This study investigated the willingness of Israeli adolescents to seek help for emotional and health problems, and their preference for various helping agents. Nearly fifteen hundred students in grades 7-12 participated in a comprehensive survey of attitudes, health status, and concerns, and the data were analyzed. Gender and age were identified as factors associated with help-seeking attitudes. Females reported a higher level of distress and greater willingness to seek help than did males. Younger adolescents tended to state that they would turn to parents for help, whereas older adolescents increasingly preferred peers. In general, the adolescents preferred to seek help from family and peers for emotional and social problems, rather than turning to professionals. Adolescents in grades 9-10 reported the highest level of distress and were least willing to seek help for interpersonal problems and depressed mood. Overall, level of distress was not directly related to willingness to seek help. In subgroups of de pressed and suicidal adolescents, an inverse relationship was found between willingness to seek help and levels of depression and suicidal ideation. Recommendations for health care services and counseling programs are discussed.
During the past decade, mental health professionals have increased their interest in studying the physical and emotional well-being of adolescents. Contrary to traditional belief, that adolescence is a period of "storm and stress" (Blos, 1962; Freud, 1958), current research shows that most adolescents do not experience severe turmoil. Nevertheless, the transition from childhood to adulthood entails dramatic developmental changes which impact both adolescents' health and their well-being (Offer et al., 1991).
Recent studies have focused on the needs of the nonclinical adolescent population, in an attempt to define the "normative" stresses in this age group. Larson and Lampman-Petraitis (1989) found an increase in negative affect during adolescence, and suggested that this may be caused by the numerous life changes experienced at this age. Larson and Ham (1993) concluded that adolescence is associated with an increased sensitivity to environmental stressors such as conflict, resulting in higher levels of distress.
There may be cross-cultural differences in adolecents' well-being. Harel et al. (1997) found that Israeli adolescents had higher levels of stress and depressed mood compared with adolescents in 23 countries in Europe and North America. In addition, a higher percentage of the Israeli sample reported physical symptoms.
Several studies have investigated adolescents' willingness to seek help and their actual use of health services for various problems. Although the literature on help seeking is sparse, some consistent findings have emerged. Most studies show that adolescents rarely seek professional help (Millstein & Litt, 1994; Offer et al., 1991; SeiffgeKrenke, 1989; Whitaker et al., 1990), instead preferring informal helping agents such as family or friends (Dunbow et al., 1990; Feldman et al., 1986; Offer et al., 1991). When they do turn to professionals for help, adolescents prefer medical personnel to mental health practitioners, for both physical and emotional problems.
Factors that have been found to be related to help seeking include a high motivation for psychotherapy, a belief in its efficacy (SeiffgeKrenke, 1989), and guaranteed confidentiality (Riggs & Cheng, 1988). Saunders et al. (1994) found that gender was the only demographic variable differentiating students who did and did not perceive themselves as needing help. Females were more likely than males to identify a need for help. Obtaining help was associated with informal help-seeking behavior, socioeconomic status (SES), parental marital status, and having a checkup within the previous year.
Contrary to expectation, help seeking does not seem to be directly related to levels of subjective distress (Keellam et al., 1981). In fact, depressed/suicidal adolescents may be those least likely to obtain help (Saunders et al., 1994). Erlich (1992) claimed that there is no direct relationship between the severity of adolescents' psychopathology or the degree of pain that they experience and their willingness to seek help. Rather, adolescents' developmental phase and their available ego strength determine their willingness to seek help.
Nadler (1991) has presented a model of help seeking that can be used to understand adolescents' behavior. In this model, the process of help seeking is described as an interaction between the characteristics of the person seeking help (self-image, achievement motivation, shyness, self-awareness, and locus of control) and the type of help sought and the identity of the helper. The act of seeking help is an instrumental, target-oriented behavior, like other coping behaviors. However, it entails psychological "costs," such as feeling dependent, inferior, and that one's self-esteem is threatened. The final decision as to whether or not to seek help is a function of all these factors (Nadler, 1991). In adolescence--when conflicts regarding dependence and self-esteem are central--the costs of help seeking may be too high.
