Adolescents' help-seeking behaviour - Semantic Scholar

Journal of Adolescence 2000, 23, 721–740 doi:10.1006/jado.2000.0355, available online at http://www.idealibrary.com on

Adolescents’ help-seeking behaviour: the difference between self- and other-referral AMIRAM RAVIV, RACHEL SILLS, ALONA RAVIV AND PAMELA WILANSKY This study examines the difference between adolescents’ willingness to seek help for themselves and their willingness to refer others for help. Participants were 512 Israeli adolescents (219 males, 293 females) in grade 10. Adolescents’ willingness to seek help from five sources was evaluated with respect to themselves and others, for both severe and minor problems. Adolescents were more willing to refer another person than themselves to most of the sources of support. Differences were more pronounced for severe problems and referrals to psychologists, school counsellors and teachers. Girls were more willing than boys to seek help from their parents and friends. Actual helpseeking behaviour was positively related to willingness to seek help from various sources of support. The results are discussed with reference to the threat to self mechanism and other costs. # 2000 The Association for Professionals in Services for Adolescents

Introduction Adolescence is a complex transitional phase fraught with confusion and the search for identity (Erikson, 1968; Harter, 1990). It is also a time of increased sensitivity and vulnerability, frequently accompanied by feelings of sadness, helplessness and depression (Dubow, et al., 1990; Kazdin, 1990; Larson and Ham, 1993; Offer et al., 1984; Windle, 1992). During this transitional period, adolescents must cope by acquiring skills to help them maintain their mental health (Hauser and Bowlds, 1990; Offer et al., 1991; Offer et al., 1984; Offer and Schonert-Reichl, 1992; Schonert-Reichl and Muller, 1996). Some adolescents experience depressive moods, a high level of tension and psychosomatic pains (e.g. Schoenback et al., 1980). The seeking of help and the utilization of support systems by adolescents have a buffering effect on reactions to stress, resulting in better adjustment and less emotional and behavioural problems (Cauce et al., 1994; Dubois et al.,1994; Ebata and Moos, 1991; Newcomb and Bentler, 1988; Schonert-Reichl and Muller, 1996; Windle, 1992). Nonetheless, adolescents do not often utilize communal support systems in general, nor professional help in particular (Dubow et al., 1990; Garland and Zigler, 1994; Millstein and Litt, 1990; Offer et al., 1984; Whitaker et al., 1990). Even when suffering from depression, drug abuse and other psychiatric disorders, adolescents often forgo help. Since the failure to seek help when necessary is considered to be an inefficient method of coping (Masterson, 1967), it is important to investigate in greater detail what prevents adolescents from seeking help. The gap created when those who need help do not receive it has been conceptualized as a service gap (Kushner and Sher, 1991; Stefl and Prosperi, 1985). The emergence of a service gap is commonly explained to be the result of a threat to the self which is believed to incur psychological costs that hinder help-seeking behaviour (Amato and Saunders, 1985; Nadler, 1986, 1987, 1991, 1997; Nadler and Fisher, 1986). Reprint requests and correspondence should be addressed to: Amiram Raviv, Department of Psychology, Tel Aviv University, Ramat Aviv, Israel 69978 (E-mail: [email protected]). 0140-1971/00/060721+20$3500/0

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There are several variables that affect help-seeking behaviour by imposing a threat to their self, such as the ego-centricity of the problem, self-esteem and feelings of inferiority and dependence (Nadler, 1986, 1987, 1991, 1997). Literature on help-seeking behaviour in general and the service gap, in particular, has mostly been based on adult sample populations (Boldero and Fallon, 1995). We suggest that a similar mechanism is at work in the helpseeking behaviour of adolescents (Whitaker et al., 1990). Therefore, referring a friend for help is a less threatening experience because the problem is less central to the adolescent’s ego. Since the problem ‘‘belongs’’ to another adolescent, seeking help for a friend does not trigger a sense of weakness and inferiority, as would have occurred had they sought help for a similar problem for themselves. Consequently, adolescents who refer another person for help may distance the problem from themselves by using the mechanism of projection. By projecting, adolescents express something about their own need for help without risking a threat to their self. Moreover, other mechanisms may be involved in this process, such as identification and empathy with the person in need. Furthermore, the adolescent’s referral of another person for help may reflect their belief in the ability of the source to help the person in need, independent of the adolescent’s personal need for help. Therefore, by measuring adolescents’ willingness to refer another for help, we receive some indication of the adolescent’s need for help while not hindered by threats to the self. This study attempts to measure the gap between adolescents’ willingness to seek help for themselves and their willingness to refer another adolescent for help. Another aim of this study is to examine how the commonly investigated variables affecting adolescents’ help-seeking behaviour influence their willingness to seek help when the threat to self is reduced. Such variables are, for instance, the source of support (e.g. Dolan, 1991; Gilat, 1993), gender (e.g. Garland and Zigler, 1994), severity of the problem (e.g. Wills, 1983) and self-image (Dubois et al., 1994). One of the central factors influencing adolescents’ help-seeking behaviour is the source of support from which help is sought. Adolescents prefer to seek help from informal sources, such as family and friends, than from formal sources, such as teachers, physicians, psychologists and school counsellors (Dolan, 1991; Dubow et al., 1990; Freidman, 1989; Gilat, 1993; Ney and Herron, 1985; Offer et al., 1991; Veroff, 1981). Despite the stereotype of conflictual and estranged relationships between adolescents and their parents, parents remain a dominant and positive source of help for adolescents (B. B. Brown, 1990; Levitt et al., 1993; Offer et al., 1992; Schonert-Reichl and Muller, 1996; Steinberg, 1990; Wintre et al., 1988). Adolescents may prefer to seek help from informal sources since the format of help usually sought is of a casual nature and thus they do not conceive this kind of help as an act of ‘‘seeking help’’. Additionally, adolescents may feel that someone close and familiar is more likely to understand their needs and will continue to value them despite their display of weakness (Coyne and Bolger, 1990; Wills, 1991). Seeking help from informal sources may be a less threatening experience to the adolescent’s self than seeking help from formal sources. Adolescents’ help-seeking behaviour is also gender dependent, such that girls seek and receive help more than boys (Dubow et al., 1990; Garland and Zigler, 1994; Schonert-Reichl and Muller, 1996). Explanations for this gender difference focus on sex-typed behaviour. Research mainly using adult populations indicate that women are presumed to be more comfortable reporting and seeking help for their problems since help-seeking behaviour is considered to be a dependent, interpersonal behaviour consistent with traditionally feminine sex-roles (Archer, 1996; Gross and McMullen, 1983; Nadler, 1997).

