Participants and recruitment.

We interviewed participants with knowledge of mental health employed in public service (city and county government) and young people (16 years and older) living in King County by recruiting a convenience sample of 15 key informants between September and December 2019. We recruited five adult key-informants in public service during a series of meetings to orient local policy makers and mental health experts to citiesRISE activities and aims. We used snow-ball sampling through youth networks known to the research team members to recruit youth key-informants from two different groups: 1) young people engaged in youth-focused initiatives in Seattle (N = 4) and 2) young people working or studying in the Seattle community (N = 6).

Data collection tools and procedures.

To ensure consistency, we conducted all interviews in English using a standardized interview guide that posed similar questions to each participant. The topics covered mental health needs among young people, common mental health problems, gaps in mental health services, opportunities for intervention, and opportunities for youth engagement. Youth participants received a $50 gift card for their participation. Participants completed one interview. All interviews were recorded and transcribed for analysis.

Data sources and measurement.

We conducted a thematic analysis of the interview data driven by our research question: what are the gaps and opportunities for youth mental health interventions in Seattle/King County? After reading the transcripts multiple times, we created case summaries and conducted an in-depth indexing of the interviews, organizing them according to the primary themes of the interview guide. We used this guide to develop a deductive code list. The research team met several times to conduct open coding, review data coded, introduce new codes, and to resolve discrepancies in coding. We created a codebook based on these discussions and coded the remaining interviews. The current paper presents findings on mental health risks and needs, gaps in care, youth engagement and intervention opportunities.

Participants and recruitment.

We invited young people and adults in the Seattle/King County area to complete brief, structured, online questionnaires from February through March 2020. Participants were recruited through fliers and links that were disseminated through school- and community organization-based mailing lists and through an Instagram promotion targeting young people in the Seattle/King County region aged 16–24. Adults over the age of 24 were also eligible to participate. We used non-probability sampling by conducting an online survey on Instagram, resulting in a convenience sample of respondents.

Data collection tools and procedures.

Informed by output from the roundtable discussion and preliminary qualitative data findings, we designed a twenty-five-item questionnaire. Questionnaires took approximately fifteen minutes to complete and were available in English.

Demographic information included participant age (in years), gender identity (woman, man, nonbinary), race or ethnicity (Alaska Native, American Indian/Native American, Asian, Asian–South Asian, Asian–Southeast Asian, Black/African American, Black African, Hispanic/Latinx/Chicanx, Middle Eastern, Native Hawaiian, Pacific Islander, White/European American, as well as any racial/ethnic identity not listed), youth identity status (youth or non-youth), birth year, employment status (studying, employed, self-employed/freelance, interning, part-time, unemployed-looking for work, unemployed-not looking for work, homemakers, military, retired, not able to work, or other), education level (no formal education, pre-school to 8^th grade, some high school with no diploma, high school graduate with a diploma or equivalent (e.g., GED), some college credit with no degree, trade/technical/vocational training, associate degree, Bachelor’s degree, Master’s degree, Professional degree, Doctorate degree), South Seattle residence (yes or no), and zip code.

Mental health priority issues and satisfaction. Relative priority of nine different mental health-related issues (overall mental health, alcohol and substance use, depression, anxiety and stress, schizophrenia and severe mental illness, suicide and self-harm, homelessness, poverty, racism and inequality, and social connectedness) was assessed with a three-level Likert scale, where each issue was rated as not important, somewhat important, or very important. Satisfaction with these same nine mental health-related issues was assessed with a three-level Likert scale, where respondents rated their perception of efforts to address each issue as not satisfied, somewhat satisfied, or very satisfied.

Barriers to mental health. Participants were presented with a list of potential barriers to youth mental health and asked to choose the three most important barriers. The barriers included lack of support from peers, lack of support from parents/guardians and family, lack of future economic opportunity (e.g., jobs), lack of future educational opportunity (e.g., college), lack of after-school activities, lack of support from the school system, lack of access to quality health care, lack of awareness and skills related to mental health, exposure to violence, exposure to racism and social injustice, unstable or unavailable housing (housing insecurity), and other barriers not listed above as identified by participants.

