Journal of Adolescent Research - Center for Mental … Might Think I Was... Research Journal of Adolescent DOI: 10.1177/0743558406295969 Journal of Adolescent Research 2007; 22; 58

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Journal of Adolescent

DOI: 10.1177/0743558406295969 2007; 22; 58 Journal of Adolescent Research

Stacey Freedenthal and Arlene Rubin Stiffman Reasons for Not Seeking Help When Suicidal

"They Might Think I Was Crazy": Young American Indians’

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“They Might Think I WasCrazy”Young American Indians’ Reasonsfor Not Seeking Help When SuicidalStacey FreedenthalUniversity of Denver, ColoradoArlene Rubin StiffmanWashington University, St. Louis, Missouri

It is well known that many suicidal young people avoid asking for help; how-ever, the reasons why are less understood. A sample of 101 American Indians(age 15-21 years) who had thought about or attempted suicide was asked open-ended questions about barriers to seeking formal and informal help whilesuicidal. The 74 participants who avoided at least one type of help most com-monly reported internal factors, such as embarrassment, lack of problemrecognition, a belief that nobody could help, and self-reliance. Structuralbarriers, such as lack of money or service availability, were only rarely cited.Findings indicate that efforts to increase help seeking among young, suicidalAmerican Indians should target beliefs about emotional problems and helpseeking.

Keywords: adolescents; American Indians; help seeking; mental healthservice utilization; suicide prevention

For many American Indians, the challenges of adolescence can be espe-cially profound. The country’s 4.3 million American Indians (Ogunwole,

2006) obviously contain vast heterogeneity; however, as a group AmericanIndian young people experience higher than average rates of social problemssuch as poverty, violence, substance use, alcoholism, and premature death(e.g., Frantz, 1999; Grossman, Krieger, Sugarman, & Forquera, 1994; Olson& Wahab, 2006). Arguably the most tragic of social problems for AmericanIndian young people is suicide. The suicide rate among American Indians

Journal of AdolescentResearch

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58

Authors’ Note: This study was funded with the following grants to the principal investigator(A.R.S.): Grant K02-MH01-797-01A1 from the National Institute of Mental Health andGrants R24-DA-13572-0 and R-01-DA-13227-01 from the National Institute on Drug Abuse.In addition, the authors thank Peter Dore for his assistance with qualitative coding.




age 15 to 24 years is more than 3 times higher than that of other youngpeople in the United States (37.4 and 11.4 per 100,000, respectively; IndianHealth Service, 2004). Research indicates that 14% to 30% of AmericanIndian adolescents, particularly high school students, attempt suicide (Blum,Harmon, Harris, Bergeisen, & Resnick, 1992; Borowsky, Resnick, Ireland,& Blum, 1999; Freedenthal & Stiffman, 2004; Grossman, Milligan, & Deyo,1991; Howard-Pitney, LaFromboise, Basil, September, & Johnson, 1992),compared to 4% to 10% of adolescents in the general population (Resnicket al., 1997; Substance Abuse and Mental Health Services Administration,2002).

Professional help and support from informal helpers, such as family andfriends, are widely regarded as an important means of suicide prevention(U.S. Public Health Service, 1999); however, only 10% to 35% of AmericanIndian adolescents and young adults use professional health services duringa suicidal episode (Mock, Grossman, Mulder, Stewart, & Koepsell, 1996). Inaddition, in one study, suicidal thoughts correlated only weakly (r = .26) withseeking help from formal or informal helpers (Bee-Gates, Howard-Pitney,LaFromboise, & Rowe, 1996). In general, studies including American Indianyoung people have shown that they most often consult friends and familyduring times of need, followed by schoolteachers, and other professionalsoutside of the specialty mental health sector (Bee-Gates et al., 1996; Novins,Beals, Sack, & Manson, 2000; Stiffman, Striley, Limb, & Ostmann, 2003).Even with the popularity of peer and family helpers, many troubledAmerican Indian young people choose to “go it alone.” Stiffman et al. (2003)determined that, in a sample of southwestern American Indian adolescentswho had three or more emotional, behavioral, or substance use symptoms,25% did not receive any formal or informal help in the prior year. Tendenciesto forego help are not unique to American Indians; in a survey of 2,386 ado-lescents in the general population who had thought about or attempted sui-cide in the prior year, only 28.83% used any mental health service (besidesschool-based services) during that same time period (Freedenthal, 2005).