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The area of problem severity was also studied using mainly adult populations. The severity of the problem in question also affects help-seeking behaviour (Fischer et al., 1983; Veroff, 1981; Wills, 1983). Minor problems are related to limited help-seeking, since the costs usually outweigh the benefit of seeking help (Wills, 1983). Usually, for minor problems, informational and instrumental help is mainly sought. In contrast, the more serious the problem, the greater the likelihood that help is sought from formal sources (Fischer et al., 1983; Wills, 1983). Similarly, for very serious problems, as symptoms increase, more help is sought from professional sources in general, and from psychologists in particular (Veroff, 1981; Wills, 1983). Accordingly, while considering the costs (i.e. social stigma and impaired self-esteem) and benefits (i.e. coping and recovery) of seeking help, adolescents may conclude that the costs outweigh the benefits when seeking help for minor problems, whereas the benefits outweigh the costs for more serious problems. Self-image is an important personality factor modifying the help-seeking behaviour of adults and adolescents (Dubois et al., 1994; Hoffman et al., 1993; Roehrle and Sommer, 1994). However, the direction of the relationship between self-image and help-seeking behaviour is still a grounds for argument (Bramel, 1968; Tessler and Schwartz, 1972). According to the vulnerability hypothesis, people with a more positive self-image are less vulnerable to a threat to their self-esteem and less affected by negative feedback about themselves. Seeking help, therefore, does not pose as much of a threat to their self-esteem. As a result, people with a more positive self-image are expected to seek assistance more often than people with a lower self-image. In contrast, the consistency hypothesis proposes that people are interested in receiving feedback about themselves that is consistent with their self-cognitions (Tessler and Schwartz, 1972). Thus, people with higher self-esteem are less likely to seek help than people with lower self-esteem since admitting need is inconsistent with their self-image. Much of the research on the relationship between self-image and helpseeking attitudes and behaviours supports the consistency hypothesis (Miller, 1985; Nadler, 1986, 1987, 1991, 1997). In the present study, the threat to self was manipulated by asking adolescents to refer another adolescent for help, reducing the threat to self and leaving their self-image intact. In sum, the present study has a unique design in that it compares the difference between the adolescents’ willingness to seek help for themselves to their willingness to seek help for a peer. We hypothesize that adolescents will be more willing to refer another adolescent for help than to seek help for themselves. Interactions are also predicted between type of referral (self or other), source of help, severity of problem and respondents’ gender and self-image. Since a relationship between attitude and behaviour has been found in general, and between help-seeking attitudes and behaviours in particular (Eagly and Chaiken, 1993; Efod, 1992; Wilansky et al., 1999), adolescents’ willingness to seek help is expected to be related to their help-seeking behaviour.

Method Participants Five-hundred and twelve Israeli adolescents (219 males, 293 females) participated in this study. All participants were in grade 10 (mean age=15?8, S.D.=0?5) and from three different high schools in the greater Tel Aviv area. The participants were from middle class families and their parents’ education was slightly higher than the average population’s education level (Statistical Abstracts of Israel, 1996).

