hypothesis, there were no gender differences in

intentions to seek help; however the hypothesis was supported in that females had a

stronger preference for face-to-face help, whilst males had a stronger preference for

online help. In support of the hypothesis, higher levels of self-stigma were related to

higher levels of shyness and lower levels of emotional competency, although no

significant relationships were identified between self-stigma and mental health literacy,

Gender (Female)

Shyness


Self-Reliance Emotional Competency

Self-stigma

Online

.34

.21

-.27

.33

.18

.13

.22

-.34

-.23

R2 = .12

R2 = .08

R2 = .13

R2 = .32

R2 = .14

Face-to-Face

R2 = .05

.38

Would Not Seek Help

R2 = .19

.18

-.40

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or self-stigma and self-reliance. As hypothesised, males were found to have lower

mental health literacy scores than females, however no gender differences were

identified in levels of emotional competency or self-reliance. The path model indicated

that the predictive ability of most of the identified barriers in predicting an intention to

seek help online were low, however there were some improvements in predicting

intentions to not seek help at all.

Results revealed that when young people aged 15-19 years are forced to choose

a preferred help source between online, face-to-face, phone, and not seeking help,

almost two-thirds of this study‟s participants preferred to seek help through face-to-face

interaction, whilst almost a quarter preferred to not seek help at all. The main reasons

stated by young people as to why they preferred face-to-face formats were because they

were more personal, their feedback was customised to their situation, and they knew

who they were speaking too. The 16% of participants who preferred online formats

stated that they appreciated the anonymity of the internet, the ease of accessing

information, and using chat rooms to talk to people who had been through the same

thing. These responses show that young people who prefer help face-to-face and online

have some similarities in their reasons for that preference, in that both groups of young

people prefer these sources as they can talk to others about their problems; the online

group simply prefer to do it anonymously. In contrast to the young people who would

prefer to seek help either online or face-to-face, a common response from the quarter of

participants who preferred to not seek help at all, was that they did not like talking about

themselves or their problems to others. Therefore, a major distinction in the groups of

young people and their preferences appears not to just be between each preferred source

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of help, but rather, between young people who are willing to seek help, either online or

face-to-face, and those who would not seek help at all.

The stronger preference for face-to-face help, over that of online or phone help,

could be explained by the „mere exposure effect‟ of attitude formation (Zajonc, 1968).

The mere exposure effect is the tendency to develop more positive feelings toward

people and objects the more we are exposed to them (Zajonc, 1968), and has been found

to be a highly robust and reliable phenomenon (Bornstein, 1989). Applying this theory,

it could be argued that the traditional face-to-face approach is the preferred method by

the majority of participants simply because face-to-face help is better established, and

young people are more familiar with the potential process, where-as online help is new

and unfamiliar. Encouragingly, advertising campaigns have been shown to increase

awareness around a number of mental health problems such as depression (Phoenix-

Research, 2006), therefore, based on the mere exposure effect (Zajonc, 1968), a

campaign introducing sources such as „http://au.reachout.com‟ (Burns, Ellis, et al., 2009)

and „www.moodgym.org‟ (Christensen, et al., 2004) may result in an increase in

preferences for help online, and possibly, an increase in overall service utilisation.

The gender differences in intentions and preferences to seek help were mixed.

Contrary to the hypothesis, the analysis of variance indicated that there were no

differences between males and females in the intention of using each help source. In

contrast, the Chi-square test indicated that there were gender differences in relative

preferences when a forced choice was measured. As hypothesised, the Chi-square test

showed that a higher percentage of females than males would prefer to seek help face-

to-face, whilst a higher percentage of males than females would prefer to not seek help

at all, or seek help online. Although these findings are in line with the hypothesis, the

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odds ratios were compared by using percentages, not actual help seeking numbers. As

these results, and those of previous studies (ABS, 2007; Angst, et al., 2002), indicate

that there are more females seeking help in the first place, it is likely that there are still

more females overall, using online sources than males. However, as Gould et al. (2002)

suggested, the „gender divide‟ which is highly visible in face-to-face formats appears to

be reduced in online sources of help. This is an encouraging sign and in the future we

may see the divide continue to reduce as males become increasingly aware of

alternative help-seeking options. Whilst the „gender divide‟ appears to be reduced in

online formats, it is also necessary to note that the largest percentage of males still

preferred face-to-face and not seeking help, over that of online help.