In general, several theories attempt to explain why individuals do notseek formal help for mental health problems, although potential explana-tions for shying away from confiding in friends and family are scarce. A fre-quently cited explanatory model for formal service use—the behavioralmodel of health care utilization (Andersen, 1995)—focuses on sociodemo-graphic and systemic factors (e.g., race, income, and service availability), inaddition to actual need for care, that may hinder or enhance access to care.This model focuses on who seeks professional help, rather than how. In con-trast, another type of model portrays help seeking as a dynamic process

Freedenthal, Stiffman / Reasons for Not Seeking Help 59




influenced by culturally relevant factors such as stigma, mistrust, and illnessperceptions (e.g., Cauce et al., 2002; Pescosolido, 1992). Owens et al.(2002) distinguished between “externally driven” (vs. “internally driven”)barriers to care (p. 736), categories that generally parallel the distinctionbetween structural and attitudinal factors impeding help seeking. Pescosolido(1992) also stressed the importance of social networks, which can persua-sively steer a person toward—or away from—professional help. Althoughthese models were not developed explicitly for adolescents and young adults,they are easily adapted to young people by also taking into account the roleof parents, teachers, and other adults who may recognize a problem exists andprovide the means (e.g., transportation, money) for a young person to receiveprofessional help (e.g., Stiffman, Pescosolido, & Cabassa, 2004).

Empirically, numerous barriers to adolescents’ receiving professional helphave been identified in the general population. Consistent with the behavioralmodel addressing access to care (Andersen, 1995), the most commonly cited(and studied) impediments to help seeking and mental health service useinclude structural factors such as costs, inadequate or no insurance, and lackof service availability or knowledge about available resources (e.g., Culp,Clyman, & Culp, 1995; Kataoka, Zhang, & Wells, 2002; Owens et al., 2002).Consistent with models emphasizing the process of help seeking, social andcultural factors also play an important, though less frequently studied, role(Snowden & Yamada, 2005). Culturally relevant attitudes and perceptionsshown to influence young people’s formal and informal help seeking includean emphasis on self-reliance (Barker & Adelman, 1994; Kuhl, Jarkon-Horlick, & Morrissey, 1997) and concerns about stigma and confidentiality(Kuhl et al., 1997). The failure to recognize the need for help also figureslargely in many studies’ findings of barriers to care among young people whoneed mental health services (Owens et al., 2002; Zwaanswijk, Van der Ende,Verhaak, Bensing, & Verhulst, 2003).

Very few studies have directly asked American Indians what stopped themfrom using formal services when they experienced emotional problems, andnone has centered on informal help seeking. A Denver survey of 374American Indians age 17 to 54 years at various social service agencies foundthat an inability to locate or pay for services was a key impediment to seek-ing professional help for mental health problems (King, 1999). Factors eas-ing access to mental health care, such as insurance, are less common amongAmerican Indians than White Americans (Zuckerman, Haley, Roubideaux,& Lillie-Blanton, 2004). The Indian Health Service (IHS), a U.S. govern-mental agency, is mandated to provide services to American Indians; how-ever, fewer than one half of uninsured, low-income American Indians and

60 Journal of Adolescent Research





Alaska Natives have access to IHS programs (Zuckerman et al., 2004), andthe agency suffers inadequate funding and staffing (Gone, 2004).

Access to care does not, however, tell the whole story. Many AmericanIndians believe that seeking professional mental health services representsthe “White man’s” system and culture (Gone, 2004). The U.S. govern-ment’s legacy of persecuting and oppressing American Indians furtherexacerbates the cultural mistrust of institutional sources of aid (Johnson &Cameron, 2001). Indeed, other recurring reasons that American Indians inthe Denver survey gave for not seeking help for emotional or substance useproblems concerned mistrust of mental health care professionals, a beliefthat professionals would not understand American Indian ways, and a lackof faith in mental health care (King, 1999). Duran et al. (2005) examinedcorrelates of four primary obstacles to care in a sample of 224 Indianmental health service users (age 15 to 54 years): (a) self-reliance, (b) pri-vacy concerns, (c) concerns about quality of care, and (d) communicationand trust issues. The authors found that anxiety disorder, service type, andsector of care positively related to privacy concerns, and that criticism andcontrol in a person’s social network made a person more likely to expectpoor quality of care. A major limitation of these studies is their inclusiononly of people who actually had secured mental health care or other socialservices. By accessing services, these people overcame whatever barriers tocare that they initially had faced. People who need help but never make itto a professional’s office may face more pronounced barriers to care.