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Instruments Demographic information. The participants were asked to indicate their gender and age, as well as their parents’ education and marital status. Willingness to seek help. The participants received two scenarios of varying severity, i.e. minor or severe. One scenario dealt with a minor problem of romantic separation, i.e. ‘‘Until recently [Danny] was an ordinary teenager. In recent months, he has fallen in love with a girl in his class who has not returned his affection. Since then, he has appeared sad, tense and bored.’’ The other scenario dealt with a severe emotional problem, i.e., ‘‘Until recently [Ori] was an ordinary teenager. During the last few weeks, for no apparent reason, he has become remote, very depressed and does not appear to enjoy anything. Moreover, he has been over-sleeping and has lost a great deal of weight.’’ The two situations were developed by three experienced clinical psychologists and validated in a pilot study (Wilansky et al., 1999). Participants received either a self-referral or referral of other version. Both the self and other versions contained the aforementioned two scenarios that also varied according to the target’s gender, i.e. male (Danny and Ori) or female (Danna and Orit). In other words, participants received one of four possible forms that consisted of both a minor and severe problem, i.e. self-referral male target, self-referral female target, referral of other male target or referral of other female target. The number of participants who responded to each version of the questionnaire is presented in Table 1. For each form, participants were asked to indicate the degree to which they would be willing to seek help (for themselves or others) from the following five sources: friend, parent, psychologist, school counsellor and teacher. These sources were chosen based upon the helpseeking literature (Cauce et al., 1982; Offer and Schonert-Reichl, 1992; Schonert-Reichl et al., 1995; Wills, 1991; Windle et al., 1991) and a pilot study (Wilansky et al., 1999). The pilot study had a similar design and was conducted with 360 Israeli adolescents (mean age=14?0 years). In the pilot study, a factor analysis of 11 sources of help revealed three main categories of sources of help, i.e. natural, professional and anonymous. Among these sources, friends, parents, psychologists, school counsellors and teachers were the ones to which adolescents most frequently turned for help. The referral of other version determined adolescents’ willingness to refer another adolescent for help. After each scenario, the adolescents were asked: ‘‘To what degree would you advise [Danny] to turn to each source?’’ The self-referral version determined the adolescents’ willingness to seek help for themselves. After each scenario, the adolescents were asked: ‘‘If you encountered a similar situation, to what degree would you consult with each source?’’ The degree of willingness to seek help for each source ranged from 1, indicating definitely would not to 4, indicating definitely would. Table 1

Participants by version, gender, and target’s gender Other-referral

Male target Female target Total

Self-referral

Boys

Girls

Boys

Girls

Total

53 48 101

73 69 142

64 54 118

74 77 151

264 248 512


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The two versions were administered to two independent samples (between design), in order to avoid the influence of one version on the other (self vs. other referral).

Self-image. Adolescents’ self-image was measured by the Self-evaluation Questionnaire (Rosenberg, 1965), which was translated and validated in Hebrew (Cohen, 1981). The questionnaire is composed of 10 items, 5 dealing with positive self-evaluations and 5 dealing with negative self-evaluations. Participants were requested to indicate on a 7-point scale the extent to which they agreed or disagreed with the sentence. The participant’s self-image was calculated as the mean of the 10 items. The reliability of the questionnaire in the present study is a=0?86. Validation of the Help-seeking Questionnaire The following variables were assessed in order to validate the Willingness to Seek Help Questionnaire.

Help-seeking behaviour. Adolescents were asked to indicate the extent they sought help from each of the aforementioned five sources of help on a 5-point scale such that 0 indicated never, 1 indicated once, 2 indicated twice, 3 indicated 3 to 4 times and 4 indicated more than 4 times. Self-coping. In order to determine how worthwhile it was for the adolescent to seek help, adolescents were either asked: ‘‘How worthwhile is it for [Danny] to handle his problem by himself, without seeking help?’’ or ‘‘If you had a similar problem to [Danny]’s, how worthwhile would it be to handle the problem by yourself, without seeking help?’’ Responses ranged from 1, indicating definitely not worthwhile to 4, indicating definitely worthwhile. Perceived severity of the problem. In order to determine the perceived severity of the problems described in the scenarios, adolescents were asked: ‘‘How severe does [Danny]’s problem seem to you?’’ Responses range from 1, indicating very minor, to 5, indicating very severe. Psychological benefit. In order to examine the benefit of seeking help from a psychologist, adolescents were asked on the referral of other version: ‘‘How much do you think [Danny] would gain or lose from seeking advice from a psychologist?’’ On the selfreferral version, they were asked: ‘‘If you were in [Danny]’s situation, how much would you lose or gain from seeking advice from a psychologist?’’ The answers ranged from 1, indicating lose to a great extent, to 5, indicating gain to a great extent. Procedure During their homeroom period, participants received randomly one of the four versions of the questionnaire, i.e., self-referral male target, self-referral female target, referral of other male target or referral of other female target was randomly distributed to participants. Adolescents were told that the questionnaires were anonymous and that they dealt with the help-seeking behaviour of adolescents. After their completion, the adolescents were debriefed as to the goals of the study. The researcher then allowed for a brief discussion about the students’ help-seeking behaviour and their attitudes towards psychologists.

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Results Willingness to seek help Although the questionnaires were randomly distributed, the background variables (i.e., gender, parents’ education and marital status) and self-image were analysed for differences between versions. No significant difference was found between versions with respect to these variables. We conducted a 262626265 MANOVA with participant’s gender, referral (self, other) and target’s gender as between subject variables and severity and source as within subject variables. Main effects were found for participant’s gender, F(1,498)=7?12, p50?01, referral, F(1,498)=112?56, p50?01, severity, F(1,498)=440?09, p50?01, and source, F(4,495)=801?96, p50?01. It was found that: (1) girls were more willing than boys to refer themselves and to refer others for help to the sources; (2) adolescents referred others, more often than themselves, for help; and (3) adolescents were more willing to refer themselves and to refer others for help for the severe problem than for the minor problem. The main effect of source will be explained through the following interactions. The relevant means and standard deviations for willingness to seek help by gender and referral are presented in Table 2.