Mental health intervention platforms. Preferences for mental health intervention platforms and approaches to improve youth mental health were assessed by asking respondents to select two ideal platforms and two priority services. The following mental health intervention platforms were presented: schools, community centers, churches, online platforms, workplaces, clinics and other health care settings, in public/on the street, or other places not listed above as identified by participants. Participants selected from the following priority services: positive youth-led mental health messaging developed by youth for youth, training in resilience and self-care, training in awareness and peer support, provision of safe spaces, access to counseling and treatment aligned with the values and traditions of the community, housing and social services, employment opportunities and career counseling, or other services, programs, or activities not listed above as identified by participants.

Acceptability of Intervention Measure (AIM). Four specific evidence-based interventions or services were described in detail, and acceptability of each intervention or service was assessed using the 4-item Acceptability of Intervention Measure (AIM) [19]. These interventions included the Friendship Bench psychosocial support model, the provision of safe spaces, peer navigation and support services, and arts-based mental health promotion and suicide prevention in schools. Items assess level of approval (e.g., “Friendship Bench would meet my approval”), appeal (e.g., “Friendship Bench would be appealing to me”), liking (e.g., “I would like Friendship Bench”), and willingness to welcome (e.g., “I would welcome Friendship Bench”) the interventions. Participants rated their level of agreement or disagreement with each statement using a 5-point Likert scale, ranging from “completely disagree” to “completely agree.” The scale provides a numerical rating that reflects the participant’s perception of the intervention’s acceptability.

Perceived risks for poor mental health among youth in Seattle.

Public service participants identified homelessness, domestic violence, access to weapons, risky home environments, substance abuse, harm by the criminal justice system, suicide, and isolation or lack of connectedness as drivers and consequences of poor mental health among youth in Seattle and King County. Youth participants and allies identified depression and anxiety, gentrification, school competition, intergenerational challenges, affordable housing, and exposure to adverse childhood events among the areas influencing youth mental health. All participants highlighted the challenges of isolation and connectedness as important factors.

Fighting hard to stay connected. Public service and youth/ally participants identified lack of connectedness as the most commonly reported risk factor for poor mental health among young people. A participant noted that while loneliness is often recognized as a health problem for older adults, young people also experience the “significant problem of isolation.” Gentrification was proposed as one explanation. Several informants explained that the rapid pace of gentrification led to the displacement of youth or their peers from communities where they had longstanding social connections. According to one participant, “The kids you start off with in grade school are not going to be the same kids that you end up with in high school,” as had been typical in the past. “Part of that has to do with the affordability issue of being able to live in the city over the long term,” another participant described. Participants highlighted the devastating impact of gentrification on communities—people were “really fighting so hard to…stay connected to the schools and communities they feel they have the most connection with.” As a result of this displacement, families were often scattered across the southern part of the county, disrupting informal support systems and exacerbating physical and emotional isolation.

Young people also attributed social isolation and lack of connectedness to the “Seattle freeze,” a cultural trait marked by social reserve and a lack of engagement with others. Youth participants from other regions of the country recounted the difficulty of making new friends and bewilderment when their usual gestures of friendliness were not returned. One participant confessed, “I didn’t understand why people were so distant…I remember I would like to smile at people on the street and they would look confused…that kind of isolation is a detriment to mental health and for youth for sure.”

Another youth participant linked isolation with self-blame, which reinforced young people’s social withdrawal. “Folks are like, I’m the only person who’s struggling with this and…I’m just doing it by myself…no one would…ever understand what I’m struggling with, you know.” Public service participants, who alluded to recent increases in suicides among youth in Seattle, linked risk with social isolation.

Mental health is taboo. Given the taboo surrounding mental health and mental illness, young people were often reluctant to discuss their symptoms, which further exacerbated their feelings of isolation. A participant noted, “There weren’t a lot of people who are open to speaking about mental health, and I think that’s also another barrier that leads people to closing everything in, not being able to speak about it and realizing…like, there’s something wrong with me, but I don’t know what it is.” Intergenerational differences in cultural understanding of mental health problems could elicit similar feelings of isolation and increased stress. In some cases, parents who had immigrated to Seattle and sought to establish a new life tended to prioritize “survival mode” over mental health, leading to a perception that mental health concerns were less important and not to be raised as a problem. Participants recognized the consequences of this dismissal. A student commented, “If at home you can’t express your emotions and at school you need to study, study, work and work…then your emotions never come out…and they’re building, they’re building, they’re building, and it turns into depression…”

Gaps in responses to mental health needs.

