While sitcoms with sassy teens stomping off and slamming doors, screaming “Why won’t you listen to me?” is an old trope, we know that many adolescents still struggle with feeling heard and being taken seriously; particularly those who have endured traumatic events. Youth exposed to traumatic events are more susceptible to a myriad of behavioural health concerns including PTSD, depression, anxiety, self-harm and suicidality leading to higher rates of truancy and drop-out, poorer physical health, substance use, addiction and engaging in high-risk sexual behaviour (Flaherty, et al., 2013, Iverson, et al., 2018).
Despite these well-established correlations, adolescents are notoriously underserved by behavioural health providers. Almost 25% of young people meet criteria for serious mental illness, but less than 10% report using subsidised mental health services (Gulliver, Griffiths, & Christensen, 2010). This gap between need and service access leads Ellinghaus, Truss, Siling, Phillips, Eastwood, Medrano & Bendall (2019) to explore the barriers impeding teens from receiving quality mental health services.
Serious barriers exist between traumatised adolescents and competent mental health treatment.
Methods
Through the use of a six-step framework, LiLEDDa, Ellinghaus et al. (2019) examined anonymous postings from 5 online forums geared towards young people seeking to process trauma-related subject matter. The forums selected for study had recent postings (at least 100 active threads within the past 3 months).
“Netnographic” research, grounded in ethnographic methods, was used to explore themes emerging from chat-threads focused on topics of study. While posters were anonymous and age could not be verified, threads which were authored by someone identifying themselves as under 13 or over 25 were excluded from analysis. Appropriate text threads from these five identified forums over a ten-month period (January through November) were collected for analysis. The data set was comprised of 295 pages of forum posts written by 176 unique posters. Two of the article’s authors coded the data (90% inter-rater reliability) and utilised any content within the broad theme of “barriers to treatment” at the provider level for review.
The University of Melbourne Human Research Ethics Committee approved this secondary data analysis approach.
Results
Two main subthemes emerged from the analysis of the content under the “provider-level barriers to treatment” theme: structural barriers and relational barriers (Ellinghaus et al., 2019):
Structural barriers
The structural barriers the adolescents identified related to their difficulty navigating a complex system they felt was designed to keep them from needed services rather than opening pathways to it. Furthermore, the lack of competent professionals, a sentiment echoed by many providers themselves, was acutely apparent in the participants commentary.
Relational barriers
The relational barriers discussed by participants fell into 4 different categories: disrupted relationships (with the provider), invalidating responses, lack of power over their process, and non-disclosure to their ongoing provider.
Most service providers referenced in the study did not acknowledge the difficulty participants experienced accessing their services, leaving them feeling mistrustful from the onset of the relationship. Without informing them about the limitations to their treatment from the beginning (for example, letting them know they only have coverage for a limited number of sessions), many youth report feeling betrayed by their providers. Many posters’ comments highlighted experiences of being dismissed and “talked-down-to” which caused them to never disclose past traumatic experiences; a primary cause of their symptoms.
Even when adolescents navigate through the complex system, they do not disclose their trauma to providers.
Conclusions
The authors’ discussion of results is best viewed through a lens of trauma-informed care principles (SAMHSA, 2014). The findings within the sub-theme of structural barriers echoed themes in other studies in the industry (Bendall et al., 2018; Bush, 2018; Damian et al. 2018; Stewart et al., 2017). Importantly, this study is hearing from adolescents who have experienced these barriers themselves rather than service providers, or adult consumers.
Another noteworthy difference with this study is the identification of clinician-client relational barriers from the young person’s perspective. Research on the importance of the therapeutic relationship when working with victims of trauma has mainly utilised the service provider’s perspective (Damian et al., 2018; Stewart et al., 2017; Chung et al., 2012).
With physical safety within the therapeutic relationship assumed, a primary trauma-informed principle emerging from the analysis was the importance of trustworthiness of the service provider. Due to the barriers within the system itself, adolescents are already justifiably sceptical of those who they eventually access.
Lack of choice and collaboration in the treatment process was also a glaringly apparent barrier highlighted in the postings. As young people felt talked down to or completely unheard, this dismissiveness served to further damage an already fragile relationship, even after several sessions into treatment.
Young people clearly reported feeling a lack of empowerment within the therapeutic relationship. The inherent power differential that, from many posters’ perspectives, is unrecognised by their provider, sets the young person in a defensive position from the onset. Additionally, adolescents struggling from traumatic experiences have often developed a fawning response to authority figures. This defence strategy of pleasing their aggressor may have helped them survive during traumatic and abusive events in their past, but it must be recognised and deactivated if the youth is to obtain desperately needed healing.
There are grave implications for young people when their providers do not take the time to establish safety, demonstrate themselves as trustworthy, provide them with appropriate treatment choice, collaborate with them in treatment planning or empower adolescents with trauma histories to advocate for themselves honestly. Without addressing this elephant in the room, adolescents report not disclosing important details about traumatic experiences or omitting them altogether. They also indicate they feel even more depressed, anxious, or suicidal after negative relational experiences with their providers, exacerbating the very issues leading them to seek treatment.
Without our mental health systems adopting a trauma-informed approach, traumatised youth will continue to fall through the cracks.
Strengths and limitations
A noteworthy strength of this study is their amplification of the voices of those who feel doomed to silently suffer the impact of their trauma. These findings support the current understanding we have while also advances the existing body of knowledge around treatment of trauma in adolescents.
A primary limitation to this study is being unable to determine participants’ demographic and other relevant information. Secondly, the study focuses solely on barriers rather than reporting any strengths within the two subthemes, leaving the reader to potentially feel as if no providers are providing traumatised youth with trauma-informed treatment.
Although traumatised youth are anonymous, this study gives them a much needed voice.
Implications for practice
This study provides a clarion call to those working within the trauma-treatment systems to examine their practices with young people from a multi-system perspective. Trauma-informed care begins with establishing safety, and it is clear that many adolescents not only feel disempowered in their own trauma-focused treatment, they also feel unsafe. Dismantling the systemic and relational barriers to trauma-focused treatments is essential for traumatised adolescent success.
Mental health providers must build trust before youth will open up to them about their trauma.
Statement of interests
This writer has no conflict of interest in this study.
Links
Primary paper
Other references
Bendall, S., Phelps, A., Browne, V., Metcalf, O., Cooper, J., Rose, B., …Fava, N. (2018). Trauma and young people. Moving toward trauma informed services and systems. Melbourne: Orygen, The National Centre of Excellence in Youth Mental Health.
Chung, J. Y., Frank, L., Subramanian, A., Galen, S., Leonhard, S., & Green, B. L. (2012). A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care. Journal of Nervous and Mental Disorders, 200(5), 438–443. https://doi.org/10.1097/NMD.0b013e31825322b3
Bush, M. (2018). Addressing adversity: Prioritising adversity and traumainformed care for children and young people in England. Addressing Adversity, 1, 1–187.
Damian, A. J., Gallo, J. J., & Mendelson, T. (2018). Barriers and facilitators for access to mental health services by traumatized youth. Child Youth Services Review, 85, 273–278. https://doi.org/10.1016/j.childyouth.2018.01.003
Stewart, R. W., Orengo-Aguayo, R. E., Gilmore, A. K., & De Arellano, M.(2017). Addressing barriers to care among Hispanic youth: Telehealth delivery of trauma-focused cognitive behavioral therapy. Behavior Therapy, 40(3), 112–118.
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