Table 2 Means and standard deviations of willingness to seek help from sources by gender and referral, and results of sources comparisons Other-referral

Minor problem Friend Parents Psychologist Counsellor Teacher Severe problem Friend Parents Psychologist Counsellor Teacher

Self-referral

Boys (n = 101)

Girls (n = 139)

Total (n = 240)

Boys (n = 118)

Girls (n = 148)

Total (n = 266)

3?60d (0?74) 2?55c (0?89) 1?80b (0?93) 1?66ab (0?90) 1?46a (0?64)

3?78d (0?46) 3?01c (0?85) 1?98b (0?88) 1?81b (0?87) 1?50a (0?69)

3?71

3?46d (0?61) 2?12c (0?87) 1?61b (0?76) 1?36a (0?52) 1?32a (0?52)

3?70d (0?50) 2?55c (0?99) 1?49b (0?69) 1?32ab (0?58) 1?28a (0?55)

3?59

3?19bc (0?95) 3?53c (0?77) 2?78b (1?07) 2?24a (1?12) 2?05a (0?94)

3?58d (0?73) 3?38d (0?80) 3?04c (0?90) 2?49b (1?04) 2?03a (0?91)

3?41

3?23c (0?76) 2?97c (0?88) 2?12b (1?01) 1?92ab (0?93) 1?73a (0?77)

3?43d (0?63) 3?08c (0?97) 2?04b (0?97) 1?58a (0?83) 1?55a (0?70)

3?34

2?81 1?90 1?75 1?48

3?44 2?93 2?38 2?04

2?36 1?54 1?34 1?30

3?03 2?08 1?73 1?63

Means within a column (minor problem and severe problem separately) having the same subscript letter are not significantly different.


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The following two-way interactions were found: participant’s gender by referral, F(1,498)=4?29, p50?05, target’s gender by referral, F(1,498)=8?86, p50?01, participant’s gender by severity, F(1,498)=6?36, p50?05, referral by severity, F(1,498)=17?07, p50?01, participant’s gender by source, F(4,495)=5?90, p50?01, referral by source, F(4,495)=10?30, p50?01, and severity by source, F(4,495)=125?56, p50?01. The following three-way interactions were found: referral by participant’s gender by source, F(4,495)=2?78, p50?05, participant’s gender by severity by source, F(4,495)=8?34, p50?01, and referral by severity by source, F(4,495)=7?46, p50?01. The following four-way interaction was found: participant’s gender by referral by severity by source, F(4,495)=3?17, p50?05. The effect of target’s gender was only found in the two-way interaction with referral, such that for the referral of other version, participants were more willing to refer the female targets than the male targets for help (means are 2?66 and 2?52, respectively), t(238)=2?51, p50?05, whereas no significant difference was found for the self-referral version (means 2.16 and 2.23 for female and male targets, respectively).

Comparison of the Sources of Help In order to explain tendencies of help-seeking toward the different sources of help (because of the four-way interaction between participant’s gender, referral, severity and source), separate comparisons of help seeking from the five sources were conducted. In other words, comparisons between sources were executed for each of the eight combinations of participant’s gender by referral version by problem severity. Comparisons were performed using paired t tests and the Bonferroni method was utilized to control for the family error rate (a=0?05) of the 10 comparisons per combination. The results are presented in Table 2. Regarding the minor problem, adolescents were most willing to refer others and themselves to a friend for help. Next, adolescents were most willing to refer themselves and others to their parents for help. Adolescents were least willing to refer to teachers, counsellors and psychologists for help. However, adolescents were more willing to refer to psychologists than to teachers, whereas they were usually equally likely to refer to teachers and counsellors. In contrast, regarding the severe problem, adolescents were most willing to refer to either a friend or parent, and more willing to refer to a psychologist than to a teacher or counsellor.

Analysis of willingness to seek help from each source Differences in help seeking patterns from each source and an interaction between the source of help and the other independent variables were found. Therefore, 26262 MANOVAs (participant’s gender, referral and severity) were conducted for each source, separately. The significant interactions of these MANOVAs are illustrated in Figure 1. Main effects of referral were found, p50?01, for all the sources except friend, such that adolescents were willing to refer another person more than themselves to a psychologist, counsellor, teacher and their parents. Main effects of severity were found, p50?01, for all the five sources. Adolescents were more willing to refer themselves and to refer others to a friend for help for a minor problem than for a severe problem. In contrast, regarding the other four sources, adolescents were more willing to refer themselves and others to these sources for help for a severe problem than for a minor problem. Main effects of gender were found for both friend and parent sources, p50?01, to which girls were more willing than boys to refer themselves and others.

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Figure 1. Illustration of the effect of participant’s gender, referral, and severity on willingness to seek help from sources. (a) Parents by severity and participant’s gender. (b) Teacher by severity and referral (c) Psychologist by severity and referral (d) Psychologist by referral and participant’s gender (e) Counsellr or by severity, referral, and participant’s gender.

The following interactions were found: (1) For parents, the difference between minor and severe problems was more pronounced for boys than for girls. Girls’ scores were significantly higher than boys’ for a minor problem. No significant difference was found between boys and girls for a severe problem (Figure 1a). (2) For psychologist, the difference between other and self-referral was larger for the severe problem than for the minor problem (Figure 1c), and this difference was also larger for girls than for boys (Figure 1d). Regarding other-referral, girls’ scores were higher than boys’. No significant gender difference was found for self-referral. (3) For teacher, the difference between versions was larger for the severe problem than for the minor problem (Figure 1b). (4) For counsellor, a 3-way interaction of participant’s gender by referral by severity was found. For all four combinations of participant’s gender by referral, adolescents were more willing to refer to a counsellor for severe than for minor problems. The difference between the referral of self and other to a counsellor for both severe and minor problems was larger for girls than for boys (Figure 1e). Gender differences were found (boys referred themselves more than girls) only for self-referral in the case of a severe problem.


