Engaging with a Mental Health Service: Perspectives of At-Risk Youth

Child and Adolescent Social Work Journal, Vol. 20, No. 6, December 2003 ( 2003)

Engaging with a Mental HealthService: Perspectives ofAt-Risk Youth

Rosemary French, M.Psych., B. A. (Hons),Melissa Reardon, B.S.W., and Peter Smith, Ph.D.

ABSTRACT: Studies suggest that only a small number of young people withdiagnosable mental health difficulties are referred for treatment. Of these asignificant proportion fail to engage in treatment or terminate prematurely.This situation is exacerbated when the young people are homeless or at riskof homelessness, and considered to be “at-risk.” With this at-risk populationthe process of engagement is likely to be a critical aspect of successful inter-ventions. Using qualitative methodology, at-risk clients of a mental healthservice (n = sixteen) were interviewed, and four primary themes crucial to theengagement process were identified. The data indicated the importance ofconsidering the young person and their multifarious life-experiences; the at-tractiveness and accessibility of the service; and the follow-up offered by theservice provider. The implications for mental health services that providecounseling for young people are discussed.

KEY WORDS: At-Risk Youth; Mental Health; Engagement.

The mental health needs of young people and the difficulty of engag-ing this population in mainstream services have been well docu-mented. International studies suggest a prevalence of general psychi-atric dysfunction amongst 15 to 25 year olds of around 14% (Davis,Martin, Kosky & O’Hanlon, 2000). Australian research consistentlysuggests an even higher prevalence of approximately 20% (Australian

Rosemary French is Clinical Psychologist, Centre for Clinical Interventions/YouthLink. Melissa Reardon is a Social Worker at YouthLink. Peter Smith is affiliatedwith Curtin University, Western Australia.

Address correspondence to Rosemary French, Centre for Clinical Interventions/YouthLink, 223 James St., Northbridge, Western Australia 6003; e-mail: [email protected].

This research was supported by a grant from the Mental Health Division of theHealth Department of Western Australia.

529 2003 Human Sciences Press, Inc.

530 CHILD AND ADOLESCENT SOCIAL WORK JOURNAL

Institute of Health and Welfare, 1999; Zubrick et al., 1995). The samestudies indicate only a very small percentage of young people witha diagnosable mental health problem seek help from mental healthservices. For example, Zubrick et al. reported a rate of only two percent seeking help. Difficulties in engaging young people at mentalhealth services are also reflected in attrition rates. A review by Arm-bruster and Kazdin (1994) suggests that between 30% to 60% of youngpeople presenting to a mental health service will not complete treat-ment. The barriers and problems inherent in accessing, receiving, andcompleting treatment are likely to be magnified for “at-risk” youth.Young people who are identified as being “at-risk” are frequently ex-posed to multiple risk factors including homelessness, contact withthe justice system, substance abuse, self-harming and suicidal behav-iors (De Anda, 2001; Mitchell, 2000). These factors are often associ-ated with the experience of disconnection and marginalization fromthe key institutions of mainstream society, and can place young peopleat increased risk of developing complex mental health difficulties(Mitchell, 2000).

The present research was conducted at YouthLink, a mental healthservice for at-risk youth aged from 13 to 25 years. Social Workers orClinical Psychologists provide individual counseling and psychother-apy, and this is sometimes on an outreach basis. The target populationis known to have experienced difficulty in accessing mainstream men-tal health services, and this could be due to a number of factors. Youngpeople referred to the service may be homeless, live transient life-styles, or lack the family support necessary to access services. Thecomplexity of their presenting problems, such as repeated crises, poly-substance misuse, abuse, neglect, and extreme social isolation, canalso contribute to the difficulties they may experience in accessingservices.

At YouthLink, the engagement of at-risk youth is considered to bea process. This is consistent with Liddle’s (1995) definition of engage-ment as the “enlistment of a single individual into therapy” (p. 42)and assertion that it is not simply “an event occurring at the outset oftherapy” (p. 40). The engagement process can take varying lengths oftime and, indeed, it may never happen. However, the process is clearlyfundamental to successful therapeutic outcomes with at-risk youth.

