A. Ivester 15

A BEHAVIORAL THEORY ANALYSIS OF SEEKING MENTAL HEALTH TREATMENT

Amanda IvesterHealth 2400: Determinants of Health BehaviorSection One

INTRODUCTION

The World Health Organization (WHO) defines mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community (World Health Organization, 2004). According to 2004 WHO data, an estimated 26.4% of Americans have some type of mental health issue. (Wang, 2007). The National Institute of Mental Health found that in 2008 only 13.4% of adults in the U.S. sought out mental health care on some kind (National Institute of Mental Health, 2010). The National Institute of Mental Health also found that during 2008 only 58.7% of Americans with a serious mental illness were receiving mental health care. Based on the WHO data, it is indicated that the roughly half of Americans with a serious mental illness who were not receiving care were not receiving that mental health care because they were choosing not to seek it. A study done by Dr. Maria Oliver et al confirmed that only about half of those surveyed said that they would seek professional mental help if they felt their health was suffering (Oliver, 2005). This study by Dr. Oliver begins to help explain exactly why mental disorders are estimated to be 14% of the overall global burden of disease; people choose not to seek mental health care (Prince, 2007). This paper will use behavior theory to analyze the various reasons that individuals do not seek mental health care.

Due to the wide variety of mental disorders, individuals who do not seek mental health care can have a very wide range of health issues, many of which are symptoms of their untreated mental illness. Health problems those that do not seek mental health care can experience include, but are not limited to, trouble breathing, loss of muscle mass, and lacerations. (Panic Disorder, Anorexia Nervosa, Self-Harm). In addition to this poor physical health, individuals that do not seek mental health care frequently have poor social health as well, experiencing damaged relationships due to lack of motivation and unpredictable mood swings (Depression, Bipolar).

Not seeking mental health care puts an individual at risk for various comorbidities and mortalities, most of which result from the fact their mental illness is being left untreated. A study done by Dr. Pan showed depression was associated with a significantly higher risk of stroke, with 106 more individuals from the group of people with depression having a stroke (Pan, 2011). It has also been indicated that the same social factors that are associated with poor mental health resulting from not seeking mental health treatment are associated with alcohol use, drug use, crime, and dropping out of school (World Health Organization, 2004). A study published by Cambridge University done on those with major depressive disorder showed that, of the study group, 42% had a coexisting fear disorder and 33% had a coexisting distress disorder (Middeldorp, 2005). This means that choosing not to seek mental health care can result in exponentially poorer mental health. Yet another marker of the dangers of not seeking care for mental health issues is the suicide rate, which increased 18.3% from 2000 to 2011 (U.S. Department of Health and Human Services, 2014).

The rate of individuals seeking mental health care in the U.S. is low enough that there is a major Healthy People 2020 objective related to attempting to increase treatment seeking. Healthy People 2020 believes that one of the most important things the U.S. can do in order to increase mental health care treatment seeking is to increase access to mental health care. Healthy People 2020 would like to see a ten percent increase in the number of primary care facilities that provide mental health treatment either onsite of by referral (U.S. Department of Health and Human Services, 2014).

THEORY

Much of the literature regarding theories related to seeking mental health treatment revolves around the idea of self-efficacy and self-esteem. It is widely believed that if individuals feel capable and worthy they will seek out mental health care. Theories that involve a major component of self-efficacy include the theory of planned behavior and social cognitive theory. The transtheoretical model has also been used to help plan appropriate care for different types on individuals in the hopes that more appropriate care will lead to more individuals seeking treatment. Understanding these three theories is key to beginning to understand why individuals do not seek care for mental health issues.

TRANSTHEORETICAL MODEL

The transtheoretical model, also known as the stages of change model, is used in order to decide the best way to provide help to individuals. The transtheoretical model is used in regards to mental health due to the assumption that individuals are more likely to seek mental health care if that care feels like it has been personalized to them (Leamy, 2011).

Those in the precontemplation stage often need more information in order to make a change while those in the maintenance stage have already changed their behavior and formed new habits. Dr. Mary Leamy led a literature review on personal recovery regarding mental health and then mapped these results onto the transtheoretical model (Leamy, 2011). This information can be used to encourage individuals to see mental health care by allowing doctors to provide the most appropriate care.

For a paper to be included in this review it must not focus entirely on clinical recovery but on personal recovery as well. The majority of the literature defined personal recovery as the individual agreeing that they were in recovery, no hospitalization in regards to mental health within the last twelve months, being mostly symptom free, providing support to others, and working and living at least semi-independently (Leamy, 2011). This literature review found that only 44% of individuals believed that recovery is an active process and only 25% believed that recovery from mental illness is an individual or unique process (Leamy, 2011). According to the literature review, connectedness was the most important process in order for an individual to recover from mental illness with 86% of studies citing this as a key component (Leamy, 2011).