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Validation of the Help-seeking Questionnaire The following three questions were asked in order to validate the help-seeking measure: (1) ‘‘How worthwhile would it be for the participants to handle the problem by themselves?’’, i.e. self-coping; (2) ‘‘How much would the participants benefit if they would turn to a psychologist?’’, i.e. psychological benefit; and (3) ‘‘How severe is the problem perceived to be?’’, i.e. perceived severity. The Pearson correlations between the aforementioned questions and willingness to seek help from the five sources are presented in Table 3. In general, the correlations for the referral of other version are higher than for the self-referral version. Although the correlation effects were not strong, the correlations could be interpreted to be a validation of the measure by the following: (1) negative correlations between willingness to seek help and selfcoping, (2) positive correlations between willingness to seek help and perceived severity; and (3) positive correlations between willingness to seek help and psychological benefit (e.g., help-seeking from a psychologist correlates positively with the perceived benefit gained from seeking help from a psychologist). In order to validate the severity of the problems, a 2626262 MANOVA (participant’s gender, referral, target’s gender and severity) was conducted with perceived severity as the dependent variable. It was found that the severe problem was perceived as more severe than the minor problem, F (1,504)=994?48, p50?01 (M=2?53 and 4?00 for minor and severe problems, respectively). Additionally, girls perceived both the minor and severe problems as more severe than the boys (M=2?44 and 2?59 for boys and girls, respectively).

Help-Seeking Behaviour A 265 MANOVA was conducted on help-seeking from the five sources with participant’s gender as a grouping factor. Main effects of participant’s gender, F(1,504)=9?36, p50?01, and source, F(4,501)=873?06, p50?01, were found. An interaction between participant’s Table 3 Pearson correlations between willingness to seek help from sources and the three validation questions Minor problem

Other-referral Friend Parents Psychologist Counsellor Teacher Self-referral Friend Parents Psychologist Counsellor Teacher *p50?05. **p50?01.

Severe problem

Self-coping

Severity

Psychological benefit

Self-coping

Severity

Psychological benefit

70?09 70?14* 70?18** 70?20** 70?10

0?03 0?16* 0?20** 0?16** 0?16*

70?14* 0?19** 0?30** 0?19** 0?05

70?13* 70?13* 70?19** 70?21** 70?09

0?04 0?18** 0?27** 0?26** 0?11

70?01 0?18** 0?28** 0?30 0?23**

70?20** 70?17** 70?05 70?11 70?10

0?12 0?07 0?16** 0?08 0?06

0?12 0?23** 0?25** 0?13* 0?06

70?07 70?04 70?16** 70?02 0?03

0?07 0?02 0?13** 70?02 70?08

0?02 0?04 0?18** 0?05 70?03

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gender and source was also found, F(4,501)=6?43, p50?01. Post hoc comparisons using the Bonferroni method with a=0?05, revealed that girls, more than boys, turn to friends and parents for help. The means and standard deviations of help-seeking behaviour by participant’s gender are presented in Table 4. In order to further validate the help-seeking questionnaire, Spearman rank correlations between willingness to seek help and help-seeking behaviour were computed separately for each of the sources, minor and severe problems, and self- and other-referral versions. These correlations are presented in Table 5. A nonparametric approach was used due to the asymmetric distributions of behaviour scores for several sources. The correlations were found to be relatively high for both friend and parents. The correlations were relatively low, yet significant, for psychologist.

Self-image Overall, the participants’ self-image scores were relatively high (M=5?60, S.D.=1?06). Adolescents’ help-seeking behaviour from a psychologist and from a counsellor correlated negatively with self-image, r(510)=70?125, p50?01, and, r(510)=70?103, p50?05,

Table 4

Means and standard deviations of help-seeking behaviour by participant’s gender

Friend Parents Psychologist Counsellor Teacher Total help

Table 5 sources

Boys (n = 216)

Girls (n = 290)

Total (n = 506)

3?09 (1?29) 2?91 (1?38) 0?20 (0?65) 0?80 (1?07) 1?14 (1?31) 1?64 (0?71)

3?59 (0?89) 3?29 (1?13) 0?26 (0?79) 0?73 (1?00) 1?14 (1?22) 1?80 (0?59)

3?38 (1?11) 3?13 (1?26) 0?24 (0?74) 0?76 (1?03) 1?14 (1?26) 1?73 (0?64)

Spearman correlations between help-seeking behaviour and willingness to seek help from Other-referral

Friend Parents Psychologist Counsellor Teacher *p50?05. **p50?01.

Self-referral

Minor problem

Severe problem

Minor problem

Severe problem

0?39** 0?25** 0?19** 0?22** 0?15*

0?32** 0?30** 0?13* 0?28** 0?31**

0?44** 0?45** 0?18** 0?26** 0?12*

0?37** 0?41** 0?17** 0?31** 0?23**


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respectively. For the self-referral version, self-image correlated positively with willingness to seek help from a parent for a severe problems, r(269)=0?165, p50?01. For the referral of other version, the following correlations between self-image and willingness to seek help were significant: (1) adolescents’ willingness to seek help from a psychologist for a minor problem correlated negatively with self-image, r(243)=70?191, p50?01; (2) adolescents’ willingness to seek help from parents for both minor and severe problems correlated positively with self-image, r(243) =0?147, p50?05, and, r(243)=0?304, p50?01., respectively; and (3) adolescents’ willingness to seek help from a teacher for a severe problem correlated positively with self-image, r(243)=0?201, p50?01.