Despite knowledge of some barriers to mental health care and help seek-ing among American Indians in general, information is scarce about obsta-cles that American Indian young people face in seeking formal or informalhelp. Research into barriers to mental health service use among AmericanIndians almost exclusively addresses adults and relies on quantitative datafrom large, scaled surveys. Furthermore, no studies have addressed whatstopped American Indian adolescents and emerging adults from going toothers for help specifically when they thought about or attempted suicide.The question is especially salient when considering the elevated suiciderates in this group, the heightened need for care that suicidality frequentlyconveys, and the disproportionate load of risk factors for suicide, such assubstance use, found in many American Indian communities (Olson &Wahab, 2006). Determining what inhibits help seeking among AmericanIndian young people during a suicidal episode could have important impli-cations for suicide prevention in their communities, particularly concerningthe potential for policies and interventions to increase access to profes-sional helpers, provide education to informal helpers, and improve outreachto troubled young people.





The current study aimed to fill these gaps in the literature by directly ask-ing American Indian young people to explain, in their own words, whatstopped them from seeking formal help (i.e., from a professional) or informalhelp (i.e., from a friend or family member) when they were suicidal. The cur-rent study’s primary research question was exploratory: What stopped partic-ipants from seeking formal or informal help when suicidal? In addition,drawing from the dominant models of health care utilization, the currentstudy aimed to determine whether participants’ reasons for not seeking for-mal help most often centered on structural factors related to access to care,such as income, insurance, and service availability, or culturally relevantprocess factors, such as attitudes, perceptions, and social support. Thus, thesecond research question asked: Did structural or attitudinal factors emergemore frequently as reasons for not seeking help?

Method

The AIM-HI Project

The current study is part of a larger, longitudinal study called the AmericanIndian Multisector Help Inquiry (AIM-HI), funded by the National Instituteon Drug Abuse from 2001 to 2006. AIM-HI investigated psychosocial prob-lems such as substance misuse, mental illness, trauma, and violence; personal,neighborhood, and community strengths; and help seeking and mental healthservice utilization in a stratified random sample of 401 American Indian ado-lescents (age 12-19 years in 2001). Participants’ average age was 15.61 (SD =1.60) when the study began. More than one half the sample (56.11%, n = 225)was female, and families of 28.50% of participants received public assistance(subsidized housing, food stamps, or Temporary Assistance to NeedyFamilies). The sample contained a blend of urban (n = 196) and reservation(n = 205) adolescents. The reservation is a community of 6,000 on more than55,000 acres in a southwestern state, almost 20 miles away from the city withthe urban study participants and close to several smaller cities. To protecttribal confidentiality, the participants’ tribes, reservation, urban area, and stateare not identified.

Interviews took place annually for 4 consecutive years. Most of the inter-view contained quantitative scales and measures, and open-ended questionsoccasionally were employed. In the first and last years of data collection, par-ticipants completed a long interview, averaging 2.5 hrs. The interviews con-tained extensive questions from standardized instruments, such as the ServiceAssessment for Children and Adolescents (Stiffman et al., 2000) and the





National Institute of Mental Health’s Diagnostic Interview Schedule (DIS;Robins, Helzer, Croughan, & Ratcliff, 1981) to make diagnoses of depres-sion, conduct disorder, and substance abuse or dependence. Interviews in thesecond and third years of data collection were much less extensive and typi-cally lasted a half-hour. The briefer interviews included the Youth Self-Report(YSR; Achenbach, 1991) and questions about substance use and mentalhealth services. Additional items, such as those related to help seeking whilesuicidal, were added based on questions posed by tribal elders, communityleaders, and investigators.

Interviews took place in person, usually at the participant’s home.Participants were paid US$20. All interviews were computer assisted (Saris,1991). Interviewers read questions from a laptop computer and directlyentered participants’ responses into the computer. The computer was pro-grammed to provide cues and to skip interview questions based on partici-pants’ responses. At the end of the interview, to protect participants at risk ofself-harm, the computer program alerted the interviewer if a participant hadresponded positively to questions about suicidality. The interviewer askedthe participant if he or she was currently suicidal, assessed for imminentdanger, provided referrals and a hotline number, and notified the field super-visor, who followed up with the participant and service providers. Providersin the urban and reservation areas were available on 24-hr call.

For the overall study and for each year of data collection, Internal ReviewBoards at Washington University in St. Louis, Missouri, the reservation’stribal council, and the urban school district reviewed, shaped, and approvedthe consent and protection procedures. In addition, the Institutional ReviewBoard at the University of Denver approved the primary author’s investigationusing deidentified data from the project.