In attempting to improve the engagement rates of young people intoboth mainstream mental health services and those targeting at-riskpopulations, different sources of evidence can inform practice. Al-though few in number, one such source for identifying factors affecting

ROSEMARY FRENCH, MELISSA REARDON, AND PETER SMITH 531

engagement are the studies that examine attrition. These studies pri-marily use quantitative methods and comprise samples from clinic-based services, school populations, and the community. Variables ex-amined have included gender and age, socioeconomic status, distancefrom the clinic, referral source, diagnosis, and parental attitudes (Bar-uch, Gerber & Fearon, 1998; Gould, Schaffer & Kaplan, 1985). Theresults of different studies are often conflicting and comparisons aredifficult because of the lack of standardization of the variables (Arm-bruster & Kazdin, 1994; Gould et al., 1985). However, support for thenotion of engagement as a process comes from the robust finding thatreasons for attrition vary according to the specific stage of treatment(Gould et al., 1985; Kazdin & Mazurick, 1994; Pelkonnen, Marttunen,Laippala & Lonnqvist, 2000). For example, social disadvantage is as-sociated with attrition during the intake phase (see Pelkonnen et al.).

Empirical research has provided valuable information for under-standing the engagement process, although a full understanding isunlikely to be captured through quantitative information alone. Con-sumers, in particular, offer a unique perspective on aspects of treat-ment provision (Macran, Ross, Hardy & Shapiro, 1999; Nicolson,1995). This perspective in evaluative and other studies is becomingincreasingly common (see de Anda, 2001). Through attempting to un-derstand the lived experience of at-risk youth engaging in mentalhealth services, we have an additional source of information that hasthe potential to improve service delivery.

As a way of gaining a more complete understanding of the engage-ment process, a qualitative study was undertaken to explore the cli-ent’s perspective. An answer was sought to the broad question: “Whatfactors affect the engagement of at-risk youth at mental health ser-vices?” Experiences of at-risk youth referred to YouthLink were ex-plored from the time of recognition of a problem through to the earlystages of forming a therapeutic alliance.

Method

In order to understand the process of engagement from the young per-son’s perspective, a grounded theory (Strauss & Corbin, 1990) method-ology was used. The interviewers (a social worker and a clinical psy-chologist) were employees at YouthLink and thus familiar with itsmethods of service delivery. However, the theoretical stance ofgrounded theory dictated that the interviewers did not begin with pre-


conceived hypotheses about engagement, but rather allowed partici-pants to describe their experiences in a way that would allow a theoryor model to emerge. Although this methodology is comparatively rigor-ous and time-consuming (Woolley, Butler & Wampler, 2000), it al-lowed a fresh and creative look at the process of engagement throughthe eyes of the consumer.

Participants

A random sample of young people who had been referred to YouthLinkover a 6-month time period were asked to participate. Potential partic-ipants were sent a letter, which was followed by a telephone call afterfour days. This resulted in a total of 16 young people, aged between14 and 21 years (m = 17 years), agreeing to participate. Of this sam-ple, 13 had recently commenced treatment with their allocatedworker. Three had been referred to the service but had decided notto proceed with treatment. Participants were offered a $10.00 (AUD)compact disc or movie voucher in return for their participation.

Consistent with similar research in this field, participation rateswere low and reflected the nature of the target group. Current hospi-talization due to suicidal ideation led to the exclusion of two youngpeople. Two other young people had requested that the service notcontact them at home due to confidentiality concerns. Three peoplegave no specific reason for their refusal. A further 18 people were un-able to be contacted due to either relocation or incarceration. Notwith-standing these exclusions, the remaining sample met the service’s re-ferral criteria (i.e., complex mental health problems, homeless or atrisk of homelessness, and unable to access more mainstream services).

Nature and Location of Interviews

Individual interviews were held at locations which were nominated bythe participants. The interviews took place either at YouthLink, inparticipants’ homes, or at alternative venues such as schools and com-munity-based youth services. It was hoped that this choice would re-sult in the participants having a sense of control over the nature andcontent of the conversation. In addition, the interviewers wanted tocreate a situation in which a narrative, rather than a clinical or medi-cal discourse, could develop.

