WVLDI Board Member Makenzie Peterson is the American Association of Veterinary Medical College’s (AAVMC’s) Director of Wellbeing. In the context of the stressors surrounding COVID-19, we asked her for some thoughts on wellbeing. Makenzie was interested especially in the profession’s discussion of suicide prevention. Makenzie notes, “There many factors that can impact someone’s mental health and wellbeing. Let’s discuss the process of help-seeking, some of the barriers, and how workplaces can support their members in seeking the help they need.”
Makenzie Peterson, MSc

How to Encourage Help-Seeking Behaviors
An evidence-based approach

There many factors that can impact someone’s mental health and wellbeing. When the profession discusses suicide prevention, one of the biggest factor involved is that 90% of individuals who die by suicide had a diagnosable mental health condition at the time of death. When discussing evidence-based ways to support mental health and do the work of suicide prevention, there’s a great body of literature on the topic and amplifying accessible and responsive mental health supports, reducing stigma around accessing care, and increasing help-seeking behaviors are just a few (the AVMA and AAVMC jointly created a great, free webinar on the topic). When focusing on encouraging help-seeking behaviors, let’s discuss the process of help-seeking, some of the barriers, and how workplaces can support their members in seeking the help they need.

What is the help-seeking process? 
In one of the few comprehensive studies into help-seeking behaviors in Australia, Rickwood et al. (2005) define help seeking in four stages: 

1. Awareness and appraisal of problems 
The ability to recognize symptoms, and that you have a problem that may require intervention from someone else. 
2. Expression of symptoms and need for support 
This awareness must be able to be articulated or expressed in words that can be understood by others, and the help-seeker must feel comfortable to do so. 
3. Availability of sources of help 
Sources of help and support in dealing with the problem need to be available and accessible, and the help-seeker must have an understanding of where/how to get that support. 
4. Willingness to seek out and disclose to sources 
The help-seeker must be willing and able to disclose their inner state to the source of help. 

For us to help people get to the help they need, we need to find ways to help them recognize that they have a problem that they can’t overcome on their own, to have the ability to express what they are feeling, to know where they can get help, and to be willing to seek out that help. 

What barriers are preventing people from seeking help? 
Many studies have been done into the key barriers to help-seeking. A detailed literature review was published in 2010 by Guillver et al. which reviewed 15 qualitative and 7 quantitative studies of people’s experiences of help-seeking for anxiety or depression. Key themes in the barriers identified to help-seeking were: 

Stigma and embarrassment 
The most frequently reported of all the barriers. Public, perceived and self-stigmatizing attitudes to mental illness create an embarrassment and fear of identifying with a mental illness or seeking help about it. Also prominent was a general concern about what others, including the source of help, might think of them if they were to seek help. 
“Because you can’t see it, it’s not real. Unless I’m in physical pain, there’s no reason to go seek help.” – ReachOut.com focus group participant. 

Problems recognizing symptoms (poor mental health literacy) 
It was frequently reported that people simply don’t know how to identify when the difficulties they are facing are beyond the normal threshold of stress. One study reported that people were aware of their distress, but continuously altered their definition of what was “normal” distress to avoid seeking help. 
“Stress is normal…” – Eisenberg (2007), in Gulliver et al. 

Preference for self-reliance 
A consistent factor in both qualitative and quantitative research was the trend that people prefer to rely on themselves, rather than seeking outside help for the problems they were facing. To seek help from someone else is often seen as an indicator of weakness, or not being capable of dealing with normal life problems.

Confidentiality and trust 
A major concern for many people was a lack of trust with respect to the potential source of help. Fears of a breach of confidentiality leading to exposure, distrust of the credibility or authenticity of providers, perceptions of judgmental attitudes, and a lack of familiarity were all identified as aspects of this barrier. 