The purpose of the present study was to examine the prevalence of emotional and health concerns of Israeli adolescents, and their attitudes towards seeking help. Three questions were addressed: (1) What are the factors that are related to help seeking in Israeli adolescents? (2) Which helping agents do these adolescents prefer? (3) Are there atrisk subgroups that will refrain from seeking help?
The literature on help seeking consists of studies that look at readiness or willingness to seek help (Riggs & Cheng, 1988) versus studies that examine actual help-seeking behavior (Ballasone et al., 1991; McGee et al., 1990; Saunders et al., 1994). The present study examined adolescents' willingness to seek help, a factor that is correlated with actually obtaining help (Seiffge-Krenke, 1989). The problem areas selected were those most frequently reported in studies of adolescents' utilization of telephone hotlines and mental health services in Israel (Gilat, 1993), and also those most frequently reported at our clinic.
Data for this study were drawn from a comprehensive survey of attitudes, health status, and concerns of Israeli adolescents. The survey was conducted during May--June 1993 in four high schools: three in Jerusalem and one in a northern city. The high schools selected were of different types: a school for the arts, two comprehensive schools (which combine regular and technical/vocational programs), and a school offering a regular program. The sample did not include dropouts.
A total of 1,415 adolescents (51% males and 49% females) in grades 1-12 participated in the survey. They were divided into three groups for the statistical analysis: grades 7-8 (15%), mean age = 13.7 years; grades 9-10 (47%), mean age = 15.7 years; and grades 11 (38%), mean age = 17.5 years. In terms of birth order, 41% were first born, 29% were second, 18% were third, and 12% were fourth or later. In regard to country of origin, 89% were Israeli born, 7% were Russian born, and 4% were from other countries. Regarding religious affiliation, 69% were secular, 28% observant Jews, and 3% religious. Eighty-six percent of their parents were married, 8% divorced, 2% separated, 2% remarried, and 2% widowed; 44% had a college education, 47% were high school graduates, and 9% had an elementary school education; 85% of the fathers and 64% of the mothers worked full-time.
The self-report questionnaire consisted of 216 items, covering the following areas: sociodemographic background, achievement, sexuality, mandatory army service, relationship with parents, peer relations, stress and anxiety, health problems, risk-taking behavior, birth control, physical and sexual abuse, suicidality, nutrition habits, and body image. Items were rated on a 4-point Likert-type scale. The questions on help seeking, adapted to the Israeli context, were based on the Minnesota Adolescent Health Survey (Blum et al., 1989).
Emotional distress. These items, which were based on Beck's depression scale (Beck et al., 1961; Beck & Steer, 1987), were borrowed from a questionnaire used for three years in our clinic. Two multiple-choice questions were used to rate the intensity and frequency of stress or depressed mood experienced in the past month. Students were asked to describe the extent to which they felt stressed or depressed by choosing one of the following response options: (1) rarely, (2) sometimes, (3) most of the time, (4) all the time. Students were identified as distressed if they reported feeling depressed or stressed all or most of the time. The decision to classify students who chose the final two responses as distressed was based on our clinical experience.
Suicidality within the past month was assessed using the following question: At the time you were feeling depressed, did you have thoughts of hurting yourself? Respondents could choose from among the following answers: (1) I did not have any thoughts of hurting myself; (2) I had thoughts about hurting myself, but I had no specific plans; (3) I would hurt myself if I had the chance; (4) I tried to hurt myself. Students who chose the first response option were categorized as nonsuicidal; those who selected either the second or third response options were categorized as having experienced suicidal ideation; and those who chose the fourth response option were categorized as suicide attempters.
Help-seeking attitudes. Students were asked whether they experienced the following emotional and health problems and concerns: family problems, depressed mood, birth control, sexual/physical abuse, drugs/alcohol, social problems, health problems, sexually transmitted diseases, problems with boyfriend/girlfriend, and concerns about mandatory army service. Students were asked to select a preferred helping agent from the following list: parents/family member, friends, and physician, school nurse, school counselor, rabbi, or other professional. They could also select the option of consulting no one for the particular problem.
The researchers administered the questionnaires in students' classrooms, following a brief explanation of the aims of the survey. Students were informed that participation in the survey was voluntary, and they were assured that anonymity and confidentiality would be maintained. The schools were promised a general feedback sheet, presenting a profile of the concerns and attitudes of their students. The statistical analysis in this study consisted of chi-square and t tests, with alpha set at .01. Data processing used Systat software (version 5.03).