The relationships between the predictor variables were somewhat as

hypothesised. As hypothesised, higher levels of self-stigma were related to lower levels

of emotional competency and higher ratings of shyness. Contrary to the hypothesis

however, no significant relationships were identified between self-stigma and mental

health literacy, or self-stigma and self-reliance. Whilst the results of the current study

do not provide support for previous research indicating that increased knowledge about

mental illnesses can reduce stigma (Burns, Durkin, et al., 2009), it does provide support

for the argument put forward by Jorm and Barney et al. (2006) that the two do not

always go together. The current results suggest that simply having an understanding of

various mental health disorders, and knowledge of whether outside support should be

obtained, does not reduce self-stigma. The lack of a significant relationship between

self-stigma and self-reliance does not provide support for the previous findings of Jorm

and Kelly et al. (2006) or Ortega and Alegria (2002), however this may be due to how

self-reliance was measured in these previous studies. Both of these previous studies

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simply used a dichotomous question asking participants whether they believed in

dealing with depression or emotional problems alone. It is likely that this dichotomous

question does not cover all the dimensions of self-reliance that are tested in the measure

used in the current study.

The gender differences within the predictor variables were also somewhat mixed.

In support of the hypothesis and findings by Jorm (2009) and Cotton et al. (2006),

mental health literacy was found to be higher in females. Additionally, as hypothesised,

there were no gender differences in levels of shyness. In contrast to findings by

Corrigan and Watson (2007), males in this study were actually found to have lower self-

stigma scores than females. Furthermore, contrary to the hypothesis and previous

research, no gender differences were identified in levels of emotional competency

(Ciarrochi, et al., 2001; Ciarrochi, et al., 2003) or self-reliance (Jorm, Kelly, et al.,

2006). The unexpected lack of gender differences could be attributed to differences in

samples. For example, the research by Corrigan and Watson (2007) was conducted in

America, with a participant age range of 18-95 years. Alternatively, the lack of gender

differences may suggest that there is a shift occurring in the ability of younger men to

communicate their emotions and their stigmatising beliefs around mental illnesses. This

shift may be occurring due to Australian national advertising campaigns, such as the

beyondblue campaign launched in 2006, which aims to raise awareness around

depression, anxiety and substance abuse problems (beyondblue, 2006). This campaign

has now been running for a number of years and has used various high profile males to

talk openly about their own mental health problems. It is possible that we are now

seeing positive results of the campaign with young males becoming more comfortable

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talking about their emotions, and having reduced stigmatising attitudes than evident in

previous studies.

In the current study, three-quarters of the sample stated they would prefer to

seek help either face-to-face or online, however, the majority of these young people also

stated that they were most likely to not seek help at all. The variation between young

people‟s preferences for certain sources of help and their actual help-seeking intentions,

indicates that there are barriers standing in the way of young people fulfilling their

preference to seek help. The predictive model provides support for self-stigma,

emotional competency, mental health literacy, and shyness in being direct or indirect

barriers to help-seeking, however, the ability of these barriers in predicting intentions to

seek help online, were low.

The path model accounted for 5% of the variance in an intention to seek help

face-to-face with mental health literacy being a direct predictor, and gender being an

indirect predictor through the effect of mental-health literacy. The connection between

mental health literacy and help seeking intentions for face-to-face formats is

encouraging as a number of interventions have shown that mental health literacy can be

improved (Kelly, et al., 2007; A. Wright, McGorry, Harris, Jorm, & Pennell, 2006). For

example, an intervention conducted by Esters, Cooker and Ittenbach (1998) which

provided information on help sources, the reality of stigma, and the symptomology,

treatment, and prognosis of a variety of mental illnesses, resulted in participants being

more favourable to seeking help from professional sources in the future. Encouragingly,

this improvement still remained at a 12 week follow up. The relationship between

higher mental health literacy and intentions to seek help face-to-face, may also provide

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further support for the argument that young people are more likely to prefer help

sources they already have knowledge about (Zajonc, 1968).