Participants reported gaps in response to the mental health needs described. They associated these gaps with difficulties accessing formal mental health services and informal sources of support (not having a place to go), young people’s lack of knowledge about how and where to seek help, and a range of cultural barriers that could diminish access to care.

No place to go. “Not having a place to go” and “not reaching out” complicated young people’s ability to access care, but the sense that services were siloed and that few options existed outside of highly structured inpatient environments was viewed as problematic by some respondents. “There is nothing really in between—a supportive program where they can, you know, relapse. If you don’t succeed, you’re failing.” A public service participant noted that the mental health system’s emphasis on numbers of beds and residential treatment conflicted with the aim to divert youth from more restrictive environments. “We’re striving to find opportunities to divert youth from those places and to be able to seek help in communities.” When youth accessed outpatient formal mental health services, the challenges of payment and confidentiality within the family arose. Some described the difficulty of not telling parents about seeking care yet needing access to parental insurance or other financial support. Some noted that few responses outside of the health system existed and that youth would benefit from more holistic approaches that “go beyond the individual” and that were not part of formal healthcare services.

Outside of formal services, several participants noted a lack of designated spaces for young people to receive formal and informal support, to connect with each other, and to experience community. A public service participant described the need for “a space where youth can go…and connect with another youth who has perhaps gone through the system, is familiar with the system and to be able to join with them…” A young participant’s perspective supported this view.

Something you could benefit a lot from is just hav[ing] a safe place to to—having a safe place…somebody that they can actually like, confide in and …like, say whatever they need to, just having a …safe areas where they can …go and not be afraid of the place being torn down or being removed to put up something like condos.

A similar idea was expressed by a participant who acknowledged the need for “a space to unload” amidst a community of people who “like, got your back,” whereas another young person missed the central gathering places for youth that an urban downtown could offer. Lack of easy transport to a gathering place for youth in the central city challenged youth people, and the absence of a “constant community,” as the same participant described, “is really one of the.biggest detriments to…youth mental health that I’ve seen or experienced just because I think it’s so important to …make those kinds of connections, and it really takes a lot of …initiative for kids in Seattle to do that.”

No one really knows how to help themselves. Youth participants reiterated that most young people lacked basic information about what to do if they experienced a problem with their mental health. School counseling services, in high schools and colleges, were thought to be insufficient for young people with significant needs and were often overwhelmed by demand. Several youth participants expressed the need for increased outreach and information about mental health care. One youth noted that school environments tend to be more reactive rather than proactive when communicating about mental health resources. “There isn’t very active promotion anywhere about mental health resources…word of mouth, I think is actually the biggest way of hearing about these resources…but like active encouragement and using them is not really present.”

Cultural barriers. Youth participants acknowledged the influence of cultural expectations on seeking help for mental health problems. One participant explained the implications of visibility when managing a mental health problem:

It’s very important that people know that if someone is dealing with the mental health issue, they’re not only dealing with their mental health, but they’re dealing with what people are going to say about them. They’re dealing with what their parents are going to think about them, what their grandparents are going to think about them.

Young people believed that social stigma attached to mental illness was prevalent across most communities, but collectivist communities were also more likely to pull together to support each other. In some settings, such as schools, being associated with mental health groups or events could lead to stigmatization, causing young people to avoid them. One participant described “cultural stigma of mental health” as a deterrent to seeking care, particularly when mental health problems were not taken seriously. Relatedly, young people requested greater availability of culturally sensitive mental health services. They reported a dearth of non-white therapists and a missing “cultural connection” with therapists available to them. This included a need for providers who understood differing generational perspectives around mental illness as well as generational differences in exposure to mental health threats. A youth participant noted that young people compared their lives to their immigrant parents’ experiences and questioned, “…like, what right do I have to be sad about this?” A public service participant identified the lack of culturally appropriate community-based youth mental health support as a gap area, particularly as alternatives to more restrictive forms of care.

You need to hear from the kids: Youth leadership and youth participation.

