Barriers and Facilitators to Seeking Psychological Assistance in School Education System

Optimization of the models for the provision of professional psychological assistance to students is one of the priority tasks of the Concept for the development of psychological services in the education system of the Russian Federation. The aim of this study was to identify the barriers and facilitators in seeking psychological help among Russian secondary school students from the perspective of experts who provide such assistance. Two series of semi-structured interviews (before the COVID-19 pandemic and during it) with 10 experts from seven regions of the Russian Federation responsible for organizing psychological work in the region were carried out. The barriers and facilitators of help-seeking identified as a result of the thematic analysis were compared with the AAAQ model (availability, accessibility, acceptability, quality of help) (WHO, 2017). Among the barriers, a special place is held by factors associated with acceptability and the perceived quality of provided assistance. Among the facilitators, experts especially highlight the factors related to the availability and the acceptability of psychological help (knowledge of the possibilities of obtaining it, its credibility, the use of new communication technologies of with a psychologist). Associated with the pandemic waving up in psychological difficulties and the expansion of remote communication have become powerful factors in the increase of availability and acceptability of psychological services.

Introduction

All over the world, including in Russia, significant efforts are being made to improve psychological support in education [3; 11]. Increasingly, both in Russia and abroad, school psychologists are considered as important service providers of mental health care for children and adolescents [7; 19]. The WHO notes that “half of all mental health disorders occur before the age of 14” [15]. The leading role in recognizing psychological distress in students belongs to psychologists working within the education system. Psychologists are also entrusted with preventive tasks to help strengthening the health of children and creating conditions for their harmonious development in accordance with the biopsychosocial ecological model [18].

In accordance with the law “On Education in the Russian Federation” [5], the powers to organize the provision of psychological, pedagogical, medical and social assistance to children are assigned to regional and municipal authorities. Despite the existence of a normative regulations on the activities of educational psychologists [3; 4], psychological support practices differ across the nation’s regions (for example, in terms of the existence of Psychological, Pedagogical, Medical and Social (PPMS) centers and coordination between them and educational psychologists). These differences may be justified by socio-cultural and territorial specifics, but may also make it difficult to ensure equal access of children to health care and preventative services.

One of the most important factors in the effectiveness of public psychological support for education is accessibility [11]. Studies show a gap between the actual usage rate and the general need for psychological help, which can reach 90.2% [8; 17]. Why such a gap exists can be answered by analyzing specific barriers to and facilitators of help seeking.

The factors determining help seeking are closely related both to the specific model of providing psychological help, and to the socio-economic and cultural context of the region in question. There have been attempts to critically analyze such models in different countries, for example, in the USA, England, and Kazakhstan [11; 13; 21]. In Russia, practically no such research has taken place[2; 6], although the study of this problem is of a high priority for the development of psychological services in the education system [3].

The objective of this study was to characterize the barriers to and facilitators of seeking psychological help among secondary school students through the eyes of the professionals who organize the provision of such help. The conceptual framework for the analysis was the AAAQ model of Core components of the right to health, developed by WHO [14]. Since education system has been transformed by the COVID-19 pandemic, describingits impact on help seeking also became relevant for the current study.

Methods

We conducted two series of semi-structured expert interviews in the summer of 2019 (before the pandemic) and in the fall of 2021 (during the pandemic). The sample was targeted and the selection criterion for experts was the positions they held: the chief supernumerary psychologists of the region and specialists recommended by them, responsible for providing psychological support within the secondary education system. The survey involved 10 experts (8 women, 2 men) from seven regions of the Russian Federation, of which 8 experts held managerial positions, and 2 were non-managers. In the second section, 8 experts who were still working in the psychological service system at the time of the survey were re-interviewed.

The telephone interviews lasted 30 minutes on average. It should be noted that the experts did not separate referrals initiated by adolescents themselves and third parties, therefore the barriers and facilitators described characterize such help seeking in general.