The interviewers used guide questions that facilitated explorationand elaboration of the participants’ early stages of contact with Youth-


Link (and, where relevant, other mental health services with whichthey been in contact). All participants were initially asked the ques-tion: “What was happening for you at the time of referral?” The inter-views then proceeded in either of two ways. The participants who hadcontinued with treatment were guided through the experience of theirfirst contact with YouthLink, through the referral process, waiting listmanagement, and their initial contact with the allocated worker. Forthose participants who were referred but did not attend the serviceor dropped out of treatment, an exploration of their decision-makingprocess was undertaken.

Analysis

The process of data collection and analysis formed a deductive-induc-tive cycle (Strauss and Corbin, 1990). The 13 individual interviews,which varied in length from 25 minutes to 70 minutes, were audio-taped and transcribed in full. Preliminary analysis raised issues thatwere explored in subsequent interviews. The interviewers, separatelyand together, examined the responses and identified significant state-ments to which groups of responses were linked. Organization andanalysis of data were aided by the NUD*IST (N4) computer program(Qualitative Solutions & Research, 1997).

The initial analysis included the preliminary development of a vi-sual model. To examine the validity of the initial analysis and prelimi-nary model, a focus group of three new participants was held. Theirexperiences of engaging with YouthLink were explored, and they werethen shown the model and invited to make critical comment. Theirresponses supported the validity of the model, with one participantcommenting, “That’s exactly what we said.” Follow-up interviews werealso held with three of the original participants to check the validityof the initial analysis and preliminary model. Some clarifications weremade and further comments were added to the database. The re-sponses generated by the second interviews also supported the valid-ity of the model.

Results

Four thematic categories emerged from the data. Themes that relatedto the young person, such as the young person’s beliefs and expecta-tions about counseling, were categorized under the label “Young Per-


son.” The three other thematic categories were labeled “Attractive-ness,” “Accessibility” and “Assertive Follow-Up,” all of which refer toaspects of service delivery that influenced participants’ engagementwith the service. The following definitions (Complete Oxford Diction-ary, 2000) guided the choice of these labels:

Attract: To draw to itself by invisible influence, said of influencing thewill and action of men . . . so as to cause them to come near, e.g., todraw them by expected advantages, curiosity, admiration, sympathy.

Accessible: Capable of being entered or reached; easy of access; such asone can go to, come into the presence of, reach, or lay hold of; get-at-able.

Assertive Follow-Up: 1) Assertive: Declaratory, affirmative; positive . . .2) Follow-up: The pursuit or prosecution of something begun or at-tempted.

“Attractiveness” describes interactions with the service which influ-enced young people’s beliefs that the service would meet their needs.“Accessibility” describes the responses that related to the practical pa-rameters of service delivery, such as mobility and cost. “Assertive Fol-low-Up” describes the actions taken by the service to maintain contactwith the participant.

The categories and themes that emerged from the initial and follow-up interview data were incorporated into the final version of the vi-sual model (Figure 1). The model was used as an aid for further ex-ploring themes with participants in the data analysis stage, and toillustrate how the themes and thematic categories were viewed to beinterrelated. The thematic category “Young Person” was conceptual-ized as central to the model since the themes that emerged within thiscategory determined why, whether, and how the young person firstsought counseling. The model shows the “engagement phase” as repre-senting the time from initial contact with the service, to the earlystage of building the therapeutic alliance. The three thematic catego-ries, “Attractiveness,” “Accessibility,” and “Assertive Follow-Up,” pro-vide the framework for themes that emerged throughout the engage-ment phase.

Young Person

Themes in this category reflect dimensions which directly relate to the“person” and their life-experience rather than clinical service provi-sion.


FIGURE 1. Model illustrating the influences on the engagement pro-cess from the perspective of at-risk youth. As shown, the thematiccategories that emerged from the interviews were Young Person, At-tractiveness, Accessibility and Assertive Follow-Up. Arrows representthe time from initial contact with the service to the early stage of thetherapeutic alliance.

Problem Awareness: Participants varied in the degree to which theyrecognized the need to “do something” about the difficulties they wereexperiencing in life. However, the difficulties were significant enoughfor them, or a significant other, to believe that counseling would bebeneficial. Several participants acknowledged that they “needed to see


someone.” Some were aware of their problem to the extent that theycould foresee the possible benefits and outcome. For example, one per-son stated, “I thought, well it would be a good idea, like, because if itworks I’ll be able to lose some anger and I won’t always be so upset,and things like that.”