Current Study

The current study includes data only from the third year of data collec-tion (2003) and involves only a subsample of 101 participants who reportedin that year’s interview that they had, at any time in their life, thought aboutor attempted suicide. In 2003, project staff were able to locate and interview356 of the study’s original 401 participants. Based on data collected in the2001 survey, those 356 participants did not differ from the 45 nonpartici-pants according to age, gender, receipt of public assistance, history of sui-cidality, or YSR scores. However, a disproportionate amount (67.35%) ofthe 45 participants who missed the third year of data collection was from the





urban area, given that roughly one half of the original sample was urban,χ2(1, N = 400) = 7.81, p < .005.

Measurement

Suicidality. To assess a history of suicidal ideation, participants wereasked, “Some people go through periods when they want to commit sui-cide. At any time in your life, have you thought about killing yourself?” Toassess a history of suicide attempt, all participants also were asked, “Didyou ever try to end your life (whether or not you thought about it ahead)?”For each item that participants endorsed, they were asked when the first andmost recent episodes were, and if they were currently suicidal. Peoplereporting a suicide attempt were asked how many times they had made anattempt.

Help seeking. Participants who endorsed either of the suicidality ques-tions were asked if they sought help specifically during the time that theywere suicidal. To address the different types of helpers consulted, threequestions were asked:

“When you thought about [or attempted] suicide, did you seek or get help froma medical or mental health professional, including an emergency room doc-tor, psychiatrist, social worker, psychiatric hospital, or other psychiatricperson or place?”

“When you thought about [or attempted] suicide, did you seek help from anyfriends or family members?”

“Is there anyone else who helped you when you thought about [or attempted]suicide, including a teacher, minister, or medicine man?”

Following each of these questions, participants who answered positively wereasked, “Who did you go to, and what is your relationship to them?” Basedon participants’ responses, helpers were divided into two categories: formalhelpers (mental health professionals, physicians, teachers, school counselors,medicine men, and ministers) and informal helpers (friends and family).

Reasons for not seeking help. For each of three initial categories of helpseeking (professional, informal, and other), participants who responded thatthey did not seek help were asked the open-ended question, “What stoppedyou from going to [category of helper] for help with your suicidal thoughtsor behavior?” Open-ended questions, rather than forced-choice items, were





used because the full range of participants’ possible responses could not beanticipated in advance (Engel & Schutt, 2005). Responses were brief, rang-ing from 1 word (e.g., shame) to 52 words.

Emotional and behavioral problems. The YSR (Achenbach, 1991) wasincluded to examine participants’ apparent level of need for help, based onthe presence of emotional or behavioral problems. Specifically, YSR scoresof participants who said they did not need help were compared to those ofparticipants who did receive help, to determine whether participants pro-fessing not to need help actually had fewer problems. The YSR is a lengthyinstrument with brief, single-sentence statements (e.g., “I cry a lot”), towhich respondents note their level of agreement (“Never or not true,”“Sometimes or somewhat true,” or “Often or very true”). Responses, whichare assigned a value from 0 to 2, were then summed. The current study usedonly 87 of the scale’s items; questions referring to school and other behav-iors specific to school-aged adolescents were omitted. The modified scalehad very high reliability in the current study (alpha = .97). To help ascer-tain whether the YSR was a valid measure of emotional and behavioralproblems in this sample, statistical analyses compared YSR scores amongall participants (n = 356) interviewed in 2003 according to whether they hadnever thought about or attempted suicide, thought about but not attemptedsuicide, or attempted suicide. YSR scores significantly and monotonicallyincreased as each level of suicidality increased: participants with no historyof suicidality had a mean score of 19.01 (SD = 16.07), the mean score for par-ticipants who reported prior ideation, but not an attempt, was 39.05 (SD =23.51), and participants reporting a prior suicide attempt had a mean score of49.80 (SD = 21.70), F(2, 350) = 67.35, p < .0001; post hoc, pair-wise t testsconfirmed that all differences were significant.

Analyses

When all data were collected, the primary author (S.F.) read through alltext responses multiple times during a period of 1 week. Next, open codingwas used to inductively create 15 descriptive coding categories, based onrecurring themes and the categories’ fit with the data and research questions(Strauss, 1987). Responses were analyzed from participants who avoidedprofessional help, informal help, or both. The principal investigator (A.R.S.)reviewed the initial coding, and after several discussions with the primaryauthor (S.F.), closely related categories were collapsed together, creating a setof nine categories; for example, categories for “embarrassed” and “stigma”




were combined, because the two overlapped considerably. To examine interrateragreement, a data manager (P. Dore) who had not reviewed the text responsescoded independently, using the preconceived categories, the complete data setfor open-ended responses about reasons for not seeking help. The investiga-tors’ and independent rater’s sets of coding were in agreement for 90.1% ofresponses, and the kappa coefficient was .87. Discrepant categorizationswere resolved by discussion and consensus.