Data processing was carried out using thematic analysis [9]. The selected topics were compared with four interrelated analytical categories from the AAAQ model [14; 20]:

A — Availability — a sufficient number of psychological services are provided;

A — Accessibility — the physical, economic and informational accessibility of services;

A — Acceptability — compliance of services with the standards of professional ethics, the cultural, gender and age characteristics of consumers of services, and their understanding of the the help provided;

Q — Quality — the qualifications of the psychologists and the scientific grounding of their psychological services.

The results of the study are illustrated with quotations.

Results

The study identified certain categories of barriers and facilitators (Table 1).

Availability

Regarding barriers to seeking psychological help, the experts highlighted the absence or irregular presence of a psychologist at school. “The Law On Education stipulates that every child has the opportunity to receive psychological and pedagogical help, but there are no clear official requirements for the presence of a psychologist at an educational organization” (No. 7).

The absence of a psychologist tied to a given school may hinder the development of a trusting relationship between specialists and children. “Not a single tenth-grader girl will tell a visiting specialist that her stepfather is sexually harassing her” (No. 3).

Accessibility

The experts highlighted some of the barriers facing accessibility of psychological help. The first is the lack of an opportunity for children to independently seek face-to-face psychological help. “Legislation does not allow us to work with a child under the age of 14 years old without parental permission” (No. 4). “When I used to work at a school, children came to me with questions, but now the child must inform their teacher, head teacher or parent that they need a psychologist, or come to me at the PPMS center. 75% of the child-psychologist’s work is lost” (No. 3).

The second is the work overload that many school psychologists deal with due to participation in various school events (for example, monitoring) or assignments from the school administration that are not related to psychology. Experts see reasons for psychologists’ work overload in their subordination to the school administration and in the administration’s poor understanding of the possibilities offered by psychological help. “There is no time for contact work… if they were outsourced [independent of the school administration], it would be better” (No. 3). “We are slipping into the stereotype that the more diagnostics a psychologist has done, the better he or she works. And the process of supporting difficult children often remains outside our purview” (No. 9).

Among the facilitators, factors regarding informational accessibility were noted, that is, the awareness of all participants in the educational process about the possibility of obtaining psychological help. “We send out information to educational institutions, we go to parent-teacher meetings... Parents do know about us” (No. 1).

The pandemic, according to experts, had a positive impact, increasing the availability of psychological help thanks to an informational campaign about possible ways of receiving it remotely. It has also increased the use of online technologies: specialists in psychological services “developed their sites, filling them with video recordings of webinars” (No. 5).

The remote provision of psychological support evens out territorial inequalities (which is a great help for remote rural schools without psychologists). “Boundaries no longer exist. A parent can consult from home” (No. 2).

However, the transition to remote counseling has exposed another form of inequality — the inaccessibility of help for those who lack technical equipment. “Not everyone has the opportunity to consult remotely. Either it costs money, or they don’t have Zoom, etc.” (No. 4).

Acceptability

The first barrier, noted by experts, was associated with stigmatization, misunderstanding the details of a psychologist’s work, the differences between their work and that work of a psychiatrist. “You ask a teenager — have you visited a school psychologist? Oh, no! If anybody sees, then it will be a nightmare ... only weird people visit psychologists” (No. 10).

The second barrier was associated with the fear of confidentiality breach. “Parents are not always ready to discuss the child’s problems in the educational organization where they are studying... Parents are afraid of disclosing information” (No. 3).

Experts noted that PPMS centers may be associated with greater anonymity among service recipients: “they come to us more often, so that no one in the educational institution knows about it, because anonymity here is higher” (No. 1).

Another barrier was the fear of negative consequences from help seeking, the transmission of information to other government agencies or possible discrimination toward the child outside the school. “They are afraid of state institutions, they are afraid that the information will get somewhere” (No. 8). “Parents are afraid to ruin their child’s life because they [state institutions] will lock the kids up and that would be it” (No. 3). “They are afraid that this will go through some kind of screening, that it will be visible somewhere later” (No. 9).