Discussion The present study explores the issue of the service gap of adolescents by comparing a group of adolescents’ willingness to seek help for themselves to a group of adolescents’ willingness to refer another adolescent for help from various sources (i.e., friends, parents, psychologists, school counsellors and teachers). This difference can be explained by the threat to self and other mechanisms. Gender, severity of the problem and source of help were also investigated for their relevancy to adolescents’ willingness to seek help.

Willingness to seek help for self versus other Generally, adolescents were more willing to refer others for help than to seek help for themselves, for both severe and minor problems. These findings support those of a pilot study examining adolescents’ willingness to seek help for themselves or for a peer (Wilansky et al., 1999). These results can be explained by a threat to self mechanism (Amato and Saunders, 1985; Nadler and Fisher, 1986; Nadler, 1986, 1987, 1991, 1997) since seeking help often implies feelings of need, inferiority and incompetence of the person seeking help (Bellah et al., 1985; Merton, 1968; Nadler, 1986, 1991; Wills, 1983). The threat to self often incurs psychological costs that exceed the benefits of seeking help, and thus inhibits help-seeking behaviour. The perception of a threat to self is alleviated to a great extent when someone else is referred for help, thus explaining the greater ease in referring others in comparison to oneself for similar problems. This difference between self-referral and the referral of another exemplifies a type of service gap. The traditional definition of a service gap is the gap created when those who need help do not receive it (Kushner and Sher, 1991; Stefl and Prosperi, 1985). We suggest that there is an additional aspect to the service gap, namely the personal service gap, i.e., the gap between an adolescent’s willingness to seek help and their less directly expressed need for help, namely, their willingness to refer another for help. We probed this gap by rephrasing traditional help-seeking questions to describe the behaviour of a peer. In responding to these questions, adolescents may have expressed through unconscious processes of projection and identification their own need for help. This method of questioning may allow for a measure that reflects a need for help that might not otherwise have been reported. Comparing adolescents’ willingness to seek help for themselves to their willingness to refer another adolescent for help may be a measure of the personal service gap. Although this gap may be an indication of one’s ‘‘real’’ need, we cannot conclude this based on this study due to its hypothetical nature. Future research may study this issue further in a naturalistic setting.

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An additional explanation for the difference found between the type of referral (self or other) may depend upon contradictory societal pressures. While substantial resources are invested into school programmes encouraging adolescents to seek help, social norms more and less explicitly promote self-reliance and refrain from help-seeking behaviour (Nadler, 1986, 1991; Wills, 1983). These opposing expectations may cause confusion and ambivalence towards seeking help. This ambivalence may be expressed as a more positive attitude towards seeking help for others and a more negative attitude towards seeking help for oneself. Furthermore, it is often easier to give advice to others than it is for oneself to follow similar advice. Since advising others to change their behaviour does not involve the same ‘‘hassles’’ as changing one’s own behaviour, it is often easier to send others for counselling than to send oneself. Finally, the difference between self- and other-referrals may reflect an effect of self-related biases, such as self-enhancement and illusory superiority ( J. D. Brown, 1986, 1990; Hoorens, 1993). For example, adolescents may distort their perception of their relative need for help in order to enhance or maintain their self-esteem. Accordingly, adolescents may have a relatively positive view of themselves and thus conclude that they do not require the same help that others may need. Future research should investigate the relative weights of these explanations in influencing the difference between seeking help for oneself or for a friend.

Willingness to seek help as a function of the source of support Clear differences were found in willingness to seek help from the different sources of support according to the type of referral. As predicted, adolescents preferred referring others for help more than themselves to parents, psychologists, school counsellors and teachers. However, no difference was found when the source of support was a friend. In accordance with the threat to self mechanism, seeking help from a professional incurs emotional costs, such as the acknowledgement of a problem’s existence (Nadler, 1991, 1997). The resulting self-threatening experience often hinders the seeking of help from formal sources such as psychologists. In contrast, seeking help from informal sources is a less threatening experience because of its greater social acceptability (Dolan, 1991; Dubow et al., 1990; Freidman, 1989; Gilat, 1993; Ney and Herron, 1985; Offer et al., 1991; Veroff, 1981; Wills, 1983, 1991). Accordingly, adolescents in the present study were more willing to refer others to formal sources (i.e. psychologists, counsellors and teachers) than they were willing to refer themselves for the same problem. Moreover, adolescents were similarly willing to refer themselves and another person to friends. Perhaps, the feelings and internal reactions related to seeking help do not arise when seeking help from natural sources (Nadler, 1987). Seeking help from a friend allows for reciprocity that minimizes the visibility of the help received, and thus diminishes the self-threatening experience (Kelley et al., 1983; Reis and Shaver, 1987; Snyder and Ingram, 1983; Wills, 1991). Since parents are also an informal source of help, similar results should have been obtained for support from parents as were found for support from peers. However, adolescents were more willing to refer another person to that person’s parents than themselves. This difference implies that seeking help from parents poses a threat to self, and seems to support theories describing a conflictual relationship between parents and their adolescent children (e.g. Blos, 1970; Erikson, 1950, 1959). This relationship often culminates in the adolescent’s need for separation from parental figures and a decreased desire to seek help from their parents. However, in the present study, parents were the next preferred source of help after friends, and they did not differ for the severe problem except for girls in the self referral. This finding