From this literature review key stages of recovery were picked out and mapped onto the transtheoretical model. Feeling stuck, overwhelmed, dependent, unaware, or in a crisis were considered to be the precontemplation stage. Feelings like accepting help, igniting a spark of hope, feeling as though one had seen glimpses of recovery, and being at a turning point were mapped as being in the contemplation stage. The preparation stage related to feelings of determination, establishing independence, or decision making. Individuals who were in the action stage regarding recovery from mental illness felt as though they were on the road to recovery, living with their disability, learning, and rebuilding. Finally, those who were in the maintenance stage described living beyond their disability, having high self-esteem, and actively coping with the stresses of life (Leamy, 2011).

This method of literature review allowed commonalities about recovery from mental illness to be easily identified. By mapping these commonalities onto the transtheoretical model, health care professionals can use these key phrases and feelings to assess what stage individuals are in regarding recovery from mental illness. Simply knowing whether an individual is in the precontemplation, contemplation, preparation, action, or maintenance stage regarding recovery from mental illness allows mental health care providers to give specific care to individuals in order to encourage them to seek care and therefore move along this recovery process (Leamy, 2011).

THEORY OF PLANNED BEHAVIOR

The theory of planned behavior is a multicomponent theory that seeks to explain why individuals do or do not plan to do certain behaviors, in this case, seeking mental health treatment. One major concept of the theory of planned behavior is perceived power, meaning whether or not an individual believes what they do will make an impact. Believing that one has the ability to make change is to say that one has high self-efficacy (Mann, 2004). Self-esteem is ones thoughts about oneself as a person. While self-efficacy and self-esteem are fundamentally different they are often intertwined because they are often either both positive or both negative. People also experience increased self-esteem in response to increased self-efficacy (Mann, 2004). Recognizing how related these factors are, self-esteem, or ones sense of self-worth, is then an important consideration as to why individuals do not seek mental health care. Individuals who are found to have low self-esteem often have the corresponding low self-efficacy. Because of this these individuals often turn to avoidance behaviors, in this case avoiding recognizing they might have a mental illness. These avoidance behaviors then result in a decreased ability to handle the stresses of everyday life and as such the individual perceives their power as very low. Due to this low perceived power the individual chooses not to seek mental health care because they believe it will not matter anyway (Mann, 2004).

While researching self-esteem it was discovered that children who were extremely socially anxious frequently had low levels of self-esteem. The conclusion was ultimately reached that self-esteem is a barrier against anxiety (Mann, 2004). This once again ties back to the idea of perceived power in the theory of planned behavior. Individuals with high anxiety, low self-esteem, and low self-efficacy may feel a sense of dread or discomfort about the idea of making life changes and seeking mental health treatment. Due to this extreme anxiety and fear they have very low perceived power and ultimately do not seek mental health treatment.

Low self-esteem can also correlate with a higher motivation to comply with the beliefs of others. Adolescents with low self-esteem are more frequently engaged in violent behavior and gang memberships (Mann, 2004). Because these individuals feel poorly about themselves they frequently fall into gangs because they feel motivated to comply with the beliefs held by those individuals in the gang. This happens because individuals with low self-esteem frequently seek a social group to belong to in the hopes to build some self-esteem and will often to conform to any group that will accept them in order to do so. (Mann, 2004). This same idea applies to why individuals do not seek care for mental health problems. Society currently holds the belief that mental health is not important and those with low self-esteem are motivated to comply with this belief and therefore do not seek mental health treatment.

SOCIAL COGNITIVE THEORY

Social cognitive theory is the idea that the individual, the behavior, and the environment all influence each other. A major individual construct of the social cognitive theory is the idea of self-efficacy. An individuals beliefs on whether or not they are able to make a difference through their own efforts greatly influence whether or not an individual seeks mental health care (Benight, 2004). Individuals who have very low self-efficacy frequently see potential dangers in their environment and spend much time thinking about the fact that they have poor coping mechanisms (Benight, 2004). This environmental threat level varies from person to person but those with low self-efficacy frequently feel doubt about their ability to manage their situation (Benight, 2004). Because of these expectations about their environment the individual is unlikely to take advantage of mental health treatment resources. This is due to the fact that they do not expect the action of seeking help to have a meaningful positive impact because they view their situation as hostile or dangerous.