Using the categories created from text analyses, univariate counts calculatedthe frequency of each reason given. Results are reported separately for formalhelp and informal help. Other quantitative analyses included bivariate compar-isons (chi-squares and t tests) to see if the frequency of specific responses dif-fered according to age, gender, location, suicide attempt history, and YSR score.

Results

Sample Characteristics

Of the 101 participants, 51.49% lived on the reservation. Ages rangedfrom 15 to 21 years , averaging 17.68 years (SD = 1.6). Female participantsconstituted 72.28% of the group; this high proportion is consistent with thegender disparity consistently found in studies of nonfatal suicidal behavior(e.g., Moscicki, 2001). One half the participants were enrolled in junior orsenior high school, 10% were in college or some other type of advanced edu-cation, and 39.60% indicated they were not attending any type of school.

More than one half (59.41%, n = 60) of the current study’s participantsreported they had only thought about committing suicide, almost 10% (n = 10)reported one suicide attempt, and an additional 24% (n = 25) indicated thatthey had attempted suicide multiple times; six of the participants reporting aprior attempt did not give the number of times. On average, participants firstthought about committing suicide when they were age 14.14 years (SD = 2.26).For those who acted on suicidal ideation, the first attempt occurred at a meanage of 13.68 years (SD = 1.96). Two thirds of participants also reported in aprevious year’s interview that they had ever thought about or attempted suicide.

Slightly more than three fourths of participants (76.24%, n = 77) turnedto at least one person for help when they were suicidal. Almost two thirds(63.37%, n = 64) confided in family, friends, or both. Fewer than one half(40.59%, n = 41) saw a mental health professional, and 12.87% (n = 13)consulted a school counselor or teacher. In addition, two participantsreceived help from a medicine man, and two others talked with a minister.Of the participants who received any help, more than one third (37.66%, n = 29)






consulted formal and informal helpers. Thus, 72 participants avoided at leastone type of help, including 24 who chose not to use any help at all.

Research Question 1: What stopped participants from seeking help whensuicidal?

Overall, the most frequently stated reasons for not seeking formal helppertained to perceiving no need for help, avoiding stigma, and turning tofriends or family for support (Table 1). Reasons for not seeking informalhelp most often centered on avoiding stigma, feeling alone, and fearing otherconsequences of disclosure, such as being committed to a hospital (Table 2).Among the 24 participants who avoided formal and informal helpers whenthey were suicidal, the most commonly cited reasons were not perceiving aneed for help (29.17%, n = 7), feeling alone (25%, n = 6), and relying ononeself (20.83%, n = 5; not shown).

In bivariate analyses, none of the reasons for avoiding help arose signif-icantly more frequently based on location, age, public assistance or suicideattempt. A higher proportion of female participants (29.27%, n = 12) thanmale participants (11.11%, n = 2) said they bypassed formal help because

Reason

Did not perceive needfor help

Stigma, embarrassment

Had other supportSelf-reliance

Felt hopeless, aloneFear of consequences

(besides stigma)CostsNo services available

%

28.81

23.73

23.7315.25

15.2511.86

3.391.69

(Frequency)

(17)

(14)

(14)(9)

(9)(7)

(2)(1)

Example

“Nothing really happened that mademe need to go to the hospital orget help.”

“I don’t really care about what peoplethink, but this time I did.”

“I went to friends for help.”“I figured it out on my own that I

should be smarter.”“I didn’t think they could help me.”“Just that someone might . . . put me

in a hospital, a padded room.”“No money.”“There is no medical place where I

live.”

Table 1Reasons for Not Seeking Formal Help When SuicidalAmong a Sample of American Indian Adolescents in aSouthwestern State, in Order of Frequency (N == 59)a

a. Some participants provided more than one reason for not seeking formal help.





they relied on friends and family for assistance; however, the difference wasnot statistically significant, χ2(1, N = 74) = 2.28, p < .15.

The specific reasons given by the participants are further described inthe remainder of this section, in order of their overall frequency when com-bining reasons for not seeking formal or informal help.

Did Not Perceive Need for Help

Seventeen participants did not seek formal help, and four participantskept their suicidality secret from family and friends because they believedthey did not need help. “I did not think it was a problem,” one participant,17, said of her previous suicidal thoughts. For some participants, not need-ing help meant not truly being in danger of suicide. A participant, 18, whoreported that she had thought about suicide but not made an attempt, said,“It wasn’t a big deal. I wasn’t gonna do anything. I knew I wouldn’t.”Similarly, another participant said, “I wasn’t seriously thinking about killingmyself. I just thought about it.” Notably, 10 of the 17 participants who saidthey did not need formal help did turn to family or friends.

