Introduction
The majority of mental disorders emerge in adolescence and young adulthood (Belfer
2008; de Girolamo et al.
2012), with three-quarters of all lifetime cases occurring before 24 years of age (Kessler et al.
2005). Mental health problems in young people significantly impact on their social, emotional, physical, and educational development (Kazdin
1993; Strauss et al.
1987), and are likely to continue well into adulthood if left untreated (Catania et al.
2011; de Girolamo et al.
2012). Fortunately, early intervention and prevention strategies can substantially improve the outlook (McGorry et al.
2011) but, in order for mental health professionals to provide appropriate intervention, assessments that give an accurate and holistic picture of the young person and their life are required (Leavey et al.
2008). These assessments need to cover multiple social, emotional, and behavioral domains relevant to the young person’s wellbeing (Bradford and Rickwood
2012). However, such assessments rely on the young person feeling comfortable enough to disclose their highly personal issues to a relative stranger. Helping young people to disclose what is happening for them early in the treatment process will enable mental health professionals to work collaboratively with the young person to provide a holistic and personalized treatment plan.
Within counselling and clinical mental health care, mental health professionals need to obtain a holistic assessment of their clients within the first or second session, so that an appropriate treatment plan can be developed. To help young people through the difficult process of self-disclosing intimate and personal information, mental health professionals can use specific psychosocial assessments. The ‘HEEADSSS assessment’, which stands for
Home,
Education/employment,
Eating,
Activities and peer relations,
Drugs and Alcohol,
Sexuality,
Suicide/depression, and
Safety, is a common assessment used throughout the United States that structures questions to maximize communication and minimize stress on the young person (Cohen et al.
1991; Goldenring and Rosen
2004). The order of the domains specifically leads the young person from the less personal domains of home life and school, through to the highly personal domains of sexuality and suicide. The domains covered by the HEEADSSS assessment are representative of the domains covered by many psychosocial assessments (Bradford and Rickwood
2012) and are commonly assessed as they reveal many of the risk and protective factors affecting mental health in young people (Cohen et al.
1991). For example, young people with emerging issues regarding their sexuality, are homeless, or are using alcohol or other illicit drugs are significantly more likely to be dealing with mental health problems (AHRC
2012; King et al.
2008; Mackesy-Amiti et al.
2012). While it is important to ask young people whether they have such demographic risk factors, the stigma surrounding issues such as sexuality, homelessness, and substance use, may hinder initial help-seeking and early disclosure (Corrigan and Rao
2012; Eisenberg et al.
2009).
The majority of psychosocial assessments take the form of a self-administered questionnaire (Harrison et al.
2001) or a semi-structured interview format (Goldenring and Cohen
1988; Parker et al.
2010). A recent systematic review of psychosocial assessment tools available for use with the general population of young people aged 12–25 years, found that young people were generally more accepting of assessments that were initially self-administered through a questionnaire, rather than those that relied completely on verbal disclosure to a clinician (Bradford and Rickwood
2012). The preference for a self-administered questionnaire may be due to the young person having increased feelings of control in the disclosure process as they have the time to organize their thoughts and feelings. For example, a study by Elliott et al. (
2004), found that the implementation of an adolescent intake questionnaire allowed adolescents to identify the issues that were of most importance to them, identify the domains they were ready to discuss immediately and those that would need to be returned to, signaled that it was okay to disclose certain information, and helped them to structure their thoughts by providing a time for personal reflection.
While there appears to be support for the use of self-administered psychosocial assessments over those that rely entirely on verbal disclosure, it is unclear whether computer administered assessments result in an increase in disclosure rates over those that are completed in a pen-and-paper format (Bradford and Rickwood
2012). The mixed research findings are interesting considering the commonly held assumption that young people disclose more personal information in online modalities due to the online disinhibition effect (Suler
2004; Wallace
2001). It should be noted, however, that the studies comparing pen-and-paper and computer administered psychosocial assessments have all used large desk top computers, which were often situated within waiting rooms (Beebe et al.
2006; Raat et al.
2007; Silber and Rosenthal
1986; Truman et al.
2003). In this format, it is likely that young people did not feel that their information was particularly private—an important aspect for young people seeking help for their mental health problems (Bradley et al.
2012). New tablet device technology, which allows young people to complete assessments on a smaller screen, may provide a greater sense of privacy. With personal tablet devices now outselling PC laptops (NPD
2013), and projected to outsell PC laptops and PC desktops combined by 2017 (Milansesi et al.
2013), this new tablet technology deserves specific investigation. There is also no research investigating how young people from different demographic groups, particularly those with strong mental health risk factors, respond to different types of assessment formats.
If early intervention is to be effective, it requires young people to feel confident disclosing highly personal information at an early stage of service engagement. This may be facilitated through self-administered assessments using tablet technology which allows young people to disclose privately in a less intimidating format. As such, the aim of the current research was to identify whether young people felt that an electronic psychosocial assessment tool (e-tool) on a tablet device could improve rates of initial disclosure of sensitive issues to mental health professionals within the standard face-to-face therapy format. We were also interested in whether these views differed for the various psychosocial domains assessed. Additionally, we investigated whether specific views were related to the age of the young person or their identification to relevant higher-risk demographic groups, including those who identified as lesbian, gay, bisexual, transgender or intersex (LGBTI), were homeless, had alcohol or other drug (AoD) problems, had previously used mental health services, or came from an Indigenous background.