In order to change mental health treatment seeking behaviors, Benight suggests the promotion of thought control efficacy. This means helping individuals to recognize that their physical environment is largely shaped by their own cognitions (Benight, 2004). The basic premise of this thought control efficacy consists of attempting to exercise control over ones thoughts in order to attempt to regulate behaviors and emotions. Thought control efficacy is particularly effective because it can help to facilitate a positive social environment which is correlated with increased self-efficacy and increased mental health treatment seeking behavior. Furthermore, successful thought control efficacy by itself can increase self-efficacy and in turn can promote mental health treatment seeking behaviors. (Benight, 2004).

INTRAPERSONAL FACTORS

Intrapersonal factors are factors within the individual that influence behavior, in this case, seeking mental health treatment. These include beliefs, values, attitudes, and knowledge about seeking mental health treatment, demographics and socioeconomic status, and psychological or personality characteristics.

BELIEFS, VALUES, ATTITUDES, KNOWLEDGE

Beliefs and attitudes about mental health treatment are often very negative. These negative beliefs greatly contribute to individuals choosing not to seek mental health care. A study by Dr. Ramin Mojtabai found that only 26.3% of Americans believed that those who seek mental health treatment are actually helped (Motjabai, 2007). A survey done asking individuals to rate the likely helpfulness of various behaviors for treating or alleviating mental illness found that very few people believed that seeking professional mental health treatment would help (Jorm, 2000). There is also a persistent belief that medications, which are often a large part of seeking professional mental health treatment, are negative and not helpful (Jorm, 2000). Furthermore it was also found that 59.8% of Americans would be embarrassed if people knew that they were seeking professional mental help (Motjabai, 2007). It was also found that much of the public viewed admission to a psychiatric ward in a hospital as a very negative thing (Jorm, 2000). These negative beliefs and attitudes also indicate that individuals place a lower value on their mental health. Because mental health is often valued less than physical health, individuals are less likely to seek care. Individuals are also frequently misinformed about the causes of various mental illnesses. For example, many people belief that schizophrenia is caused by life events, when in reality it is only triggered and made worse by life events. This belief about schizophrenia leads individuals to believe that seeking mental health treatment is unnecessary and the individual simply needs make a few life adjustments.

Individuals also frequently have very poor knowledge about getting mental health treatment. 33% of individuals stated when surveyed that the majority of their knowledge about mental health treatment came from a friend or family member who had been treated for mental illness (Jorm, 2000). Much of the other knowledge individuals have about seeking mental health treatment comes from the media or various unregulated self-help books (Jorm, 2000). Individuals also frequently lack knowledge about what types of professionals to see out for mental health care, believing that a general practitioner is almost always sufficient. This poor knowledge about what mental health treatment is actually like and how to receive it also contributes to why individuals do not seek mental health care.

DEMOGRAPHICS AND SOCIOECONOMIC STATUS

There are several demographic groups that are the least likely to seek mental health care. Men are less likely to see mental health care than women. Individuals of a lower socioeconomic status are unlikely to seek mental health care (McAlpine, 2004). Being of a lower socioeconomic status also typically means that an individual does not have insurance, which further makes them less likely to seek mental health care (Wang, 2007). Of all races in the United States, African Americans were the least likely to seek mental health care, being twice as likely as any other group to choose not to seek care (Conner, 2010; McAlpine, 2004). Older adults seek mental health care far less often than younger adults do (Segal, 2005). Individuals who are less educated are also less likely to seek mental health care (McAlpine, 2004). Living in a rural area makes an individual less likely to seek mental health care (Wang, 2007). Based on this, the least likely individual to seek care is an unmarried, older, less educated African American male of a low socioeconomic status living in a rural area (McAlpine, 2004).

INTERPERSONAL FACTORS

Interpersonal factors are factors between the individual and other individuals that make them more or less likely to do a behavior, in this case, seeking mental health treatment. Interpersonal factors include support, social interactions, and social influence from family and friends. Often individuals who would benefit from seeking mental health care do not due negative social interactions regarding mental illness. Those without a mental illness often label those with mental illness as having social-skill deficits and poor physical appearance (Corrigan, 2004). The shame and stigma of carrying the label of mentally ill and all that it entails is often enough to prevent individuals from seeking mental health care. There is also a wide spread public belief that individuals with mental illness are dangerous, likely to be violent, and likely to commit crimes (Corrigan, 2004; Jorm, 2000). These negative societal beliefs about mental health prevent individuals from getting care because they greatly desire to avoid this stigma.