Before analyzing students' help-seeking attitudes, the prevalence of various health and emotional concerns was examined according to age and gender. It was found that a higher percentage of females than males reported feeling depressed (34% vs. 16%) and stressed (46% vs. 25%). Females also reported a higher incidence of suicidal ideation than did males (27% vs. 14%). In addition, comparisons with males indicated that females were more concerned about relationships with parents, reported a higher incidence of sexual abuse, had more somatic complaints, and experienced greater dissatisfaction with their weight.
Adolescents' Willingness to Seek Help
In general, students reported that they were willing to seek help for various emotional and physical problems (Table 1). Race, SES, parental marital status, father's level of education, and birth order were not significantly associated with willingness to obtain help. However, gender and age were found to play a significant role both in willingness bo seek help and in the selection of helping agents.
Gender Differences in Help Seeking
Females expressed a greater willingness than males to seek help or both emotional and health problems. These differences were most salient for family problems, depressed mood, boy/girlfriend problems, and social problems (p [less than] .01), as can be seen by the differences in the percentages of females and males who stated that they would not seek help from anyone (Table 1).
Age Differences in Help Seeking
As shown in Table 2, younger adolescents tended to express a willingness to seek help from their parents for most problems, whereas the older groups indicated that they would rely somewhat less on parents and more on peers (p [less than] .01). Adolescents in the middle grades were more likely to report that they would not seek help from anyone if they felt depressed (20% in grades 9-10 compared with 17% in grades 7-8 and 16% in grades 11-12) or had social problems (20% in grades 9-10 compared with 13% in grades 7-8 and 18% in grades 11-12). This finding is of particular concern, since students in this age group also reported higher levels of stress and depression compared with other groups.
Preferred Help-Seeking Agents
Although the students reported a willingness to seek help (from family and friends), they were not very willing to seek professional help. Further, they would rather turn to friends than to parents for social or romantic problems, or if they felt depressed. They stated a preference for parents when dealing with family issues, health concerns, or abuse. In addition, the family was clearly preferred by Israeli adolescents as a source of information and support regarding mandatory army service. When concerns were clearly physical or medical, adolescents were willing to consult a physician and were less likely to consult peers. An exception was the need for information on contraception; both males and females seemed to prefer consulting with friends rather than with a physician on this matter. Overall, females expressed a willingness to turn to peers more often than males did, whereas the opposite was true regarding professional help.
A Group at Risk -- Adolescents Who Refrain from Seeking Help
The survey questions addressed willingness to seek help in hypothetical situations. In order to get closer to identifying actual help-seeking behavior of distressed adolescents, willingness to seek help and preferred helping agents among students who reported feeling depressed (Table 3) or suicidal (Table 4) were examined.
Results indicated that distressed adolescents were not more likely to express a willingness to seek help than were their nondistressed peers. In regard to social problems, a larger percentage of distressed adolescents than nondistressed adolescents reported that they would refrain from seeking help. In terms of preferred helping agents, both distressed and nondistressed adolescents preferred friends to parents (with the exception of nonsuicidal students' willingness to seek help for family problems and nondepressed students' willingness to seek help for depressed mood). However, within the distressed groups, the preference for obtaining help from friends and more salient.
Two factors accounted for differences in seeking help from both professional and nonprofessional agents: gender and age. Females were more willing than males to seek help. This is in accord with previous studies (Saunders et al., 1994; Offer et al., 1991; Millstein & Litt, 1994; Petersen et al., 1991; Riggs & Cheng, 1988), which have found that adolescent females seek therapy more often than do males and report feeling more depressed, anxious, and suicidal. Here, females not only were open to the idea of seeking professional help, but a larger proportion of females than males reported that they had been in therapy or were in therapy at the time of the study (19% vs. 10%, p [less than].01).
One possible explanation may lie in the different ways that males and females express distress. Males tend to express distress through aggression, whereas females are more prone to introspection and the sharing of emotions (Gilligan, 1992). The greater awareness of internal emotional experiences and need for intimacy makes females better candidates for psychotherapy and counseling, as well as informal types of help. Saunders et al. (1994) have suggested that females' greater willingness to seek help stems from their ability and readiness to identify themselves as having a problem. The findings here, which show that females on the whole experience greater distress than do males, point in a similar direction.
