Perspectives on help-negation Dr Coralie Wilson cwilson@uow.edu.au Illawarra Health and Medical Research Institute & Graduate School of Medicine University of Wollongong
Presentation abstract Help-negation refers to the process of help avoidance or refusal that commonly occurs in clinical and non-clinical samples with varying forms and levels of psychological symptoms. In the last decade the effect has been established as an inverse relationship between the severity of symptoms and help-seeking for suicidal ideation, depression, and general psychological distress, for a variety of professional and non-professional help sources [see Wilson CJ, Bushnell JA, Caputi P. Early Intervention in Psychiatry, 2011; 5: 34-39, for a review]. Findings from now over 20 help-negation studies suggest that at least some types of psychological symptoms or processes associated with the development of specific symptom-types act as significant barriers to help-seeking. They also raise important implications for our future prevention initiatives and policies that rely on proactively seeking and accessing help. How successful can we expect future initiatives to be if a consequence of experiencing psychological distress, even in its very early stages of development, is a tendency to withdraw from specific helping opportunities or to avoid help altogether? Internationally, help-negation research has moved from establishing the help-negation phenomenon to a new phase of investigation. The new phase aims to identify the determinants of help-negation for a range of psychiatric and medical illness or disease symptoms, together with the cognitive, affective, behavioural, neurological and social variables underpinning and strengthening the help-negation process. Projects currently running and under development in my team's helpseeking research program examine help-negation in relation to a broad range of symptoms, in clinical and community samples with different demographical variables, and answer the following questions: What are the patterns of help-negation for different psychiatric and physical symptoms of illness/disease? What are the correlates and determinants of help-negation? What are the neurological and neuropsychological mechanisms involved in help-negation? What is the role of social networks in help-negation? What is the best way to inoculate different groups against help-negation? What are the implications for national and international policy? This paper describes emerging results from this new phase of help-negation research, and proposes directions for future research, prevention, intervention, and policy. 2
What is help-negation? First described as: the unique pattern shown by acutely suicidal clients who have reached a state of utter hopelessness concerning treatment, [to] soundlessly abandon, politely terminate, or angrily reject treatment Clark & Fawcett 1992 p40 Defined as: the process of help withdrawal or avoidance found among those currently experiencing clinical and subclinical levels of different forms of psychological distress Wilson et al EIP 2011 3
Why focus on help-negation and helpseeking? Help-seeking is a generic protective factor Receiving appropriate help early can protect against developing serious mental disorders, and suicidal thinking Rickwood et al MJA 2007 4
Understanding the determinants of the helpnegation process provides a potent opportunity to target intervention strategies that successfully facilitate appropriate and timely help-seeking 5
Samples Adolescents War veterans / refugees Emerging adults Teachers* Healthy adults Patients with a diagnosis Patients without a diagnosis 6
Across samples: 20 studies 2000-2012 Symptoms ranged from low intensity to clinically relevant; majority of participants reported low symptom levels Consistent pattern of reluctance to seek help as symptom levels increase 7
Example I: Adolescents, mean age 15 years Intention-type Symptomtype Friends/ Family MH Professional Would not seek help Combined n Published studies Suicidal thinking -.37 *** -.26 ***.30 *** 859 JClinPsyc 2005 JOYA 2010a Depression -.27 *** -.10 **.21 *** 1497 ClinPsyc 2007 General distress NA -.09 *.30 *** 688 JOYA 2010a YSA 2011 *** Averaged Correlation p<.001, ** p<.01, * p<.05 8
Example II: Young adults, mean age 20 years Intention-type Symptomtype Friends/ Family MH Professional Would not seek help Combined n Published studies Suicidal thinking -.31 *** -.18 ***.30 *** 713 JClinPsyc 2001 JOYA 2010b Depression -.27 *** -.10 **.21 *** 350 ClinPsyc 2007 General distress -.20 *.03.34 *** 109 AMH 2010 *** Averaged Correlation p<.001, ** p<.05, * p<.05 9
Intention-type Hypothesis tested Is help-negation for suicidal thinking explained by: Friends/ Family MH Prof No help # Published studies: Year Sex? no no no 5: 2001-2010 Religious affiliation? no no no 1: 2005 Prior help? no no no 2: 2001-2005 No current desire for help? no no no 1: 2010 Hopelessness? no no no 4: 2001-2010 Depression and/or anxiety symptoms? no no no 1: 2010 General psychological distress symptoms? no no no 1: 2010 Attitudes towards counselling? no no no 1: 2005 Treatment fears and need for autonomy? no YES no 1: 2005 10