An intention to seek help online was only directly predicted by an intention to

seek help face-to-face, although, the predictive model was able to account for 14% of

the variance in this intention. Of the three tested help sources the model could best

predict an intention to not seek help, accounting for 19% of the variance. This was

through the direct relationships of a low intention to seek help face-to-face and higher

self-stigma attitudes, and, the indirect relationship of lower mental health literacy, lower

emotional competency, increased shyness and being female. The increased ability of

the identified barriers of self-stigma, emotional competency and shyness in predicting

an intention to not seek help at all, over an intention to seek help online, suggests that

whilst online help may theoretically accommodate these barriers it either does not

accommodate them to a significant extent, or, young people who are challenged by

these barriers are not willing to try online help in the first place in order to see that it

does accommodate them. If the latter is the case, there are some concerning

implications as this suggests that simply providing help through different means is not

going to increase the likelihood that young people facing these barriers will actually use

these new sources. These particular young people may need more than just an increased

perceptual awareness of the available sources to increase their behavioural intentions

(Ajzen, 1989; Katz, 1960; Zajonc, 1968).

The functional approach to attitude change suggests that attitudes are formed

based on the degree to which they satisfy different psychological needs, and in this

sense, this theory is an active, rather than passive approach (Katz, 1960). Katz suggests

that one of the ways we form attitudes is through an adjustment function were positive

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attitudes form in the process of achieving a particular goal. Based on this theory, it

would seem that young people who are faced with particular barriers actually need to

experience help-seeking through the various avenues to determine for themselves

whether or not it does address their individual barrier/s or concerns, thereby determining

whether that source has addressed their psychological requirement (Katz, 1960). This

opportunity could be provided through a whole school intervention which introduces

young people to alternative help-seeking sources, and allows students to trial them,

before they are even needed. An intervention such as this would allow young people to

decide which sources of help address their individual concerns, possibly changing their

attitude to that source and thereby increasing their intention to seek help when needed in

the future.

The relatively low predictive abilities of self-stigma, emotional competency,

mental health literacy, self-reliance and shyness in predicting an intention to seek help

online, also indicate that other variables are likely predictors of this intention. For

example, an increased intention to seek help online may be more evident for young

people faced with speech or hearing difficulties (Blanchard, et al., 2008), restrictions in

mobility due to physical conditions or location (Rochlen, et al., 2004) or concerns

around the cost and time required to seek help face-to-face (Evans et al., 2011; Ho, Hunt,

& Li, 2008). Further, intentions to seek help online, may be better predicted simply by

the level of knowledge young people have about where they can go for help online. For

example, Jorm (2009) found that that recall of mental health organisations by 12-25

year olds varied dramatically, with the highest recollection being for beyondblue,

recalled by only one-third of the sample. Since such low percentages of young people

were able to identify mental health organisations in the study by Jorm, it is likely that

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the participants in the current study could not identify where they would go for help

online, and therefore, rated their intentions to use it as low regardless as to whether or

not they thought it may accommodate their reasons for not seeking help.

Overall, the findings of the current study show that the highest intentions of

young people are to not seek help at all, even if clearly symptomatic. Further, one in

four young people actually prefer to not seek help, generally because they do not like

talking about themselves. Whilst there are online sources available such as

„reachout.com‟, and „moodgym‟, which allow young people to find information, read

other‟s stories and complete cognitive-behavioural based exercises without disclosing or

interacting with others (Barak, et al., 2009), it is likely that young people are unaware of

them (Jorm, 2009). This suggests that organisations need to continue using innovative

methods to both promote and provide services to ensure all young people are not only

aware of them, but their needs are catered for. Finally, organisations need to remain

aware that at this point in time the majority of young people still prefer face-to-face

approaches and their needs and preferences should not be forgone in order to provide

new services online.

Limitations of the Study

One of the aims of this study was to bring together a number of previously

identified barriers to help-seeking in order to determine whether combined, they could

explain intentions to use various sources of help. Whilst testing all these barriers

together provided a multivariate approach to understand the complex barriers faced by

young people, it required a lengthy survey. Although there were very few missing data,

the length of the survey may have affected how carefully the participants answered each

question. Further, whilst the sample had a relatively equal spread of participants across

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the public and private schools, and year groups, all participants were from Canberra.