As for age-related differences, younger adolescents were more willing to seek help than were older adolescents regarding social and emotional (boy/girlfriend) issues. Students in the middle age group (grades 9-10) deserve special attention. They reported higher levels of stress and were less willing to obtain help for interpersonal problems and depressed mood. Similar findings were reported by Larson and Ham (1993), who noted that the high level of stress in this age group is associated with both external and internal changes (e.g., new school, new relationships, increased sensitivity to conflict). They reported an increase in negative affect between parents and adolescents at this age, which they attribute to the adolescents' growing autonomy and the strengthening of ties to peers.
Adolescents' ability to cope with stress at this age is limited. Although they prefer not to turn to parents, they have not yet developed the inner resources needed to cope on their own. Nor is turning to peers for help always an option for these youngsters. At this age the need to belong is at its highest, and they may fear being perceived as deviant. These distressed adolescents thus may isolate themselves from potential sources of help.
Preference for Helping Agents
In general, the adolescents stated they would seek some kind of help for various problems. However, they clearly preferred family and friends over professional helping agents, which is consistent with finding from previous studies (Offer et al., 1991; Dunbow et al., 1990). Thus, contrary to what many parents may feel, adolescents do perceive them as being a source of support, although there are issues on which adolescents prefer to consult friends. These findings are also consistent with results from another part of the survey, in which adolescents reported a generally satisfactory relationship with their parents.
The younger group generally preferred help from parents, whereas the older group indicated somewhat less reliance on parents and a greater willingness to consult peers. This trend reflects the younger group's heavier dependence on adults, and the older adolescents' efforts to separate from their families. The differences between the younger and older groups were most salient for social and emotional issues. However, regarding health concerns, even the older adolescents preferred to consult their parents.
The preference for friends as helping agents fits adolescents' developmental needs, such as developing autonomy (Blos, 1962). Peers fulfill the important function of providing feedback, which assists adolescents in the process of identity formation (Erikson, 1968) and may enhance self-esteem (Harter, Waters, & Whitesell, 1998). Feedback from friends is particularly useful for social/romantic problems, since friends understand the "social scene" much better than do parents. Parental interest and guidance on these issues may be experienced as irrelevant and intrusive. On other issues, such as health problems, problems in the family, and army service, parents remain an important source of help. Sharing these issues with parents may be experienced as less of a threat to independence than the sharing of "personal do-main" issues, such as social life, romantic involvement, and emotions. The fact that parents were preferred over friends in regard to the issue of mandatory military service reflects the significance o f this experience in the life of the Israeli family.
The finding that adolescents preferred peers to professionals raises important questions about the quality and type of help they receive. Although peers serve as an important source of support, they are not trained to provide help for severe problems. Thus, turning to peers is not always appropriate, and may place adolescents at risk. The adolescents were not asked about their reasons for not seeking professional help; however, there are several possible explanations: (1) adolescents' inability to identify problems for which they can get professional help, and lack of information and skills for getting the help they need; (2) concerns about confidentiality and a need for privacy (Gans et al., 1991); (3) seeking help confirms the sense that there is a "problem," which arouses shame, embarrassment, and anxiety, particularly when it is an emotional problem.
Another obstacle to help seeking may be the adolescents' perceptions that professionals cannot provide them with the help they need. Several studies have shown that health care providers may lack knowledge and skills pertaining to adolescent medicine and that they are often unaware of adolescents' particular needs (Blum & Bearinger, 1990; Joffe & Radius, 1991). Figueroa et al. (1991) examined the attitudes of medical residents toward adolescents and found that adolescents were perceived as dishonest and noncompliant, which made it difficult for residents to understand them or work with them. Kuhl, Jarkon-Horlick, and Morrissey (1997) found that the central barrier to help seeking was perceiving family, friends, and self as sufficient to deal with problems. The least significant barriers were stigma, confidentiality, and affordability.