Reason

Stigma, embarrassment

Felt hopeless, aloneFear of consequences

(besides stigma)Did not perceive need

for helpSelf-reliance

Had other support

%

37.84

16.6216.62

10.81

10.81

2.70

(Frequency)

(14)

(6)(6)

(4)

(4)

(1)

Example

“I thought that they would think Iwas weird or that they’d telleveryone in my family and theneveryone else would know.”

“I felt that no one cared.”“They would lock me up.”

“I felt I didn’t need them.”

“It was my problem, so I helpedmyself.”

“I felt I was alone and the only wayI could get help was going to somebody whose job it was to helpkids.”

Table 2Reasons for Not Seeking Informal Help WhenSuicidal Among a Sample of American IndianAdolescents in a Southwestern State (N == 37)a

a. Not all 37 participants who avoided informal help provided a reason.





To examine the possibility that participants who saw no need for helpactually might not have needed it, two analyses were performed. First, YSRscores were compared to see if participants who asserted no need for helpactually had fewer behavioral and emotional problems than participantswho had received any help while suicidal. Participants who said they didnot need help had a mean YSR score of 47.76 (SD = 24.84), compared to amean score of 44.36 (SD = 25.00) among the participants who did consultsome type of formal helper, t(57) = .047, p = .64. Second, a nonparametricequality of medians test determined there was no significant difference inthe median scores of 43 and 42, respectively. These results indicate that par-ticipants who professed no need for assistance had the same level of emo-tional problems as those who actually received help.

Embarrassment and/or Stigma

Almost one third of participants (31.94%, n = 23) who avoided at leastone type of help gave reasons related to stigma, embarrassment, and fears ofothers’ knowing. “I would think that it would be out there and then every-body would know, but I just wanted to keep it to myself,” a female partici-pant, 17, who lived in the large city said. A 19-year-old who lived on thereservation and avoided all types of helpers when he had suicidal thoughtsgave the same pithy explanation each time he was asked why he did not tryto get help: “Shame.”

Embarrassment and stigma prevented many participants from seekingsome, but not all, help. Almost two thirds of participants (62.50%, n = 15)who gave this as a reason for avoiding one type of help nevertheless did useanother type of help. Of these, six used a formal helper, and nine receivedhelp from family or a friend. For example, the 17-year-old mentioned ear-lier who did not want “everybody” to know of her problems and whowanted to “keep it to myself” did later state that she confided in her bestfriend and her boyfriend when she was suicidal. Conversely, a 16-year-oldwho lived on the reservation said she did obtain professional help; however,she refused to confide in any friends or family members about her suicidalthoughts because “they might think I was crazy or something.”

Had Other Support

One fifth (20.83%, n = 15) of participants who avoided at least one typeof help cited the availability of other support as a reason for not using a dif-ferent type of help. In all but one case, other support was a reason for notusing formal help; one person said that receiving professional help eliminated





the need for him to talk with friends or family about his problems when hewas suicidal. A girl who thought about, but did not attempt, suicide said, “Italked it over with my mom, and we talked through it and got over it.”Similarly, a female participant who had attempted suicide stated, “I justtalked about it with my cousin. Afterwards, I felt better.” It is not surprisingto note that of those who avoided all types of help, none reported having anyother support as a reason.

Felt Hopeless and/or Alone

About one in five participants (20.83%, n = 15) who avoided at least onetype of help said they had believed that nobody could or would help them,whether because of potential helpers’ incompetence (n = 6), disinterest (n = 5),or inability to understand (n = 4). For example, one participant, 18, said sheavoided getting professional help because “I didn’t think it would do anything.”Two participants reported that they had used professional help in the past, butwith unsatisfactory results: “I don’t think it works. I’ve gone before and thedoctor didn’t do his job right,” a female participant said. Potential helpers’ lackof compassion, rather than competence, was an issue for other people. One par-ticipant, 19, did not tell any friends or family when she attempted suicidebecause “I felt that no one cared.” Even if others cared, they simply might notunderstand or take the person seriously. A 20-year-old who indicated that hehad attempted suicide said, “I felt I was alone. There was nobody else who hadthe same problems like mine, and the problems were not serious enough toanyone but me, which I thought were very big problems.” Four of the sixpeople who reported avoiding informal help because of feeling hopeless oralone did turn to a formal helper. Similarly, 4 of the 10 participants whoavoided formal help for this reason were helped by friends or family.