This limits the generalisability to the wider Australian population as the higher average

weekly income of Canberrans (ACT Department of Treasury, Economics Branch [ACT

Treasury], 2011), potentially results in this sample having better access to information

technologies than other young people around Australia. In addition, although the

sample was large enough to ensure high statistical power for a path analysis (Kline,

1998), it was not large enough to test all hypotheses of interest such as determining

whether school-grade level had an impact on help-seeking preferences. Finally, because

the study was of a cross-sectional nature the relationships devised from the path model

cannot be conferred to be directional or causal. While these relationships were the best

statistical fit, their causal direction is untested.

Future Research

To further understand the causal nature of the barriers identified in the current

study a longitudinal approach is required. Future studies should also use a longitudinal

approach based on the mere exposure theory (Zajonc, 1968) to test whether promoting

various help-seeking sources can in-fact, alter attitudes and intentions to seek help for

those sources. Since the barriers identified in this study were unable to account for any

more than 14% of the intentions to seek help online, it would also be useful to

investigate the reasons for this further. A study based on the functional approach to

attitude formation (Katz, 1960), which implements a whole school program introducing

young people to online sources, and allowing them the freedom to investigate how they

work and what is required of them as help-seekers, then retesting preferences and the

barriers of self-stigma, emotional competency, mental health literacy, self-reliance and

shyness may help in understanding whether or not these barriers are accommodated by

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online sources. Further, a study using focus groups of young people who prefer online

help may aid in identifying other reasons why they prefer this source and the types of

young people who are likely to be attracted to online help. These young people‟s

stories and experiences could also be used to encourage others to seek help.

Understanding the types of young people who use each help source will assist

organisations to effectively promote their services to the groups of young people most

likely to benefit from them.

Conclusion

In summary, the results of this study show that young people aged 15-19 from

Canberra, still prefer traditional face-to-face mental health service delivery, although, a

small group would prefer online help. Unfortunately, one in four participants still

preferred to not seek help at all. Of particular interest is the overwhelming lack of

preference for phone help. Further, the highest overall intention is actually to not seek

help at all. This suggests that whilst organisations should continue to provide face-to-

face services to cater for the large group of young people who still prefer this traditional

method, they should continue to use innovative methods to provide and promote their

services, in a constant attempt to attract those young people who are still unwilling to

seek help.

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Appendix A

Adolescent Help Seeking Survey

Instructions

This survey asks about:

The types of services you would likely seek help from for emotional problems

How you would feel about having some emotional problems

Some personality traits

Your understanding of various mental health concerns

This is an anonymous survey – do not write your name anywhere. For each question, circle only ONE of the options provided. There are also spaces to add other responses which aren‟t listed.

You are free to stop the survey at anytime.

Section A

First, just a few questions about you:

Please tick the appropriate box.

A1. Age: 15 16 17 18 19+

A2. Gender: Male

Female

A3. School:

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Section B

Please read the following scenario:

You have been feeling unusually sad and miserable for the last few weeks. You are tired all the time and have trouble sleeping at night. You don’t feel like eating and have lost weight. You can’t keep your mind on your studies and your marks have dropped. You put off making decisions and even day-to-day tasks seem too much for you.

Below is a list of people who you might seek help or advice from if you were experiencing the above problems. Please circle the number that shows how likely it is that you would want to seek help from each of these sources as your first point of contact if you were experiencing the above problems..

If I was feeling that way I would seek help from…

Extremely Unlikely

Extremely Likely

B1 Phone Line Help

A Crisis line (e.g. Lifeline or Kids helpline

1 2 3 4 5 6 7

B Other counsellor over the phone 1 2 3 4 5 6 7

B2 Online Help

A Help from a website (e.g. ReachOut, Beyondblue, MoodGym)

1 2 3 4 5 6 7

B Help through email with a professional (delayed feedback)

1 2 3 4 5 6 7

C Help through instant chat with a professional (instant feedback)

1 2 3 4 5 6 7

B3 Face to Face

A Help face to face with a youth worker

1 2 3 4 5 6 7

B Help face to face with a private psychologist

1 2 3 4 5 6 7

C Help face to face with a school counsellor

1 2 3 4 5 6 7

D Help face to face with a counsellor not associated with the school

1 2 3 4 5 6 7

E Help face to face with a GP / Health practitioner

1 2 3 4 5 6 7

B4 No Help

A I would not seek help 1 2 3 4 5 6 7

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B5)

Overall, if you felt like what is described in the scenario would you prefer to have help: (please tick one box)

Over the phone

Online

Face to Face

I would not seek help

B6)

If you have a strong preference for a certain help source (or have sought help when feeling down before) please state what it is and why you prefer it.