Motivation to Seek Counseling: Some participants stressed the im-portance of self-motivation as the basis for seeking counseling. Theybelieved the decision to seek counseling was one that had to be madeby themselves. This was reflected in the statement: “It had to be up tome to want to do it and not up to anybody else.” In addition, the deci-sion to seek counseling had to be made for themselves, as illustratedby the statement: “It’s something I get out and do for myself.” Otherparticipants stressed the significant role that others had served inencouraging them to participate in counseling. For one participant,encouragement came from a vocational counselor who perceived per-sonal issues were impinging on job readiness:

Probably the [Employment & Training agency] worker kept me in place,like I mentioned the fact I am not usually motivated and he goes, “wellcome along, it’s probably better at counseling [than I am].” So he kindof got me in it. As soon as I came here it was fine, sort of thing. Yeah,that extra push was what kept me motivated.

Others were encouraged by family members, with one participantstating, “It was my sister . . . She just looked at me one day and said‘I don’t know what’s wrong and you don’t have to tell me, but here,’and she gave me a little pamphlet.” General Practitioners also pro-vided encouragement:

The doctor put me on to it. He said it would be a good idea to go for it,so I said “yeah,” because I was having a few troubles at the time. Ialways take advice from a doctor. I usually trust them.

Some participants felt coerced to attend. For example, threatenedwith homelessness, one participant stated, “My mum said ‘go there orget out’.” In such cases there appeared to be an “ulterior motive” forcounseling which was helpful in initially getting the person “throughthe door.” Despite this, most continued to attend counseling sessionsafter their initial reluctance. One participant who declined to engagecited parental pressure as an important factor in that decision makingprocess, stating, “My parents wanted me to come, I was kind of feelinga bit pressured.”


Perceptions of Counseling: The prospect of engaging in a mentalhealth service was mediated by participants’ perceptions of what thecounseling process might involve and what others could think of them.These perceptions included stigma (e.g., “What will people think ofme?”), as well as apprehension about the counseling process (e.g., “Ifelt like I might be put on the spot . . . asked questions that I didn’tknow how to answer”). A small number of participants declared thatat no time did they feel stigmatized, and of those who were concernedabout stigmatization, most appeared to have overcome such concerns.This is illustrated by the general acknowledgment of the “very strongstigma attached to being counseled,” followed by a comment by thesame participant: “I don’t care what people think (of me) any more.”Fears of entering counseling were often based on prior negative expe-riences (e.g., “I thought they would do just the same thing [as theothers and], just throw me on medication”). However, for the majorityof participants, these perceptions of counseling were tempered bytheir actual experience (e.g., “It’s not that scary”). For others, how-ever, the fear of “talking” to another person about their problems con-tinued to be a barrier to engaging in the counseling process, as evi-denced in the following statement: “I find counseling a very difficultprocess . . . I don’t want to talk to people.”

Knowledge of Services: Participants stated the importance of havingknowledge of available counseling services. Some suggested that, hadthey known about the service they may have sought help earlier. Thiswas reflected in the comments: “I just didn’t know how to go about it,so I just left it,” and “I only found out about it through (an adult psy-chiatric inpatient hospital) and then it (my problems) had alreadygone too far.” Participants saw the value of disseminating informationabout the service to their peers (e.g., “More pamphlets”) who were alsoin need of counseling. They highlighted the need for counseling ser-vices to have a stronger profile within the youth community or “youthculture or something, so people know it’s there. So if they feel theyneed to use it they can.”

Attractiveness of the Service

Consistent with the definition of “attract,” themes within this categorywere those that influenced young people’s decision to “want to comenearer” to counseling. The issues raised appeared more to be about


the less tangible aspects of service delivery, and the “process” of theirexperiences rather than the structure of the service.

Feeling Understood: The sense of being understood by workers atthe service was fundamental to all participants. Phrases used by par-ticipants to describe feeling understood included “felt comfortable,”“she listened” and “didn’t judge.” One participant described the impor-tance of being “listened to” during her initial telephone contact withthe service: “She asked me what was going on and I gave her a briefrun-down on my situation, how I was feeling. She listened. She washelpful.” Another said,

She was just nice and friendly . . . she obviously had a lot of experience’cause she was sitting there saying things to me that I knew that I wasdoing and she would have no idea unless she’d known what she wastalking about . . . she made me feel comfortable.