Self-Reliance

Responses were categorized as “self-reliance” if participants indicatedeither that they had effectively helped themselves—that is, they resolved thesuicidal thoughts or behavior on their own—or that they believed they shouldnot need others’ help. “I figured it out on my own that I should be smarter,” a16-year-old said when explaining why she did not seek professional help aftershe attempted suicide. A reluctance to burden others also caused some partic-ipants (n = 3) to feel that they should be their own helper. For example, an 18-year-old who did not turn to anybody when she attempted suicide said, “Inoticed that everyone has their own problems, and if I were to ask them forhelp or advice, I would feel like I am burdening them with my own problem.”




Of the 24 participants who received no help at all when suicidal, 20.83% (n = 5) cited self-reliance as one of their reasons.

Other Fears (Beyond Stigma)

About 12% of participants (n = 9) who avoided at least one type of helpsaid they did not seek any help because they feared the potential conse-quences, aside from stigma and embarrassment, of disclosing their suicidalthoughts or suicide attempt. Most commonly, in four of the nine cases wherefear was a factor, participants’ fears concerned being involuntarily commit-ted to a psychiatric hospital. A girl, 17, who attempted suicide said, “I wastoo scared to tell anyone what was going on in my head, and I didn’t wantto be committed.” In the same vein, an 18-year-old who thought about sui-cide said she worried that “they would lock me up.” Other fears concernedgetting into trouble (n = 1), being removed from their family’s home (n = 1),or triggering anger and rebuke in their parents (n = 1). Participants’ fearsrevolved around not only the consequences but also the meaning of poten-tially being deemed unstable. “Did not want to hear what they had to say,” afemale participant, 18, with prior suicidal ideation said.

Research Question 2: Did structural or attitudinal factors emerge morefrequently as reasons for not seeking formal help?

Of the 73 responses given for not seeking formal help, only three (4.11%)concerned structural barriers to care. Two participants reported that financialconcerns kept them from pursuing professional help. One person, 18, said sheknew of no mental health services where she lived; this respondent had movedfrom the large city to a reservation several hours away in an isolated part ofthe southwestern state. An additional 54 (76.06%) responses addressed attitu-dinal factors, such as stigma and perceived need for help, and the remaining14 (19.72%) concerned the availability of informal supports.

Discussion

This article reports the first study to ask American Indian young peoplewhy they avoided one or more sources of help at the time they thought aboutor attempted suicide. The major findings concern the attitudes, fears, andbeliefs (vs. structural barriers to care) cited by the vast majority of partici-pants. Most prominent among these reasons were lack of perceived need for





help, embarrassment and stigma, feelings of being alone or hopeless, andfear. Notably, of all the reasons given for not seeking at least one type of help,only two concerned structural barriers (transportation and costs), and veryfew participants cited these reasons. Instead, people gave reasons consistentwith Owens et al.’s (2002) “internally driven” barriers to care (p. 736). At thesame time, internally driven and externally driven barriers to care at times areintertwined, given that stigma, fear, and other internal reactions may arisefrom structural factors in one’s culture and environment. For example,stigma accompanying suicidal thoughts may vary by cultures and communi-ties. Similarly, procedures for involuntary commitment can account for inter-nalized fears. Structural barriers to care also might emerge more prominentlyif internal barriers were overcome; participants in the current study simplymay never have sufficiently entertained the idea of seeking help to take intoaccount how to pay for it, get to an agency, or find a service provider.

Calling on family or friends also figured largely into participants’ deci-sions not to use formal help. However, it is possible that using informal sup-ports constitutes a constructive alternative, rather than a barrier, to seekingformal help. Whether informal supports create a resource or barrier dependson the quality of the help they provide, a factor not investigated in the cur-rent study. Friends might exert negative peer pressure by encouraging self-destructive behaviors, discouraging other help seeking, or responding in astigmatizing fashion. Conversely, friends and family themselves can provideservices similar to those of mental health professionals by listening, givingadvice, and providing information about available resources (Stiffman et al.,2006). Pescosolido, Wright, Alegria, and Vera (1998) found that large socialsupport networks decreased the likelihood of a person obtaining professionalhelp for mental health problems.