Source:

Why I prefer it:

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Section C

Please read the scenario again:

You have been feeling unusually sad and miserable for the last few weeks. You are tired all the time and have trouble sleeping at night. You don’t feel like eating and have lost weight. You can’t keep your mind on your studies and your marks have dropped. You put off making decisions and even day-to-day tasks seem too much for you.

Below is a list of statements about how you might feel if you had a problem like the one described.

Please circle the number that indicates how strongly you agree or disagree with each statement.

If I was feeling that way… Strongly Disagree Disagree

Neither Agree or Disagree Agree

Strongly Agree

C1 I would feel embarrassed 1 2 3 4 5

C2 I would think I should be able to „pull myself together‟

1 2 3 4 5

C3 I would feel like I was good company

1 2 3 4 5

C4 I wouldn‟t want people to know that I wasn‟t coping

1 2 3 4 5

C5 I would feel ashamed 1 2 3 4 5

C6 I would think I should be able to cope with things

1 2 3 4 5

C7 I would feel like a burden to other people

1 2 3 4 5

C8 I would see myself as weak if I took antidepressants

1 2 3 4 5

C9 I would feel disappointed in myself

1 2 3 4 5

C10 I would think I should be stronger 1 2 3 4 5

C11 I would feel inadequate around others

1 2 3 4 5

C12 I would feel embarrassed about seeking professional help

1 2 3 4 5

C13 I would feel inferior to other people

1 2 3 4 5

C14 I would think I only had myself to blame

1 2 3 4 5

C15 I would feel I couldn‟t contribute much socially

1 2 3 4 5

C16 I would feel embarrassed if others knew I was seeking professional help

1 2 3 4 5

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Section D

For the following questions please read each item carefully and decide to what extent it is characteristic of your feelings and behaviour.

Circle the number that indicates how characteristic it is of your feelings and behaviour.

Very Very Unlike Me Unlike Me Neutral Like Me Like Me

D1 I feel tense when I am with people I don‟t know well

1 2 3 4 5

D2 I am socially somewhat awkward

1 2 3 4 5

D3 I do not find it difficult to ask other people for information

1 2 3 4 5

D4 I am often uncomfortable at parties and other social functions

1 2 3 4 5

D5 When in groups of people I have trouble thinking of the right thing to talk about

1 2 3 4 5

D6 It does not take me long to overcome my shyness in a new situation

1 2 3 4 5

D7 It is hard for me to act natural when I am meeting new people

1 2 3 4 5

D8 I feel nervous when speaking to someone in authority

1 2 3 4 5

D9 I have no doubts about my social competence

1 2 3 4 5

D10

I have trouble looking someone right in the eye

1 2 3 4 5

D11

I feel uncomfortable in social situations

1 2 3 4 5

D12

I do not find it hard to talk to strangers

1 2 3 4 5

D13

I am more shy with members of the opposite sex

1 2 3 4 5

D14

During conversations with new people, I worry about saying something foolish

1 2 3 4 5

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Section E

For the following questions please read each item carefully and decide to what extent you agree or disagree with each statement.

Circle the number that indicates how much you agree with each statement.

Strongly Disagree Disagree Agree

Strongly Agree

E1

It‟s not practical to decide what kind of a job you want because that depends so much on other people.

4 3 2 1

E2 In a group I prefer to let other people make the decisions.

4 3 2 1

E3

You can‟t be expected to make a success of yourself if you had a bad childhood.

4 3 2 1

E4 Luck decides most of the things that happen to me.

4 3 2 1

E5 The main reason I‟m not more successful is that I have bad luck.

4 3 2 1

E6 Someone often has to tell me what to do.

4 3 2 1

E7

When things go well for me, it is usually not because of anything I did myself.

4 3 2 1

E8 I feel very uncomfortable if I disagree with what my friends think.

4 3 2 1

E9

It is best to agree with others, rather than say what you really think, if it will keep the peace.

4 3 2 1

E10

I don‟t know whether I like my new clothes until I find out what my friends think of them.

4 3 2 1

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Section F

For the following questions please read each item carefully and decide to what extent you agree or disagree with each statement.