The preference for alternative types of help was also seen as a barrier. “Although it was possible to refer to a psychologist, they went to church, to fortune-tellers, astrologers. Some crazy money was paid to such private organizations” (No. 9).

The pandemic has fuelled inadequate perceptions among young people about the need for help thanks to low levels of mental health literacy (low levels of recognition of the symptoms of mental distress in oneself and others). “Separation problems have been exacerbated [for teenagers during the pandemic] when they are at home and are placed under excessive control. We are already seeing cases of self harm come in” (No. 3).

When the experts are identified as facilitators, we see destigmatization of psychological help, increasing confidence in the service specialist, and a rise in the relevant forms of online communication. The importance of popularizing practical psychology was noted, providing meetings with psychologists to show “that it’s not shameful, it’s not scary and nothing terrible will happening to you here” (No. 10). Effective strategies for developing confidence in psychologists proposed included increasing the involvement of psychologists in everyday school life: “participation in class meetups and parent-teacher meetings, where they can show what they have to offer” (No. 4); the inclusion of psychology classes in the curriculum for 8—11 grades: “I already knew them like the back of my hand. Surely at least someone would remain after classes for a break, and I had to whisper with them one-one-one behind closed doors” (No. 3); the use of forms of online communication that are effective for adolescents and parents, for example, “psychological support clubs, where they simply offer advice, including via chat” (No. 6).

The pandemic has pushed much of healthcare online, normalizing such a medium of provision and making it more accessible. Experts noted that teenagers “live” on sites developed by psychologists, “look at our actual work, and then it’s not so scary [to visit a psychologist]” (No. 5).

The pandemic contributed to an increase in the possibility of anonymous online referrals for help: “We made a page where the child could apply anonymously online” (No. 8); “some feel safer online” (No. 4).

Quality

Experts have noted the following barriers to visiting a psychologist related to the quality of the services provided:

— objectively low qualification levels among psychologists in the education system. “The psychologist writes in the report — Vasya has the character of a rectangle, according to the zodiac — is a leo” (No. 8).

— a psychologist is subjectively perceived to have low qualifications due to a confusion of social roles. “The art teacher went to college and became a psychologist, but in the eyes of the students, (s)he is still just an art teacher” (No. 10).

— low assessment of the effectiveness of a psychologist’s work when experiencing unpleasant emotions after interacting with him/her. “It is not always possible for recipients of psychological help to assess its benefit adequacy. For example, the procedure may be unpleasant but beneficial” (No. 7).

— low-quality infrastructure (conditions for working with a psychologist). “His office in the basement, it is uncomfortable and stuffy”, therefore, according to the expert, it is necessary to “find or create the right environment to facilitate psychological help” (No. 2).

The increase in the workload of remote psychologists during the pandemic has exposed the quality limitations of online work. “Online consultations have shiftef from therapeutic work to educational work” (No. 1). “The empathy that should be present face to face isn’t there” (No. 3).

Among the facilitators, the experts noted that highly subjective evaluations of the effectiveness of the help received from a psychologist could sometimes count: “wow, that help was so effective” (No. 4).

Table 1

Barriers and facilitators of seeking psychological help by students and their parents/legal representatives in relation to the AAAQ model

(Italics highlights the factors specific to the pandemic period)

AAAQ Model Components	Barriers	Facilitators
Availability	Absence or irregular presence of a psychologist at school
Accessibility	Lack of the possibility for children under 14 years of age to seek help independently Overload of a given psychologist Lack of software or devices for remote communication	Increasing knowledge about the service Development of a remote format of psychological support
Acceptability	Stigmatization Fear of privacy violation Fear of negative consequences and discrimination against the child Preference for other types of help (fortunetellers, etc.) Counterproductive perceptions about the need for psychological help	De-stigmatization of psychological help Trust in the appointed psychologist Utilizing relevant online forms of communication Increasing the anonymity of the referral
Quality	Low qualification level of educational psychologists (objectively and subjectively perceived) Poor perceptions of how effective the psychologist is Poor infrastructure (location, equipment) Inherent limitations of the online counseling format	Good conditions for the psychologist’s work (in accordance with their position functions); technical equipment for remote work Perceived competence of the psychologist