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emphasizes the importance of parents as a source of support for adolescents (Bar-Tal et al., 1991; B. B. Brown, 1990; Levitt et al., 1993; Ran-Gur and Binyamini, 1990; SchonertReichl and Muller, 1996; Wintre et al., 1988) and adolescents’ preference to seek help from informal sources (Dolan, 1991; Dubow et al., 1990; Freidman, 1989; Gilat, 1993; Nadler, 1987; Ney and Herron, 1985; Offer et al., 1991; Veroff, 1981; Wills, 1983, 1991). These seemingly contradictory findings may reflect adolescents’ ambivalence towards their parents. On the one hand, they feel threatened by seeking help from their parents, but on the other, they feel as comfortable seeking help from their parents as they do from their friends. This notion is supported by theorists (e.g. Blos, 1970; Mahler, 1963) who view adolescence as a period of ambivalence marked by a need for both separation from and dependence upon parents. Seeking help from a psychologist was of special interest because of the importance of psychological assistance in times of crisis. Adolescents’ willingness to seek help from a psychologist for themselves and others was dependent upon the perceived severity of the problem. Additionally, willingness to seek psychological help was negatively related (significant but small correlations) to the perceived worthiness of dealing with the problem by themselves. These relationships were not always found for other sources of help. Accordingly, adolescents can be trusted to properly evaluate a problem’s severity and assess the worthiness of seeking help from psychologists.

Willingness to seek help as a function of problem severity In the present study, adolescents were capable of discriminating between minor and severe problems. They perceived a problem deemed to be serious by clinical psychologists as more severe than a problem which experts considered to be minor. Additionally, adolescents thought it more worthwhile to deal with minor problems on their own, whereas for severe problems, they thought it more beneficial to seek help. Similarly, adolescents were more willing to seek help, both for themselves and for others, for severe predicaments rather than for minor ones. As previously mentioned, the difference between adolescents’ willingness to seek help for themselves and their willingness to refer others for help was determined separately for both minor and severe problems. However, this difference was more pronounced for the severe problems. These findings can also be explained by the aforementioned threat to self mechanism, i.e. minor predicaments may not pose as much of a self-threatening experience as more serious ones. Nevertheless, even with the greater threat to self implicit in more serious problems, adolescents are still more willing to seek professional help for these difficulties. Similarly, adolescents may not seek professional help for minor problems, despite the minimal threat they pose, since they logically feel that they can manage these problems on their own or with the help of natural sources. Accordingly, adolescents may weigh both the severity of the problem and the threat to self when deciding whether to seek help from certain sources of support. We realize that the difference in participants’ reaction to the problems presented can be explained not only by problem severity, but also by problem type (Boldero and Fallon, 1995), since the minor and major problems presented are qualitatively different (i.e. the minor problem was of a relational nature and the major problem was of an emotional nature). Although we believe that problem severity is the main cause for the differential reactions given by the participants since they were able to correctly distinguish between problem severity, future research should try to control the problem type as well.

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Willingness to seek help as a function of participant’s and target’s gender In the present study, girls were more willing than boys to seek help in general. These findings support the vast amount of literature associating more positive attitudes towards helpseeking behaviour and its use by girls and women than by boys and men (Dubow et al., 1990; Garland and Zigler, 1994; Gilat, 1993; Nelson-LeGall and Glor-Scheib, 1985; SchonertReichl and Muller, 1996). However, the main effect of gender was mainly a result of referral of self or other to informal sources of help, i.e. parents or friend. However, the 2-way and 3-way interactions that were found for various sources deserve to be examined for gender differences regarding each source separately. Referral of other to a psychologist was higher for girls than for boys, while no difference was found regarding self-referral. The similarity found between boys and girls in their self-referral to a psychologist appears to be somewhat contradictory to the current literature dealing with gender differences in help-seeking behaviour. This can be explained by the hypothetical character of the questions that were presented to the participants, which made it easier on the boys to admit readiness to refer themselves for help. The difference between boys and girls is evidenced in their willingness to refer others for help. In this case, girls are more willing to refer others for help to a psychologist than are boys. This can be explained both by the fact that girls are more sensitive to others’ distress and perhaps by the fact that girls’ relationships are of a more intimate and open nature at this age (Ruble and Martin, 1998). Although counsellors also belong to a formal source category, referral to them is low overall. Regarding gender differences in referral to counsellors, boys, more than girls, refer to a counsellor when the problem is severe. No gender differences were found in the referral of other. This may be explained by the fact that, in Israel, the counsellor works on the school premises making him more available and accessible to students, particularly for those with learning problems (Klingman and Ajzen, 1990). It appears that girls are more selective than boys hence, for severe problems, they are more likely to refer to the psychologists or to the non-formal sources for help. The difference between girls’ referral of others and of themselves to formal sources of support was significant, whereas there was no significant difference between boys’ referral of themselves and others to these sources. Different mechanisms may differentially influence male and female adolescents’ help-seeking behaviour from sources of support. Female adolescents may be more strongly influenced by the self-threatening mechanism, whereas male adolescents may be more strongly influenced by their perceived competency and trust in the support system. Boys tend to use defences such as denial and avoidance, whereas girls tend to express their feelings and seek social support (Bird and Harris, 1990; Chovan and Chovan, 1985; Fuerstein, 1989). Male adolescents may not consciously experience the same threat to self as do female adolescents, since they deny their need for help. This denial may be manifested in their similar referral of self and others for help. Female adolescents’ greater sensitivity towards others, as compared to male adolescents (for a review see Ruble and Martin, 1998), may be an additional mechanism mediating the difference between their referral of themselves and of others. The combination of girls’ more positive attitudes toward psychological help and their perception of problems as more severe than boys may contribute to their greater readiness to refer others to formal sources of help for severe problems. The gender of the target in the scenarios was varied in order to control for any confounding effects between this and other variables in the study. As expected, the target’s


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gender showed minimal influence on other variables. However, in the referral-of-other version, both male and female participants were more willing to refer a female target than a male target. This difference may be attributed to the social stereotype of help-seeking behaviour. Specifically, that help-seeking behaviour by women is more socially acceptable and perceived as being more positive than when exhibited by men.