Circle the number that indicates how much you agree with each statement.

Strongly Disagree Disagree

Neither Agree or Disagree Agree

Strongly Agree

F1 I am often confused about what emotion I am feeling

5 4 3 2 1

F2 It is difficult for me to find the right words for my feelings

5 4 3 2 1

F3 I have physical sensations that even doctors do not understand

5 4 3 2 1

F4 I am able to describe my feelings easily

5 4 3 2 1

F5 When I am upset, I do not know if I am sad, frightened or angry

5 4 3 2 1

F6 I am often puzzled by sensations in my body

5 4 3 2 1

F7 I have feelings that I cannot quite identify

5 4 3 2 1

F8 I find it hard to describe how I feel about people

5 4 3 2 1

F9 People tell me to describe my feelings more

5 4 3 2 1

F10 I often do not know why I am angry

5 4 3 2 1

F11 It is difficult for me to reveal my innermost feelings, even to close friends

5 4 3 2 1

F12 I am often confused about what emotion I am feeling

5 4 3 2 1

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Section G

For the following questions please read the brief description provided in the box and decide whether each person has a serious problem, and if so, what they should do about it. There are no right or wrong answers – we just want to get some different points of few about what different people would think and do.

Sam is 17 years old and is living at home. Since starting at a new school last year Sam has become even more shy than usual and has made only one friend. Sam would really like to make more friends but is scared of saying or doing something embarrassing. Although Sam‟s grades are ok, Sam rarely speaks in class and becomes increasingly nervous, trembles, blushes and feels like vomiting if required to speak in front of the class. Sam never answers the phone and refuses to attend social gatherings. Sam knows the fears are unreasonable but just can‟t seem to control them, and this is really upsetting.

G1. If Sam was your friend, how worried would you be about their overall emotional well-being? (Please circle the appropriate response)

a) I would not be at all worried about their emotional well-being.

b) I would be a little bit worried about their emotional well-being.

c) I would be quite worried about their emotional well-being.

d) I would be extremely worried about their emotional well-being.

G2. In five words or less, what do you think is the matter with Sam?

G3. Do you think Sam needs help for the problem? (Please Circle)

No Don‟t Know Yes

If “Yes”, from whom?:

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Leigh is 18-years old and lives at home. Leigh has been attending school irregularly over the past year and has recently stopped attending altogether. Over the past 6 months Leigh has stopped seeing any friends and begun spending a lot of time in the bedroom and refusing to eat with the rest of the family or have a shower. Even though Leigh‟s parents know there is no one else in the bedroom, they have heard Leigh shouting and arguing as if someone else was there. When they try and encourage Leigh to go out, Leigh whispers that they can‟t leave home because the neighbour is spying on them. They know Leigh is not taking drugs as Leigh never leaves the house or sees anyone to get them.

G4. If Leigh was your friend, how worried would you be about their overall emotional well-being? (Please circle the appropriate response)

e) I would not be at all worried about their emotional well-being.

f) I would be a little bit worried about their emotional well-being.

g) I would be quite worried about their emotional well-being.

h) I would be extremely worried about their emotional well-being.

G5. In five words or less, what do you think is the matter with Leigh?

G6. Do you think Leigh needs help for the problem? (Please Circle)

No Don‟t Know Yes


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Taylor is in year 12. Taylor‟s friends have been planning to go away together on a cruise for schoolies week and have been planning it for some time. Lately however, Taylor has not seemed interested in the trip, in-fact Taylor has not seemed interested in anything for a couple of months. Taylor has lost their characteristic spark and energy, and regularly appeared to be sad and tearful. Taylor has also been drinking increasingly more alcohol over the past year, and recently forgot to confirm the trip with the travel agent on the allocated day, due to a hangover. Taylor was very upset about this saying things like “I‟m useless”, and “good for nothing”, and that “I might as well just be dead because no one would care if I wasn‟t here anymore”.

G7. If Taylor was your friend, how worried would you be about their overall emotional well-being? (Please circle the appropriate response)

i) I would not be at all worried about their emotional well-being.

j) I would be a little bit worried about their emotional well-being.

k) I would be quite worried about their emotional well-being.

l) I would be extremely worried about their emotional well-being.

G8. In five words or less, what do you think is the matter with Taylor?