An interesting finding in the present study was that only a small percentage of adolescents reported that they would turn to school counselors for help. The reasons for this are not clear, and may be related to the difficulty of maintaining confidentiality within the school system (Cromer, 1992). A recurrent complaint expressed by adolescents at our clinic was that information in the school system tends to "leak" to teachers and administrative staff, making them feel insecure about discussing personal issues with the counselors. Another problem that we identified in our consultation work with high schools pertains to a role conflict encountered by school counselors: whether to focus only on the identification of adolescents in distress or to provide treatment. The ambiguity of their role may confuse students about the kind of help they can get from the counselors.
Adolescents at Risk
Two at-risk subgroups were identified. One group consisted of students in the middle grades (9-10) who reported a higher level of stress and depression compared with students in the other grades. The second group consisted of students from all age groups who experienced high levels of stress and depressed mood, and who reported that they were not likely to seek any kind of help. Offer and Schonert-Reichl (1992) and Saunders et al. (1994) also reported an inverse relationship between level of distress and help seeking. It seems that adolescents who are depressed and/or suicidal find it difficult to see a way out of their situation, and cannot believe that help is possible. Saunders et al. (1994) differentiated between identifying a need for help and actually obtaining help. They found that suicidal adolescents identified themselves as having problems, but did not seek any help. They hypothesized that depressed adolescents suffer from a variety of psychiatric disorders, which makes it difficult for potential h elpers to create an alliance with them.
Offer and Schonert-Reichl (1992) suggested that obtaining help is an interactive process: adolescents signal their distress and people in the environment (parents, peers) encourage them to obtain additional help. In the case of depressed adolescents, distress is turned inward, making their signals less apparent and thus less likely to elicit a response. The lack of response leaves these depressed adolescents isolated and perhaps further discouraged. When depressed or suicidal adolescents do seek help, they often prefer peers, who are not qualified to deal effectively with such serious problems.
There are several factors that limited the generalizability of these results. First, the sample did not include those who had dropped out of school. Dropouts may be at higher risk, with even less willingness to obtain help. Second, adolescents were not asked about their reasons for refraining from help seeking, a question that would have increased our understanding of their behavior. Third, adolescents' willingness to seek help (i.e., attitudes) was investigated, rather than actual help seeking. The rationale was that a positive attitude is the first step toward actively seeking help. Despite these limitations, the results of this study lead to several recommendations.
1. Since peers are often the preferred helping agent, they should receive appropriate training. Such training would include identifying signs of distress and means 0! obtaining professional help. For example, a suicide prevention program conducted in Israeli high schools (Ayalon & Lahad, 1992) has trained adolescents to recognize signs of depression and suicidality in their friends, and refer them for professional help. In addition, adolescents can be educated about professional help and the importance of encouraging their troubled friends to seek such help. Another program involved the use of a school-based peer support group for adolescents ages 14-19 with mild emotional problems (Wassef, Ingham, Collins, & Mason, 1995). The group was facilitated by adults who were not mental health workers, and focused on a variety of social and emotional issues. The group sessions helped adolescents find new ways to deal with problems, alleviate stress, and increase self-esteem.
2. In order to help students in the middle grades (9-10), school counselors can initiate workshops with parents and teachers, alerting them to signs of depression and educating them about help seeking. It is also recommended that more peer-based programs be implemented with this age group.
3. On a larger scale, it is recommended that training of health care providers be tailored to the particular needs of adolescents. This includes instruction not only about typical disorders (e.g., depression, drug use, eating disorders), but also about adolescent psychology and the process of getting into treatment. They should learn to deal with initial rejection of help and denial of distress, occasional "no shows," and problems of compliance. Greater willingness and readiness to work with this population will increase health care providers' credibility in the eyes of adolescents.
4. Further research is required to understand the help-seeking attitudes of clinical populations (who have sought help) and their expectations from treatment. Differences in attitudes toward help seeking, and in level of distress, between adolescents who are in treatment and those who are not should be examined.
Orya Tishby, Miriam Turel, Omer Gumpel, Uri Pinus, Shlomit Ben Lavy, Miriam Winokour, and Semi Sznajderman, TAFNIT--Jerusalem Institute for Adolescents, Jerusalem, Israel.
Reprint requests to Miriam Turel, TAFNIT--Jerusalem Institute for Adolescents, P.O. Box 3813, Jerusalem 91037, Israel.