The importance in the current study of illness perceptions, shame, fear, andother attitudinal factors belies a frequent research focus on income, insurance,and access to care as adolescents’ and emerging adults’ barriers to receivinghelp (e.g., Burns et al., 1997; Busch & Horwitz, 2004; Newacheck, Hung,Park, Brindis, & Irwin, 2003). The current study’s findings highlight theimportance of taking into account cultural and process-oriented factors wheninvestigating why young people avoid formal or informal helpers. The reasonsfor not seeking help given here, including stigma and perceptions of need,may well vary according to different cultural groups (Cauce et al., 2002).Unfortunately, the current study sample’s exclusive composition of AmericanIndians makes it impossible to investigate comparisons across cultures. Thefindings of numerous internalized, attitudinal barriers to care neverthelessunderscore the need to go beyond income, insurance, and demographic factors






as reasons for not seeking help. Research into help seeking and mental healthservice use frequently focuses on fixed demographic and financial factorsconsistent with Andersen’s (1995) model of access to care; one review foundthat 395 studies employed that model between 1975 and 1995 (Phillips,Morrison, Andersen, & Aday, 1998). Supplementary or altogether alternativemodels include those of Pescosolido (1992), who emphasized the socialdynamics of help seeking, and Cauce et al. (2002), who stressed culture andcontext in the various stages of deciding whether to seek help.

Finally, although American Indians face unique barriers to mental healthcare related to the IHS and cultural mistrust, such obstacles did not explic-itly emerge in the current study. A potential explanation may lie in the rela-tively brief questioning related to help seeking. A more in-depth interviewof the American Indian young people—in addition to interviews of theirparents, partners, and others in their social networks (Pescosolido et al.,1998)—may well have uncovered more culturally nuanced or structural rea-sons for their foregoing at least one type of help when they were suicidal.

Limitations

The study had several limitations. The open-ended responses were briefand constituted part of an overwhelmingly quantitative survey. Measurementof help seeking addressed help sought for any suicidal episode, and studyparticipants who had experienced suicidality on more than one occasion mayhave sought help at one time but not others. As such, the current study prob-ably underestimates the proportion of young people who did not seek helpduring a specific suicidal episode. In addition, the questions did not differ-entiate between help seeking before or after a suicide attempt. Information islacking about what the young people disclosed to their helpers, and whetherthe help seeking actually helped. Another measurement issue concerns thelack of questions about suicidal intent, severity of suicidal ideation or suicideattempt, making it impossible to discern those individuals at highest risk forsuicide. The current study also did not include indicators of suicide riskbesides mental health and behavioral problems (e.g., stressful life events);however, research indicating that more than 90% of suicide victims had apsychiatric disorder (e.g., Beautrais, 2001) attenuates this limitation.

Limitations of the sample include the study’s relatively small number ofparticipants, which limits statistical power, and the lack of a non-Indiangroup with which to make comparisons based on cultural differences. Inaddition, because the study participants reside in a limited area of theUnited States, the results may not apply to all young American Indians. Inparticular, the study’s focus on American Indian young people in or near an





urban area hinders its generalizability to rural areas; the reservation understudy, though technically rural, is surrounded by large suburbs and close toa major city. Mental health professionals are in such short supply in ruralAmerican Indian communities that youth in need of professional help maybe sent out of the community, or even out of the state, to receive services(Allen, LeMaster, & Deters, 2004). The specter of being isolated from one’scommunity and posing additional burdens on loved ones might furtherexacerbate barriers to care among rural Indian youth.

Summary and Implications

Notwithstanding its limitations, the current study makes progress inunderstanding some American Indian young people’s reasons for not seek-ing help when they thought about or attempted suicide. No other study hasasked American Indian adolescents and young adults why they decided notto ask others for help when they were considering taking their life. Theresults show that in addition to diminishing structural barriers to care, clin-icians, policy planners, and others in suicide prevention need to recognizeand attend to the importance of internally driven barriers among AmericanIndian young people, if not all young people in general. Many reasons thatparticipants gave for not seeking help are potentially modifiable througheducation of young people and their potential helpers. Examples includeprograms promoting mental health literacy (e.g., Kitchener & Form, 2002)and fighting stigma related to mental health problems and help seeking(Corrigan, 2004). Researchers need to investigate how barriers to care mayvary within American Indian communities, and among young people ofother cultures, races, and ethnicities. Suicidal behavior is a constant publichealth concern among many American Indian communities, and the factthat some young people would rather contemplate dying than seek helpillustrates the detrimental power of shame, stigma, and other internal barri-ers to seeking help even when help may be needed most.

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Stacey Freedenthal is an assistant professor at the University of Denver Graduate School ofSocial Work. Her research centers on suicidal ideation, attempted suicide, and help-seeking inadolescents and young adults. She also is a licensed clinical social worker.

Arlene Rubin Stiffman is the Barbara A. Bailey Professor of Social Work at WashingtonUniversity in St. Louis, George Warren Brown School of Social Work. Her research focuseson child and adolescent mental health, addictions, high-risk behaviors, and mental healthservices.





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