G9. Do you think Taylor needs help for the problem? (Please Circle)

No Don‟t Know Yes


Thank you for completing this survey.

If anything in this survey has caused you distress, please contact your

school counsellor or Lifeline (13 11 14).

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Appendix B

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Appendix C

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Appendix D

Dear Parent(s)/ Guardian(s)

Re: Invitation for your child to participate in a research survey on “Factors

influencing young people’s choice of professional help for their mental health

concerns”

We are seeking permission for your child to participate in a study relating to adolescent

preferences for mental health concerns.

The purpose of the study is:

1. To investigate whether there is a preference for types of help for mental health

problems (whether there is a preference form online, phone line or face-to-face

services).

2. To identify the characteristics of young people who prefer online services so that

services can ensure they are providing appropriate support to all young people.

The ACT Department of Education & Training and the University of Canberra

Committee for Ethics in Human Research have both approved this study. The principal

researcher is conducting this project as part of 4th year thesis requirements to attain a

Bachelor of Science (Psychology) Honours degree at the University of

Canberra.

Participation will entail:

1. Completing a 20 to 30 minute anonymous survey consisting of a general help

seeking questionnaire, a self-stigma for depression scale, a self-reliance scale, a

scale of emotional competence, a shyness scale and questions relating to their

mental health literacy. Your child will not be asked about their current mental

health.

2. Your child will complete this survey during one in-class session, or during their

own time using an online version.

This study will be anonymous and completely confidential. No individual information

will be identifiable to the researcher and group data will be stored securely according to

University of Canberra guidelines.

Participation in this study is voluntary and no child will be approached to participate

unless parental approval is received. If parental consent is given, then your child will be

asked separately whether they would like to participate. It will be explained that

participants are free to stop the survey at anytime or skip any sections they would prefer

not to answer.

If you would like any more information please contact the project‟s supervisor

Professor Debra Rickwood. Ph: 6201 2701 or email at

[email protected]

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Factors influencing young people’s choice of professional help for mental health

concerns

If you DO NOT wish your child to participate please tick the box and return this

consent form to the school by_____

(If you do not complete this consent form it will be assumed that you have provided

your consent.)

I have read and understood the purpose and requirements of this study on my child.

I do not wish my child to participate in this study.

Parent/ Guardian Name:_____________________________________

Child‟s Name:_____________________________________________

Signature:________________________________________________

Date: ____________________________________________________

A summary of the findings of this research will be provided to your school by the

end of the year.

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Appendix E

RESEARCH PARTICIPANT INFORMATION SHEET:

Factors affecting young people’s choice of professional help for mental

health concerns Project Aim To identify which factors contribute to young people‟s choice of professional help when

they are concerned about a mental health problem. Of interest is whether young people

prefer online, phone line or face-to-face services as these all vary in their levels of

anonymity and type of communication. The factors of interest include self-stigma,

mental health literacy, emotional competence, shyness, and self-reliance.

Benefits of Project

It is anticipated that by understanding the factors that contribute to young peoples‟

preference for a type of mental health service, services will be able to tailor their

interventions to address all young people.

Participation

Participation will entail completing a 20-30 minute survey addressing the factors of

interest.

Participating in this study is voluntary and you are free to withdraw at any time, without

penalty. You may also avoid answering questions that you do not wish to answer.

Confidentiality and Anonymity

All responses will be treated confidentially and no identifying information will be

reported. Data will be secured, stored and disposed of according to University of

Canberra guidelines. Only collated data will be reported. No individual data or details

will be disclosed.

This study is being conducted by the principal researcher in order to meet part of the

requirements for a Honours Degree in Psychology at the University of Canberra. The

ACT Department of Education & Training and the University of Canberra Committee

for Ethics in Human Research (Approval no. CEHR 11-55), have both approved this

study.

Access to a summary of the results will be available through the School Principal on

completion of analysis. For any further inquiries or information please contact the

research supervisor, Professor Debra Rickwood ([email protected])

If you wish to participate in this study, please begin

If you do not wish to participate in this research please leave the survey blank

and it will be collected at the end.

If at anytime you feel distressed as a result of the questionnaire please contact the

school counsellor or ring Lifeline on Ph: 13 11 14

Factors influencing young peoples choice of professional help for mental health concerns

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