These false negative beliefs about mental illness also rob individuals of social support from their friends and family. The individual who would benefit from seeking mental health care then has friends and family who believe that professional mental health treatment is less effective than self-help and lives in a society that stigmatizes mental illness (Corrigan, 2004; Jorm, 2000) Furthermore, individuals are unlikely to have anyone to make comparisons against regarding seeking mental health. If anyone they know is in fact receiving mental health treatment, it is frequently not made known (Thoits, 2011). This lacking of social reference groups make individuals unlikely to seek mental health care. These interpersonal factors ultimately converge to make individuals far less likely seek mental health care.

ORGANIZATIONAL, COMMUNITY, ENVIRONMENT, AND POLICY FACTORSOrganizational, community, environment, and policy factors are all factors in the external environment that influence whether or not an individual will seek mental health care. Organizational factors are related to particular organizations, such as a workplace or college. Community factors are factors where the individual lives and spends time. Environment factors refer to things in the individuals physical environment that influence whether or not they seek mental health treatment. The single biggest environmental factor influencing whether or not someone will seek mental health care is if there is access to this care. Finally, policy factors are laws that influence if an individual will seek mental health care.

There are few, if any, workplace based programs that encourage individuals to see mental health treatment (Wells, 2004). Colleges and schools as organizations typically have more programs in place for mental health promotion and to encourage treatment seeking. However, a literature review done by Jane Wells found that only seventeen out of 425 school-based mental health promotion programs met the required criteria of being unambiguous about their aims, keeping detailed records, and adjusting the program based on results (Wells, 2004). Many of these schools were in poor areas with large numbers of ethnic minority groups, meaning that these programs were intentionally set up in areas where people are unlikely to see mental health treatment in order to hopefully change that behavior (Wells, 2004). Wells identified three types of school based-programs that encouraged the seeking of mental health treatment: school-wide, parts of the school, and classroom based. All of these programs sought to measure how individuals felt about seeking mental health treatment and set aims to remove negative feelings about seeking mental health treatment. Classroom-based programs were shown to be more effective in encouraging the seeking of mental health treatment due to their personalization (Wells, 2004). Many community-based factors regarding the likelihood of seeking mental health treatment stem from church-based health promotion programs. While these programs have the potential to reach eighty percent of Americans, they also may be ineffective due to the fact that people who are religious frequently have social support and better mental health, meaning they likely already seek mental health care in some form if they need it (Campbell, 2007). Despite this potential set back of this type of community intervention, they are particularly useful because they frequently highlight the effect of mental health on physical health (Campbell, 2007). These church-based programs that promote seeking mental health care attempt to connect established beliefs back to mental health in the hopes that individuals will see the importance of seeking care. These programs are one of the only community factors to encourage the seeking of mental health treatment. Unfortunately these programs are seldom grounded in established theoretical framework and therefore frequently have less than satisfactory results (Campbell, 2007). One reason in particular these programs often fail is that they fail to communicate with each other or with other organizations.

Most environmental factors aimed at increasing mental health treatment seeking behaviors target the environment. The U.S. Department of Health and Human Services through the Healthy People 2020 initiative deemed that access to mental health treatment was low enough to create specific objectives aimed at increasing treatment access in order to encourage treatment seeking behaviors (U.S. Department of Health and Human Services, 2014). The biggest thing being done to increase access to mental health treatment, and therefore increase treatment seeking behaviors, is attempting to integrate primary care and mental health care (Pomerantz, 2008). Before attempts were made to integrate care within Veterans Affairs hospitals, acquiring an appointment with a mental health profession could take six week and sometimes even longer. Nearly half of all people who bothered to make an appointment never came (Pomerantz, 2008). After these factors were identified, steps were put into place to abolish these negative environmental factors and instead create an environment that encouraged the seeking of mental health treatment. By integrating primary care and mental health care wait times dropped from over two months to less than thirty minutes and twice as many people were seeking mental health care (Pomerantz, 2008). This Veterans Affairs hospital intervention shows how vitally important of an environmental factor easy access to mental health treatment is if one wants to encourage the seeking of mental health treatment.