Additionally, Rickwood et al. suggested that the feeling or perception of hopelessness was a strong contributor to the help negation effect (a consistent pattern where the higher someone’s levels of distress, the less likely they are to access support). 
“I felt that no person or support service could help.” – Dubow (1990), in Gulliver et al.

Individual factors in help-seeking 
In the review of existing literature, Gulliver et al. found research that looked at what facilitates help-seeking behavior was far less comprehensive. Three key factors which had been reported in the previous studies were: 

1. Positive past experiences 
Three studies investigating facilitating factors reported positive past experiences of help-seeking or support as a significant influence on help-seeking. This could also include increased mental health literacy and service knowledge from earlier help-seeking. 
2. Social support and encouragement from others 
Influencers such as parents, partners, loved ones who are supportive and open to professional support as a factor in good health and wellbeing, or friends who have had positive experiences, were positive influences on help-seeking. Interestingly, people were observed to be more likely to seek or recommend help for a friend, than to seek help themselves. 
3. Emotional confidence/mental health literacy 
Rickwood et al. found that one of the most important factors in help-seeking was people having the ability and confidence to identify and articulate their emotions, and their ability to recognize and understand the symptoms of a mental health difficulty.

Workplace supports to help-seeking 
There are ways that workplaces can encourage help-seeking behaviors in others: 

  • Normalize people talking to counselors/ therapists, trusted friends, engaging in evidence-based peer-support programs, and calling/texting helplines. 
  • Avoid perpetuating stereotypes about mental illness, people losing their jobs and being on unemployment, etc. that may be stigmatizing and harmful. 
  • Avoid using stigmatizing language, such as “crazy,” “psycho,” “lazy,” “freeloader,” etc. and avoid allowing such labels to be used to describe coworkers or clients. 
  • Support and encourage people to develop a “personal care plan” that sets out how they plan to seek help if they need it and who they should contact if they become unwell. 
  • Include resource information/links in the majority of your communications material. 
  • Have a range of printed resources available that people can take home and read in private. Online resources and fact sheets can also be helpful if you want to reduce paper handouts. 
  • Recognize that making an initial phone call for help can be hard for someone. Ask permission to forward their details to services that can support them or ask to make an email introduction connecting them to the right person. 
  • Don’t make promises you can’t keep. Only encourage and offer help when you know that help will be available. Be aware of eligibility requirements before you refer people to other services, so you don’t set them up for disappointment and frustration. 
  • Be aware that cost, location, restricted opening hours, eligibility requirements, culture, literacy, and stigma can all be barriers to help-seeking. Work to make your resource offerings as inclusive as possible. 
  • Model help-seeking behaviors not only for mental health concerns but also for other common challenges such as stress, divorce, death, etc. 

If members of the veterinary profession are looking for an evidence-based peer-support program, the American Association of Veterinary Medical Colleges (AAVMC) recommends the Shanti Project. The program is coordinated by Dr. Katie Lawlor, a psychologist out of Stanford. 

About The Shanti Project program for veterinarians:

The peer-support groups are virtual, and because of the legal constraints of practicing across state lines, the groups function as facilitated psych-educational groups. The program is evidence-based, and they always have two licensed mental health professionals (MPH) running the groups, so that in the event a participant is in crisis, a trained MHP is available to assist that person, while the other continues to run the group.

For each group session, they have a general topic/theme (example; boundary setting), with flexibility built in, should the group want to focus on a different topic that day. The Shanti Project received significant donor funding which allows them to operate their services at no cost to veterinarians. The organization itself is under the auspices of PAWS, a non-profit organization out of San Francisco. Veterinarians interested in joining a group may email Dr. Lawlor directly at klawlor@shanti.org and can also see their webpage at Veterinary Mental Health, Support, and Resiliency Group for more information about the program.

Based on their evidence-based approach, the full integration of licensed mental health professionals, the ethical standards of privacy and practice being met, and my conversation with Dr. Lawlor, AAVMC feels comfortable recommending this peer-support service to veterinarians.