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Willingness to Seek Help, by Gender
and Preferred Helping Agent
Problem Parent/Family Friend Professional No One
Males 53% 25% 5% 17%
Females 45% 41% 3% 11%
Males 30% 46% 2% 22%
Females 23% 60% 3% 14%
Males 23% 57% 3% 17%
Females 27% 61% 2% 10%
Males 28% 40% 11% 21%
Females 35% 43% 8% 14%
Males 63% 21% 4% 12%
Females 59% 28% 5% 8%
Males 42% 26% 17% 15%
Females 41% 35% 12% 12%
Males 42% 19% 24% 15%
Females 59% 20% 12% 9%
Males 56% 4% 36% 4%
Females 73% 1% 24% 1%
Males 21% 37% 23% 19%
Females 36% 27% 25% 12%
Males 31% 11% 48% 11%
Females 43% 12% 38% 7%
Note. Differences between genders were
significant (p[less than].01); n = 692
for males, n = 658 for females.
Willingness to seek Help, by Age
and Preffered Helping Agent
Problem Parent/Family Friend Professional No One
Grades 7 - 8 54% 21% 6% 19%
Grades 9 - 10 48% 32% 4% 15%
Grades 11 - 12 48% 37% 4% 11%
Grades7 - 8 36% 41% 5% 17%
Grades 9 - 10 28% 50% 2% 20%
Grades 11 - 12 23% 61% 1% 16%
Grades 7 - 8 32% 52% 6% 9%
Grades 9 - 10 29% 53% 3% 17%
Grades 11 - 12 17% 69% 3% 11%
Grades 7 - 8 41% 32% 14% 13%
Grades 9 - 10 32% 39% 9% 20%
Grades 11 - 12 27% 48% 7% 18%
Grades 7 - 8 70% 14% 2% 14%
Grades 9 - 10 64% 21% 4% 10%
Grades 11 - 12 54% 32% 6% 7%
Grades 7 - 8 49% 18% 17% 16%
Grades 9 - 10 42% 32% 14% 11%
Grades 11 - 12 36% 34% 14% 15%
Grades 7 - 8 55% 12% 24% 12%
Grades 9 - 10 50% 22% 16% 12%
Grades 11 - 12 50% 19% 18% 12%
Grades 7 - 8 63% 1% 35% 2%
Grades 9 - 10 66% 3% 30% 2%
Grades 11 - 12 66% 2% 29% 3%
Grades 7 - 8 27% 30% 23% 20%
Grades 9 - 10 30% 32% 23% 17%
Grades 11 - 12 29% 33% 26% 13%
Grades 7 - 8 40% 11% 39% 11%
Grades 9 - 10 36% 12% 41% 10%
Grades 11 - 12 38% 11% 43% 7%
Note: Differences between age group were significant (p [less than]
.01) except for sexual/physical abuse and veneral diseases; n = 192
grades 7 - 8, n = 600 for grades 9 - 10, n = 99 for grades 11 - 12.
Willingness to Seek Help, by Depression
Level and Preferred Helping Agent
Problem Parent/Family Friend Professional No One
Nondepressed 30% 51% 1% 18%
Depressed 19% 59% 4% 18%
Nondepressed 53% 31% 3% 13%
Depressed 37% 39% 7% 17%
Nondepressed 32% 42% 9% 17%
Depressed 28% 39% 10% 23%
Nondepressed 26% 58% 3% 13%
Depressed 21% 61% 3% 15%
Note. Differences between nondepressed and depressed groups were
significant (p [less than] .01); n = 941 for nondepressed, n = 324
Willingness to Seek Help, by Suicidality
and Preferred Helping Agent
Problem Parent/Family Friend Professional No One
Nonsuicidal 53% 29% 6% 14%
Ideation 34% 43% 4% 17%
Attempters 34% 45% 0% 21%
Nonsuicidal 31% 52% 1% 16%
Ideation 15% 60% 1% 22%
Attempters 10% 45% 0% 45%
Nonsuicidal 32% 42% 9% 17%
Ideation 31% 40% 9% 20%
Attempters 18% 36% 11% 36%
Nonsuicidal 26% 58% 3% 13%
Ideation 24% 60% 2% 14%
Attempters 14% 57% 4% 25%
Note. Differences between suicide
groups were significant (p[less than]
.01; n = 977 for nonsuicidal, n = 259
for ideation, n = 29 for attempters.