Being understood, and importantly, not being judged was a signifi-cant factor in participants’ decisions to continue with counseling. Thiswas evident in the following comment: “I’m thinking that if I’d beenlooked down on for some of my personal choices and behavior, and ifI was criticized . . . if I’d have been given shit about it, I wouldn’t havecome back.” Similarly, another participant commented, “I neededsomeone who would understand and, like, listen to what I have to say,not even advice, just to listen, and someone to talk to.”

Participants also identified the importance of the service being“youth-specific.” They believed that a youth-specific service would bet-ter understand their own experience, as well as those of young peoplegenerally, as one person remarked: “’Cause I was young ‘YouthLink’sounded good. Like they, you know ‘Youth—Link’, they’d be trainedto work with youth.” Another said, “I didn’t want (to talk to) peoplelike my grandparents, or my parents, anything like that ’cause I feellike they don’t understand me.” Some participants felt the age of thecounselor to be of significance, believing that younger counselorswould better relate to young people (e.g., “[Counselors] should beyoung”). Others thought the “attitude” rather than the age of the coun-selor was of importance: “I guess I knew that (despite her age) shedidn’t have the same attitude as my parents or as the older genera-tion.”


Confidentiality: The issue of confidentiality strongly influenced par-ticipants’ views of counseling. Some participants cited previous experi-ences with mental health services where confidentiality had not beenmaintained. One participant stated,

Well I was once seeing this counselor and my friend was seeing the(same) counselor, and she (my friend) said stuff to me that I had said tothe counselor, and I thought “Hey, that’s supposed to be confidential.”She knew we were friends but she didn’t do a very good job of keepingit confidential.

While some participants were adamant they did not want their par-ents or others to know they were receiving counseling, others werehappy that their parents were aware but did not want the content ofsessions to become known. For others, the mere possibility that infor-mation raised with their counselor may be discussed with another wassufficient to engender a feeling of mistrust, and as a consequence, re-stricted their level of disclosure:

In the car on the way back my mother was telling me that the counselorwas a friend of a friend, or something like that, and that just put me offeven more. I didn’t tell her the truth the whole time. [This time] Iwanted it to be completely private. I didn’t want anybody that my familyknew.

Individual Counseling: Many participants expressed the opinionthat they did not want their parent/s involved in the counseling pro-cess and so chose to engage with a service that would see them indi-vidually. One participant stated: “I could come on my own . . . I didn’thave to have my Mum come with me. It was all up to me.” It wasconsidered that the inclusion of parents often “caused more problemsthan helping.” Although intended to improve intra-family relations,the potential for family sessions to have a detrimental rather thanconstructive outcome for the young person was highlighted in the fol-lowing statement: “I had a session with my whole family and it wasthe worst experience of my life. I felt like I was on the stage and every-one was asking me questions . . . I felt a freak.”

Receiving Information: Participants highlighted the importance ofreceiving information about the service, the counseling process andwhat the service had to offer. For example, a participant stated that


when she phoned to make a self-referral, “[The duty officer] wentthrough everything that you do, and in fact, that you work with youngpeople or people under 25 or something like that, and that you haveall different counselors and everything.”

While on the waitlist, participants thought it was important thatthey were kept informed regarding what they could expect from theservice. One person remarked, “They always rang up and told me howlong it would be (the waitlist) . . . and I talked to them for a littlewhile. It was all right.” Another participant emphasized the impor-tance of knowing what to expect before she arrived for her initial coun-seling session, highlighting the sense of uncertainty that was allevi-ated as a consequence:

If I hadn’t had that phone contact in that time before I got to see theworker, I wouldn’t know what to expect. Because I spoke to them on thephone I sort of knew what to expect – who I was getting and what shewas like.

Choosing the Level of Disclosure: A number of comments made byparticipants indicated that perceived control over the content and tim-ing of their personal disclosures was important. Some participants ex-pressed no discomfort in giving preliminary information over the tele-phone, while others preferred to wait until meeting their allocatedcounselor before disclosing more than was required for the referral.The latter case is illustrated by the comment: “In a way I wasn’t com-fortable in giving all the details on the phone, (but) I still felt safe inthe fact that I could talk if I had been able to.”