Youth/ally participants in our study were actively involved in promoting or leading projects, initiatives, or organizations interested in youth mental health. As such, they emphasized the importance of youth involvement in the development and promotion of youth mental health interventions or activities. For some community organizations, the value of youth participation was built into the structure, with one participant describing an organization where youth constituted 50% of the representatives on the board of directors. Others described youth-led exercises and projects where youth creativity, energy, humor, and words defined the intervention. They emphasized the importance of young people having the space and mandate to invent ways to relate to each other, and several observed “brilliant” and “poignant” activities resulting from these efforts. One participant, mused, “And when people see youth empowered in that kind of way, I think it really changes their perspective on their expectations of what these youth can do…in their life as well.” A policymaker expressed support of youth leadership and posed the question, “How do we help those young leaders and those young individuals who have a voice… you know, take those risks and speak up and feel valued enough that they can kind of keep that momentum going and not be isolated with that?”

Another participant described the level of youth leadership and involvement required to design shared spaces for youth mental health and a desire to see “without tokenizing…kids who have struggled with mental health care in Seattle in on the conversation surrounding mental health…they should be the ones working on the initiative…organizing employment and organizing what the [space] should look like…” Youth being integrally involved in the organization of the space was particularly significant because their pride in the project, i.e., their sense of ownership, would enable them to reach out to more young people, inviting them to join as organizers or co-creators of a shared space. Another participant emphasized the importance of designing interventions for specific communities, explaining that “mental health isn’t cookie cutter,” and ensuring a sense of belonging was a necessary part of design. This participant described the process of piloting a program, collecting feedback, and tailoring the program to meet the needs of participants.

Even with youth-led mental health activities, intentional outreach and a credible initiative were required for youth participation. Social media and word of mouth were identified as powerful and effective means for young people to inform others about mental health resources or programs. One participant discussed the challenge of credibility when disseminating information and encouraging participation in mental health activities, noting that the support of adult experts could lend credibility to young people. Partnering with people with subject matter expertise could safeguard against youths’ worries that they were leading conversations without the required knowledge.

On the other hand, young people also experienced their perceived lack of expertise by adults as a form of discrimination. Some participants spoke of youth input not being respected or their qualifications to talk about mental health being questioned. These beliefs played out in interactions in public spaces. “We would be at the table, but we would never get a chance to speak. We would never really get a chance to share our input. We’re kind of there to just be like a little model—to show off like, ‘look we have kids on our side.’” Others questioned more generally, “Do people actually want to hear our voice? Older people than us? Actually, want to hear our voice? Then do they actually act upon them?”

Interventions.

Challenges to youth mental health were most frequently attributed to social and relational problems (i.e., intergenerational, family, or cultural mental health stigma), and the suggested interventions corresponded to these perceived causes. These ranged from creating positive and accepting environments that help “people feel wanted, involved, engaged, and valued” to implementation of specific services like mental health first aid. Services that addressed family reconciliation after encounters with the criminal legal system or that worked to dismantle the “school-to-prison pipeline” were relevant and were viewed as part of efforts to address the harms of structural racism. Alternatives to therapy, like peer support, were also noted, as were more general approaches to stabilizing and supporting families. A public service professional noted, “For those who have their family and that’s where they turn for their core support…finding ways to stabilize that part of the system I think is helpful. It’s not an easy one, though.”

Community institutions, such as schools, despite their challenges, were seen as important places to promote mental health. Youth leaders in the community actively engaged with schools by conducting workshops, mobilizing peers, and educating students, teachers, counselors, and educational personnel. They also explained how other community programs that engage young people in activities such as sports, theater, or shared hobbies could be used to explicitly introduce mental health themes or create communities that foster connection and support. For these programs to succeed, it was essential for young people to be centrally involved in their development and implementation, allowing them to contribute creatively. One participant remarked on witnessing young people create what they needed for mental health, “I think young people are so smart about making this stuff …joyful…Really, it was the most brilliant thing I’ve ever seen.” Youth participants articulated the nuance required for success: young people should not be tokenized in partnerships with experts or other adults, and they should also have access to people with knowledge and expertise they lack.

Open-ended feedback.

Participants had the option to provide additional context to their positive or negative reactions, as well as options to adapt the interventions in the survey (Table 4). Suggested adaptations included adding a training component on social justice for individuals delivering psychological interventions (e.g., the Friendship bench); ensuring that spaces reserved for youth to gather were safe places for Black people as well as people of color; and encouraging the recruitment of people with lived experiences of adversities to participate in peer support programs.

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Table 4. Open text comments on interventions described in the cross-sectional quantitative survey of youths and adults.

https://doi.org/10.1371/journal.pone.0288214.t004