Recent results among young adults 11
Case-controlled sample I: Wilson Caputi et al 2012a First year health students (regional NSW) 2010 2000 Total sample 630 630 Male: Female 1:3 1:3 Age range 18-50 years 18-50 years 18-20 years 70% 70% 21-24 years 18% 18% 25-50 years 12% 12% Age Mean (Standard Deviation) Cultural affiliation European / Australian 20.94 (5.16) years 21.39 (5.77) years 91% 98% 12
Summary: Logistic regression analyses with current suicidal ideation level predicting intention to seek help for suicidal thoughts INTENTION 2010 2000 Friends and family no*** no*** Mental health professional / Telephone crisis line no*** no** no** no** Not seek help from anyone yes*** yes*** ***Odds Ratios within 95% Confidence Intervals, p<.001, ** p<.01; adjusted for age 13
Results suggest help-negation for suicidal thoughts has not changed among university students in the last decade! Adjusting for depression made no significant difference to the pattern of results To what extent is this pattern driven by sex? 14
Case-controlled sample II^: Wilson Caputi et al 2012b First year health students (regional NSW) Male Female Total sample 180 180 Age range 18-50 years 18-50 years 18-20 years 70% 70% 21-24 years 18% 18% 25-50 years 12% 12% Age Mean (Standard Deviation) Cultural affiliation European / Australian ^Subset of Case-matched sample I 20.94 (5.16) years 21.39 (5.77) years 91% 98% 15
Summary: Logistic Regressions with current symptom levels predicting intention to seek help for the matching symptomtype; male group INTENTION Stress Anxiety Depression Suicidal ideation Friends and family yes no no* no** Mental health professional / Telephone helpline yes yes no* yes no** no** no no* Not seek help from anyone yes yes*** yes** yes*** ***Odds Ratios within 95% Confidence Intervals, p<.001, **p<.01, *p<.05 ; adjusted for age and need for autonomy 16
Summary: Logistic Regressions with current symptom levels predicting intention to seek help for the matching symptomtype; female group INTENTION Stress Anxiety Depression Suicidal ideation Friends and family no** no no** no*** Mental health professional / Telephone helpline no yes no yes no* no* no*** no* Not seek help from anyone yes** yes yes** yes ***Odds Ratios within 95% Confidence Intervals, p<.001, **p<.01, *p<.05; adjusted for age and need for autonomy 17
Differences between males and females in the pattern of results INTENTION Stress Anxiety Depression Suicidal ideation Friends and family YES no no no Mental health professional / Telephone helpline YES no no no no no no no Not seek help from anyone no no no no Males intended to seek help for stress; females did not 18
Results across help-negation studies suggest: Help-negation occurs with low intensity symptoms of common mental disorders and suicidal thinking Patterns of help-negation different for arousal symptoms vs depression and suicidal ideation Little difference in patterns of help-negation for males vs females 19
Across help-negation studies for suicidal ideation: Help-negation process appears to relatively stable Help-negation process is stronger for friends and family than mental health professionals; this has not changed in 10 years Association between symptoms and intentions to not seek help from anyone remains moderate and significant; this has not changed in 10 years 20
Biological and neurological underpinnings are implicated (+ social and cognitive factors) 21
Implications for suicide prevention and early intervention: Prominent help-seeking barriers must be addressed and helpseeking must be promoted simultaneously across interpersonal and individual domains Elevated distress and low help-seeking intention are prominent barriers Key domains are: families and friends health care professionals (GPs and mental health specialists) individuals themselves Wilson et al EIP 2011 22
Strategies to address prominent barriers: Increase emotional and mental health literacy; address negative beliefs about the help-seeking process (including negative perception of social support) Increase knowledge of the help-negation process Target low help-seeking intentions; increase help-seeking and giving skills Wilson et al EIP 2011 23
Interventions that use these strategies must: Focus on developing integrity in delivery Focus on developing sustainable delivery methods Focus on ways to prepare and motivate contexts for delivery Rigorous research including longitudinal trials, must match design to context 24
In my view Mental health policy must be based on translational research that simultaneously identifies the bio-psychosocial determinants of the help-negation process; help-negation research provides opportunity for improved prevention, early intervention, and health service development 25
Questions? Thanks for your attention Contact: cwilson@uow.edu.au 26