While most U.S. laws dealing with mental health revolve around involuntary commitment to mental institutions, there several notable U.S. policies aimed at increasing the proportion of individuals that seek mental health treatment. Many of these policies intend to foster treatment seeking by increasing access to treatment. The Community Mental Health Act of 1963 was signed into effect by John F. Kennedy and created funding for mental health facilities (Facilities, 2008). The New Freedom Commission on Mental Health was a committee created by George W. Bush in 2002. Its purpose was to research the current state of the U.S. mental health system and identify ways individuals could be encouraged to seek treatment at national, state, and community levels (Cunningham, 2008). The Mental Health Parity and Addiction Act of 2008 required insurances to provide the same amount of money and benefits towards mental health treatments as do towards other medical costs (Wellstone, 2008). The final U.S. policy that encourages the seeking of mental health treatment is the Mental Health Services Act of California. This law was established in 2008 and amended in 2012. The Mental Health Services act of California provides funding for mental health treatment programs (Felton, 2010). This funding has been used to train individuals to provide care, create community mental health promotion programs, and monitor the number of individuals seeking mental health treatment (Felton, 2010).

PREDISPOSING, ENABLING, AND REINFORCING FACTORS

Predisposing factors are factors that make an individual more likely to do a behavior that occur before a behavior is done. Enabling factors are factors that make it more likely for an individual to perform a behavior by making it easier or possible to perform that behavior. Finally, reinforcing factors are factors that occur after the behavior is done that make it more likely for the individual to continue the behavior (Wright, 2006).

Predisposing factors regarding seeking mental health treatment were limited knowledge about treatment available as well as limited knowledge about signs of when to seek treatment (Wright, 2006; Motjabai, 2007). Other predisposing factors about whether or not an individual will seek mental health care is the individuals belief that they are not susceptible to mental illness and fear of stigma or being locked due to seeking mental health treatment (Wright, 2006; Jorm, 2000). Individuals are very unlikely to seek mental health treatment if they are unaware of their options or even that they need it at all. This lack of knowledge compounded with fear surrounding mental health treatment can make it unlikely for an individual to seek mental health care. Enabling factors in regards to seeking mental health care mostly revolve around accessibility and availability. The most vital enabling factor to target in order to make individuals more likely to seek mental health care is to improve the knowledge that individuals have about care, sources of help, and their susceptibility to mental illness (Wright, 2006; Jorm 2000). By giving individuals more accurate knowledge about mental health treatment you have effectively increased their access to it. An individual who knows what types of mental health care are available and when to get it is far more likely to seek out mental health treatment than someone with incorrect and negative ideas about mental health treatment.

Positive feedback from peers and social support are the most important reinforcing factors when dealing with seeking mental health treatment (Wright, 2006; Corrigan, 2004). Individuals stated that they needed someone they knew and trusted to help them recognize that they had a mental health problem and then encourage them to seek treatment (Wright, 2006; Corrigan, 2004). By creating this network of social support you make it more likely for an individual to seek out and continue mental health care, because one of the biggest reasons people avoid mental health treatment is the stigma surrounding mental health.

SUGGESTIONS FOR INTERVENTION

There are several factors that could be targeted in order to improve the rate that people seek mental health treatment. Providing knowledge about mental disorders allows individuals to recognize when seeking treatment is appropriate and can often increase their knowledge of how and where to seek help (Jorm, 2000; World Health Organization 2001). The World Health Organization (WHO) suggests that the environment is another important fact to target to increase the rate that people seek mental health care. In order to alter the environment to be more friendly towards seeking mental health treatment WHO recommends integrating mental health care with primary care as well are giving care within communities (World Health Organization, 2001).

These two factors, knowledge and environment are the most important factors to target in order to encourage individuals to seek mental health treatment. Increasing knowledge about mental illness and mental health treatment is important because it will have a domino-like effect. Correcting misinformation about mental illness and mental health treatment will in turn change individuals beliefs about seeking mental health care and when individuals have changed those beliefs they less likely to stigmatize seeking mental health treatment and become more likely to provide social support to individuals who seek mental health care (Jorm, 2000). Targeting the environment in order to increase access to mental health treatment is important because even if people dont view seeking mental health treatment negatively, if there little treatment to be had and what is available is difficult to get, individuals will be unlikely to seek mental health care (Pomerantz, 2008).

Targeting knowledge and access to mental health care is also important because these two factors can be changed relatively easily and still have a large impact on mental health treatment seeking behaviors. The effectiveness of targeting access has been shown with Veterans Affairs hospitals; twice as many individuals were seeking care after there was more care available for them to get (Pomerantz, 2008).

Strategies for targeting these two factors will include community mental health promotion programs. These smaller programs will have more ability to change knowledge (Wells, 2004). In addition to these various community based education programs, there will also need to be a way to get this increased mental health care access. This can be done by teaching primary care providers to provide recommendations for mental health treatment and using community health workers to set up mental health treatment programs within communities. These strategies should be used because they will be cost-effective and likely to have an impact because individuals are more likely to seek mental health care if it feels personalized to them (Wells, 2004).

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