Similarly, in the early stages of contact with clinicians, control overcontent and timing of disclosures highlighted participants’ sensitivityand hesitation at exposing personal issues to strangers. The followingcomment describes a participant’s feelings at an initial session withtheir clinician: “I don’t usually like talking to other people unless I getto know them and get their trust . . . so it made it quite hard.” Anothersaid, “The first time I let her (the counselor) do most of the talking. . . I just wanted her to tell me things before I could actually say myproblems, and I felt I didn’t want to say anything.”

Physical Environment: The physical environment of the counselingservice was also important to some participants in the early stages ofengagement. One participant said, “If you’re trying to relax and beopen with people, you need to feel like that (relaxed and open), rather


than walking in to an office where I feel really closed up.” Some partic-ipants felt that their discomfort could be alleviated by changing thecounseling setting: “Go outside or to the church or coffee shop or some-thing. It’s just a more relaxed, open atmosphere, rather than fourwhite walls.”

Accessibility

The category “Accessibility” includes several themes that relate to theparticipants’ ability to access the service. These themes describe as-pects of the structure that made the service a practicable option forparticipants.

Free Service: Participants emphasized that, had there been a costinvolved, their limited financial resources would have prevented themaccessing the service. For example, one participant commented: “Ionly worked part-time and I was living at home. I didn’t even havemoney for fuel half the time, let alone counseling.”

Extended Opening Hours: At the point of entry into the study, allparticipants who had continued engaging with the service had man-aged to find appointment times within regular office hours. However,the issue of extended opening hours was raised as an important factorfor participants when making their first phone call to the service. Oneparticipant stated,

I think it would have been easier for me if I could have spoken to some-one straight away, but you have to have your working hours, you can’tbe open all the time. But even on weekends . . . it would have been eas-ier just to make first contact.

Based in Local Community: Although YouthLink has the capacityto provide outreach services, some participants stated that they wouldhave preferred the service to have been based locally. There were tworeasons for this. First, paradoxically, the very difficulties for whichsome people were seeking help made it difficult for them to accessservices. Symptomatic difficulties experienced while travelling intothe city center were a barrier, with one person remarking, “I just getvery paranoid when I am in big amounts of crowds and that’s why Ididn’t really want to come to [the city].” Second, the practical issuesof time, distance and cost related to travelling were expressed as de-


terrents to engagement, with another participant stating, “It wouldmake it easier if there was a place down here (40 kilometers away). . . instead of having to travel back and forth (to the city).”

Outreach: For some participants the ability of the service to meetthem initially at a place outside the office environment was importantto the process of engagement. One participant who had been ex-tremely depressed on referral revealed, “I was so glad that she cameto me because I probably wouldn’t have gone in . . . yeah, I wantedsomeone to talk to but I didn’t have the motivation for anything.” An-other participant, who was initially ambivalent about receiving coun-seling indicated that the counselor’s willingness to go out of his waydemonstrated a degree of care, which influenced his decision to “giveit a go.” He stated,

I was sort of saying I don’t really want to go into (the city) . . . and hesaid he would meet me and he would come to (the urban location). I justwent, OK. So I thought anyone who was willing to catch a train andcome to (the urban location) for me, I’ll give him a go, so I did.

Both the above-mentioned participants commented that after a fewsessions in the community they were prepared to travel to the Youth-Link office to receive counseling.

Assertive Follow-Up

‘Assertive Follow-Up’ encapsulates young people’s experience of theaction taken by the service to initiate and maintain contact.

Minimal or No Waitlist: The length of time for participants betweenthe initial referral and being allocated a counselor varied from one tofour weeks. Participants emphasized the importance of keeping thewaitlist to a minimum. They highlighted that being on a waitlistwould lead them, as one participant said, to “think that I’m not impor-tant.” They also stressed the critical nature of personal problems, andthat they should be addressed “before they get any worse or they’re(the presenting person is) not going to talk to anybody.” This was alsoemphasized in the insightful comment, “Any more than two to threeweeks seems like a long time, especially something like counselingwhich is generally when you know you need it, you really do need it,and you need it now.”