Discussion
The aim of the current research was to investigate how young people feel about the use of an electronic psychosocial assessment tool, using small tablet device technology, and whether it would be a barrier or facilitator to initial disclosure of sensitive issues to mental health professionals. In general, most participants felt that the e-tool would be particularly useful in helping them disclose the domains that they were most embarrassed about, and overall would be open to the idea of using the assessment e-tool to initially indicate concerns in all of the relevant psychosocial domains. Views were similar to the findings of Elliott et al. (
2004), in that participants felt that the e-tool would help provide a structure to their thoughts and the overall session by allowing them to identify issues of importance and take the time to decide what they were ready to disclose. These views indicate that young people would like greater input into the mental healthcare process and their discussions within session. Providing young people with increased feelings of involvement in their mental health care may lead to greater patient satisfaction (Swanson et al.
2007) and improved mental health outcomes (Clever et al.
2006) and is in line with the overall move toward shared decision making (SDM) in healthcare (Charles et al.
1997; Simmons et al.
2012). The smaller proportion of young people who felt they ‘Want to talk’, were mostly concerned around the need for non-verbal cues. This stemmed from the belief that some young people may under-report the seriousness of their mental health problems. Interestingly though, the majority of participant groups who had responses categorized under the theme ‘Want to talk’, also had responses categorized as reasons why they felt the e-tool could be of benefit, indicating that even those young people who held a preference to talk, could also see the positive utility of an e-tool.
There were some differences in the willingness to use the e-tool across the different age groups. Participants aged 15–21 years, most strongly identified with the belief that the e-tool would help them initially disclose, while participants aged 22–25 years were more likely to want to just talk. Participants aged 12–14 years did not appear to identify more strongly with either theme. This age trend may be an indication of varying levels of mental health literacy, digital experience, and/or knowledge of traditional health care modes of delivery. The youngest participants probably have the lowest levels of mental health literacy and health care seeking experience (Furnham et al.
2013) and, therefore, are unlikely to have strongly formed views on the subject. Participants aged 15–21 years are more likely to be currently struggling with sensitive issues (Pottick et al.
2008) and therefore more likely to be able to identify with what it would be like to disclose the problem, and how this could be made easier through the use of technology. Finally, it would be expected that those participants aged 22–25 years have greater knowledge and experience in seeking mental health care through the traditional face-to-face method; consequently, they are more likely to prefer to talk as this is the method they are most familiar with.
Some differences were also identified when comparing responses across the demographic groups. The Indigenous group were particularly interested in the use of an e-tool as they felt it would reduce the likelihood of experiencing judgmental reactions from clinicians and help them identify their issues of greatest concern. Considering the well documented history of discrimination and disempowerment of Indigenous communities, and how this continues to affect their mental health and wellbeing (Wexler
2009; Williamson et al.
2010), the comments made by this demographic group are particularly important. If the e-tool can decrease the fear of judgment, and increase the input by Indigenous youth in their treatment experience, we may see significantly greater help-seeking and satisfaction in mental health services by these young people. In contrast, participants who were homeless held a stronger preference to talk, emphasizing the importance of non-verbal cues. These participants were currently staying in a short-term supportive housing environment staffed by professionals working in the traditional face-to-face service model; consequently, like the older participants in the study, their preference may be based upon their familiarity with the face-to-face model. Additionally, this group is likely to be highly aware of the stigma surrounding homelessness and the likelihood of young people attempting to conceal the severity of their current situation (Hudson et al.
2010; Kidd
2007). As this group of participants were currently involved in a homeless support service they may have realized the benefit in seeking help and recognize the need for professionals to use non-verbal cues to identify issues in other young people who may be attempting minimize their problems.
For a qualitative design, this study had a large number of participants recruited from two major metropolitan areas of Australia. Nevertheless, active participation was required on behalf of the participants and the sample is likely to be biased towards those with an interest in improving mental health care for young people. Further, because the interactive e-tool has not yet been developed, understanding the concept required some abstract reasoning abilities on behalf of the participants, and some found this challenging. Finally, due to the already large number of interview groups being run, it was not possible to further split groups by gender, which would have been of interest as gender and age have an interactive effect on mental health help-seeking (Zwaanswijk et al.
2003). These help-seeking effects may also be evident in the willingness to disclose personal issues. This research also only investigated the views of young people and future research needs to determine how mental health professionals would view the use of such a tool. Mental health workers spend a great deal of time on assessment and it is often used as an opportunity to engage with the young person and build rapport. Therefore, their views on such a change to practice also need to be well understood.
Helping young people disclose sensitive issues is vital for mental health professionals in providing early intervention and prevention (Leavey et al.
2008; McGorry et al.
2011). The results of the current study provide support for the use of a psychosocial assessment e-tool within face-to-face mental health care with most young people stating that the e-tool would help in the disclosure of particularly embarrassing problems, and is a preferable method of disclosure as it increases their control over the help-seeking and disclosure process by allowing them to structure their thoughts and indicate areas of most importance. The possibility that an e-tool could provide young people with feelings of greater input into their treatment is an important implication and is in line with the increasingly popular move towards SDM in health care. By working in a flexible manner and providing the option for young people who would prefer to initially disclose by using an e-tool to do so, clinicians will be giving their clients greater choice and input into their mental health care which will likely lead to significantly better patient satisfaction and improved overall health outcomes (Clever et al.
2006; Swanson et al.
2007).