Relationship between help seeking behavior and willingness to seek help The relationship between attitude and behaviour is a complex one (Eagly and Chaiken, 1993). This study, like others, deals with hypothetical attitudes and intentions and not with real situations of help-seeking behaviour (Raviv et al., 1992). Although studies have been done using information regarding real help seeking situations (Dubow et al, 1990; Boldero and Fallon, 1995), we must keep in mind that these studies relied on the participants’ self reports. Still, finding a connection between attitudes and help seeking behaviour serves to somewhat validate these attitudes. Although the significant positive correlations between one’s attitude toward help-seeking behaviour and one’s actual help-seeking behaviour are not very strong, they indicate consistency. Thus, adolescents with a positive attitude toward the referral of self or other for help, note that they have turned to sources of help in their own lives. The seeking of help from a friend or parent is significantly more common than seeking help from a psychologist, counsellor or teacher. It is interesting that the correlations for self-referral are greater than the correlations for the referral of other. This finding may be evidence of the fact that when an individual is ready to admit his/her willingness to seek help, it may also reflect that individual’s openness toward seeking help in real life. Of course, it is important to qualify these explanations by reminding that these questions did not deal with actual help-seeking behaviour. Also, the present study does not examine the influence of other factors on help seeking behaviour such as problem type, problem severity, etc., which may, of course, have had an effect on the results. Further research should study these factors in greater detail.

Willingness to seek help as a function of self-image Much of the current literature supports the consistency hypothesis (Miller, 1985; Nadler, 1986, 1987, 1991, 1997). Scohnert-Reichel et al. (1995) assert that the relationship between adolescents’ self-image and use of support systems is unequivocal. The present results support the latter. In accordance with the consistency hypothesis, adolescents’ self-image correlated negatively with their willingness to refer a friend to a psychologist for a minor problem, and their help-seeking behaviour from a psychologist and a counsellor. The support for the consistency hypothesis with respect to psychological help is logical given the conception of psychologists as threatening figures (Fischer and Turner, 1970). In accordance with the vulnerability hypothesis, adolescents’ self-image correlated positively with their willingness to refer themselves to their parents and the other person to his/her parents for help in the case of a severe problem. This correlation may be evident given the less threatening image of parental figures, and the major use of formal source by adolescents. These findings suggest that the relationship between self-image and help-seeking behaviour is mediated by factors such as the source of help and the perceived severity of the problem. Given that the above explanations are based on small-magnitude correlations, they require further research. One of the methodological explanations given for the small correlations is the fact that the questionnaire may have been affected by positive biases and social desirability. This was apparent from the high average score and small standard deviation of the self-image scores.

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Limitations and future research The notion of a personal service gap provides the basis for an assessment of the influence of a self-threatening experience on the help-seeking behaviour of adolescents. A major limitation of this study is that the personal service gap was not measured by comparing the self- and other-referral questionnaires of the same participant. This design was not chosen since several methodological problems can ensue when presenting both versions to the same person, such as the responses to the first version contaminating the responses to the other, as well as the reluctance of people to answer to what they perceive as being the same question. However, a rigorous randomized allocation of the versions was carried out. We find it important to reiterate that participants were randomly assigned to the two experimental groups and checked for compatibility. No differences were found between the two groups regarding the main independent variables: age, gender, socioeconomic status, parents’ education, parents’ marital status and self-image. Despite the difficulties, future research should replicate this research with a within-subject design and counterbalance the presentation of the self- and other-referral versions. Such a design may be able to contribute to the validation of the concept of a personal service gap, particularly if such research will include actual help-seeking behaviour. Another limitation of this study is that the questionnaire is not based upon standardized instruments. However, several questions were posed in order to validate the help-seeking questionnaire. Furthermore, similar results were obtained in a pilot study with fewer independent variables (Wilansky et al., 1999). Finally, there are several implications that should be taken into consideration. Adolescents were able to differentiate between the severity of problems presented and also demonstrated an awareness of the necessity of seeking help in general, and from formal sources in particular. Nonetheless, a threat to self mechanism is implicit in the seeking of help, regardless of the problem severity. Accordingly, educational programs could be designed to minimize this tendency. It is also important that preventive programs addressing the large service gap, not only encourage adolescents to seek help, but also deal with the complex and sometimes contradictory messages adolescents receive. Since adolescent peer groups have been found to have a primary influence on adolescents’ social and psychological growth (Savin-Williams and Berndt, 1990), it is important to design and implement programs within educational settings that emphasize the peer group as the major source of support to which adolescents turn.

Acknowledgement The authors wish to thank Sharon Mashraki-Pedhatzur for her help in the preparation of this manuscript.

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