Personal Contact: Participants stressed the importance of receivingtelephone rather than postal communication to establish and main-tain contact, and to keep appointments. This is illustrated by the fol-lowing two comments: “[If I had received a letter in the post] Iwouldn’t have gone” and “For me, if the counselor themselves is notactually initiating to make the phone call, I probably wouldn’t.”

Maintaining Contact: The service’s assertiveness in maintainingcontact emerged as important. For one participant, at the point of re-ferral it was important that the service continued trying to returnher telephone calls, even though initially she chose not to answer thetelephone. The following quote illustrates the importance of the ser-vice’s response in the face of a young person’s ambivalence:

It was about seven o’clock at night or something and so you were shut,and I left my name and my phone number and I had a person ring backnext morning and I think I was at home, I just didn’t answer it. Andthen it was two to three days after that somebody rang again and saidto ring back. Again I didn’t and then it wasn’t until about a month orsix weeks later I rang again and left my number . . . and somebody rangback and that’s when I spoke to them.

Participants expressed the importance of receiving weekly telephonecalls while on a waitlist to receive counseling. One participant stated,“Just having someone phone up and make sure I was all right and shelet me let some things out. So letting feelings out was good, just tohave that in the meantime before I got into counseling.”

At times, assertive action by the clinician was required to initiatecounseling:

. . . The counselor rang me—he was quite persistent. At the start I wasa bit—sort of—how about give it some time and then I’ll ring you. Thenhe kept calling, so I said “Okay” and I was ready to see someone.

Participants also found that the service’s persistence in maintainingcontact during the early stages of counseling in the face of non-atten-dance or inability to attend appointments, was important to engage-ment. One participant felt the service’s assertiveness was essential,since non-attendance was often a manifestation of the problems forwhich young people present to a mental health service. He stated,“The way I look at it, if people have got it together, the reason they’vegot it together is because they can keep to appointments, and dothings when they’re supposed to do ’em.”


Discussion

Prior research highlights the difficulties clinicians face in engagingyoung people into mental health services (Armbruster & Kazdin,1994; Baruch et al., 1998). Clinicians must consider a disparate arrayof factors that impinge on the young person’s decision to make contactand then to engage in counseling. This research has examined thesalient factors that are facilitators or barriers to engagement from theyoung person’s perspective.

Many of the issues that emerged from this research may seem self-evident. However, if clinicians are experiencing difficulties engagingyoung people, or desire to improve their interactions with them, thenthere is a continuing need to identify what can be done to enhance theprocess of engagement. Hearing the perspective of young people whohave first-hand experience of the process of engagement provides aunique opportunity to improve service delivery.

In the model that was developed (Figure 1), the young person wasvisualized as the focal point in the process of engagement. Impor-tantly, the experience of engaging in a mental health service was qual-itatively different for each participant. Themes emerged which fea-tured strongly for some participants but not for others. One youngperson might be deterred by the perceived stigma or fear of counsel-ing, while another will display a confidence that precludes such fears.A degree of coercion to attend counseling might work for certain peo-ple, yet for others it may have the opposite effect and harden theirresolve not to attend. Some people react warmly to a therapist’s per-sistence in establishing an initial contact, yet others are likely tomaintain their distance and perceive they are being “hassled.” Suchobservations underscore the heterogeneity of the client group evenwhile a service has inclusion criteria that are common across all refer-rals (e.g., at-risk of homelessness). Conceptualizing young people ascentral to the engagement process thus serves as a reminder that ser-vices must modulate to their needs, rather than expecting all youngpeople to conform to engagement practices of a standard type.

The model indicates that even before there has been direct contactwith a mental health service, the individual needs of the young personshould be considered, as beliefs, attitudes and expectations aboutcounseling can influence engagement. For example, when a young per-son is acknowledging difficulties it is important to consider how andby whom counseling is suggested. The current results suggest that the


best person to raise the issue of counseling is someone whom theyoung person trusts and who may be able to enhance the young per-son’s motivation to pursue counseling. For one person this may be afamily member, for another it may be a general practitioner. Havingknowledge of available services or access to information on serviceshas been identified as important for young people who may be consid-ering counseling. Youth-friendly marketing is an example of actionthat can be taken by service providers to improve knowledge and en-courage engagement. Clearly, an important aspect of this is to ensurethat services appear both attractive and accessible.