Discussion

In observing the growing number of referrals, the experts tend to underestimate the size of the gap between the need among students and parents for psychological help and how much is provided and in what form. Studies in European countries have also pointed to an obvious discrepancy between the amount of services provided and the needs of their consumers [22], which becomes particularly evident during periods of social crises. Since experts do not distinguish between referrals initiated by adolescent themselves or by a third party, adolescent-initiated referrals may also be underestimated. Meanwhile it is extremely important to differentiate these forms of help seeking — if the parent or teacher acts as the initiator of the referral to the child’s psychologist, then such an experience does not contribute to the child’s readiness for repeated referral [12].

Experts see the fear of confidentiality violation as one of the key barriers to seeking psychological help, but the sources of these fears may vary. Some believe that faith in confidentiality within an educational organization is made possible by building trust in a familiar specialist, and point out that students and their parents have more concerns about external organizations (PPMS centers) that may transmit personal information to other institutions. In contrast, other experts report fears about disclosure within the organization where an adolescent studies, and perceptions of greater anonymity outside of it. Assessing the extent to which such fears are widespread and legitimate, and what format of help beneficiaries associate with greater confidentiality, is an important task for future empirical research.

The transformational processes triggered by the COVID-19 pandemic have highlighted additional barriers and facilitators. The digitalization of psychological support was assessed by the experts ambiguously. Remote help increases access by expanding the geography of coverage, opens up new forms of assistance (using social networks and instant messengers), and increases the acceptability and quality of services provided. Other studies emphasized the psychologists’ growing arsenal of tools thanks to the rise of telepsychology [1]. But both the technical and qualitative limitations of the online format of work can become barriers. The availability of remote psychological help for low-income families is decreasing. This raises the ethical issue of using remote forms of psychological support associated with a relatively new form of digital inequality [16]. At the same time, according to experts, this form of work may be inferior to the traditional one in terms of the quality of support provided.

The AAAQ assessment model (Availability, Accessibility, Acceptability, and Quality of service) has proved to be a heuristic for delineating the barriers to and facilitators of help seeking. This study revealed that all four of its components currently require attention. When improving psychological help services, it is necessary to take into account cultural factors of the acceptability of help seeking [10]. In our study, the following barriers were identified: the specifics of understanding mental health norms and pathology, the ability to recognize mental ill-health in oneself and others, and preferences for alternative, near-psychological types of support.

The main limitation of this study is that the views of the experts who provide mental health services may not coincide with the views of the potential beneficiaries. However, the opinions of such experts is extremely important, since it will be the driver for transformation of the psychological help system.

Conclusion

The study made it possible to characterize how the barriers to and facilitators of seeking psychological help in the education system are seen by the experts responsible for its provision in the regions of Russia. The analysis of the experts’ presented the conclusion that the barriers and facilitators identified by them are consistent with all analytical categories of the AAAQ model. Today, factors related to the availability of psychological support services within the education system, the accessibility of these services for all participants of educational relations, as well as the acceptability and quality of the services provided are vital. The greatest number of barriers identified by the experts is associated with the acceptability (stigmatization, violation of confidentiality, fears, etc.) and the quality of the services provided (low level of specialists’ qualifications, poor views of the effectiveness of such support).

Factors facilitating the seeking of psychological help were mainly related to the availability of he services. Measures aimed at de-stigmatization, building a trusting relationship with a particular psychologist, and increasing the anonymity of referrals would make psychological services more inviting. The increase in psychological problems associated with the COVID-19 pandemic and the prevalence of remote forms of communication had been powerfuls factor in the growing availability and acceptability of psychological services for students. The data obtained can be used to develop measures to improve psychological services in the education system.

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