The three thematic categories of attractiveness, accessibility, andfollow up provide a broad framework for clinicians assisting youngpeople, and within these parameters individual needs and experienceswill vary greatly. However, the overarching theme that was central tothe narratives of all participants, was the desire to “feel understood.”Participants’ feelings of being understood by the counselor stands incontrast to their experience of most other formal and informal rela-tionships. A significant aspect of being understood was the associatedfeeling of not being judged. It seemed that there was an inverse rela-tionship between the young person’s desire to reveal informationabout themselves and the degree to which the therapist was regardedas judgmental. The more judgmental the therapist, the less inclinedthe young person is to reveal significant information about them-selves. Our impression is that, had clients not felt understood, nonewould have proceeded with counseling.

There are, of course, constraints to service delivery, not least ofwhich are determined by the service itself. For example, Le Surf andLynch (1999) discuss the issue of confidentiality and the impact ofdifferences in policy across services. Some services in Australia, suchas psychological services within some schools, are legally required toinform parents of, for example, illicit substance use. Other serviceshave different requirements that may depend on whether the youngperson is judged by the clinician to be a “mature minor.” Most ser-vices, although there are exceptions, have policies that direct clini-cians to break confidentiality, should the young person be assessedto be suicidal or homicidal. These differences in policy can clearly beconfusing for people negotiating mental health or other services. Argu-ably, as Le Surf and Lynch (1999) also assert, the best course of actionis to ensure that clients are fully informed of the limits of confidential-ity and can then make a reasoned decision about engaging in that


service. This principle would apply to all aspects of service deliverywhich may affect a young person’s appraisal and subsequent engage-ment in mental health services.

The themes that emerged also underscore the complex develop-mental period being negotiated by young people. The broad age-spancovered by many adolescent mental health services is a time duringwhich young people are striving for autonomy and individuation fromthe family, and identity issues are heightened (Bandura, 1972). Ingeneral, the interviews illustrated the need for “self-determination,”from the strong belief that counseling had to be “for themselves” tothe insistence on engaging in a service that offered individual counsel-ing. The interviews are a reminder to be aware of differing needs. Oneperson will seek active guidance, while another might want someonejust “to listen.” More broadly, a knowledge of development and assess-ment of an individual’s specific needs will help clinicians make aninformed decision as to whether an individual approach or one thatemphasizes family therapy, or both, is indicated.

Participants in this study are likely to be more marginalized, orperhaps have more complex problems, than young people accessingmainstream mental health services. Consideration should thereforebe given to how the samples might differ. We would argue that theneed for “assertive follow-up” is the most distinctive difference in apopulation that is frequently disconnected from parental and othersupport that might facilitate appointment-keeping. Under these con-ditions a clinician’s actions in tracking the young person is likely tobe critical. Nicol et al. (2000) outline the extent of mental health prob-lems amongst a marginalized (offending) population of young people.Nicol et al. conclude that mental health service initiatives that employ“rigorous follow up” are the ones most likely to be successful in engag-ing marginalized young people (p. 260). This finding was supported bythe current results, which emphasized the importance of follow up toyoung people, including sensitive action taken by clinicians to initiateand maintain contact.

With even the “best” of services it is unrealistic to expect a 100%rate of engagement. Young people may choose not to engage, or toterminate treatment for a number of reasons that are unrelated to thequality of assistance provided by a mental health service. For exam-ple, they may feel coerced, they may not identify they have a problem,or they may feel that their problems have been resolved. Cliniciansmay believe that clients have terminated treatment before problemshave been fully addressed. However, it should be remembered that,


regardless of whether clients choose to engage at that particular time,a sensitive response to their needs will lay the foundation for theirwillingness to return to counseling in the future.

Conclusion

This research has highlighted the many complex and interrelated fac-tors that are salient for young people that can either help or hinderthe process of engagement. As clinicians it is possible to maximizerates of engagement of young people into mental health services byunderstanding this complexity. However, the complexity of the pro-cess and the differing needs and preferences of young people indicatethat rigid and prescriptive practices are limited in their clinical util-ity. Instead, it demands a vision that holds the young person as cen-tral to the process, and that adopts a flexible approach that listens,understands and modulates to the needs of each individual youngperson.

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Documents

Engaging with a Mental Health Service: Perspectives of At-Risk Youth