(p. 51) Treatment Gap: Barriers to Providing and Receiving Services
Clearly, mental disorders are relatively common, with approximately 50 percent of people in the United States expected to experience a diagnosable psychiatric disorder during their lifetime—and remember that this omits subclinical dysfunction, which does not qualify for formal diagnosis, as well as other conditions (e.g., stress, loneliness) that impair everyday functioning. One might expect that the attention and resources allocated to providing care for these disorders would be on par with their scope and impact on individuals and society. Alas, no. Resources provided for mental health care are paltry; there are too few resources, too few people delivering services, two few services available where treatment is needed most, and too many treatments that are of questionable value (effectiveness) even when they are delivered. (Other than that, things are great!)
This chapter will expose the gap between treatment services that are needed and those that are provided, as well as barriers to providing and receiving services. Before moving on to my primary goal of proposing and promoting novel strategies and solutions to reduce the burdens of mental illness, I want to examine key problems and impediments that are firmly in place now because new models of treatment and delivery will need to surmount current barriers to be effective.
(p. 52) Treatment Gap: Limited Clinical Services for Those in Need
Two basic issues are our starting point, namely, the extent to which individuals in need of services actually receive care and precisely what that care is. In an ideal world, we might want all in need of services to actually receive them. We would also want those services to have the benefit of strong evidence showing that they make a difference. In reality, in the United States (and worldwide), conditions depart drastically from these ideals. Let me highlight the evidence to support this claim.
The treatment gap refers to the difference between the number of people who have disorders or suffer psychological dysfunction (prevalence) and the number of those who actually receive care (Kohn et al., 2004). The World Health Organization (WHO Mental Health Survey Consortium, 2004) provided extensive data on the treatment gap from surveys of more than 60,000 adults in 14 countries in the Americas, Europe, Middle East, Africa, and Asia. The proportion of respondents who received health care treatment for emotional or substance use disorders during the 12 months preceding the survey ranged from a low of 0.8 percent (Nigeria) to a high of 15.3 percent (United States). These percentages reflect those who received treatment among those in need, and also show that the vast majority of individuals in need (99.2 percent and 84.7 percent, respectively) did not receive treatment.
Perhaps treatment is differentially available as a function of severity of disorders and impairment. In the prior report, disorders were evaluated by severity. Serious disorders were defined largely by individuals reporting that they were totally unable to function for at least 30 days in the past year in light of their disorders. As might be expected, the proportion of individuals who received treatment was much higher among those with severe versions of their disorders (ranging from 14.6 percent [Lebanon] to 64.5 percent [Spain]). In the United States 52.3 percent of individuals with severe dysfunction received mental health services. Of further interest is that in the United States, 8.1 percent of individuals with subclinical dysfunction received treatment. Overall, developed countries provided more services than did developing (low-income) countries, as shown in this study. It is all the more dramatic to confront the limited services provided in the United States, where only 15 percent of those in need received care.
If one looks at specific domains of dysfunction in detail based on data from large surveys, the gap in services is further corroborated. For example, a large survey evaluated more than 46,000 adults in US households and found that 8.4 percent meet criteria for depression (Olfson, Blanco, & Marcus, 2016). Only 28.7 percent of those people actually received treatment for depression. A sample of more than 36,000 adults in the United States revealed a lifetime prevalence of 29.1 percent for alcohol use disorder (Grant et al., 2015), but only 19.8 percent of them ever received any treatment! Similarly, as part of the same sample, 9.9 percent met criteria for a drug use disorder over the course of their lifetime. Yet only 24.6 percent had received any treatment. A 2016 report by the US Surgeon General noted (p. 53) that only 10 percent of people with a substance use disorder receive treatment for their disorder. This is an enormous gap, especially in light of data that drug use, abuse, and overdose and opioid addiction are on the rise (Rudd et al., 2014). Finally, a survey of 50 countries, spanning low-income to upper-middle-income countries, focused on services provided for individuals with schizophrenia (Lora et al., 2012). A median of 31 percent of these individuals received care. This leaves 69 percent with the disorder not receiving treatment. Understandably, as different disorders, countries, locales, sampling methods, and measures change, so do the percentages. Consequently, no percentage serves very well as a single statistic about the treatment gap. Yet, based on all the different numbers, the inevitable conclusion is stark and simple. Most people in need of mental health services receive no treatment.
Important to add here is that there are considerable ethnic and cultural disparities in access to mental health care. For example, in the United States, ethnic minority groups (e.g., African, Hispanic, and Native Americans) have much less access to care than do Americans of European descent (e.g., Holliday et al., 2009; McGuire & Miranda, 2008; Wells et al., 2001). The situation is even worse (lower percentages of people who receive treatment) when ethnic and cultural disparities combine with other factors that hamper care. For example, in general, children are much less likely to receive services for their mental health problems than are adults. They are even less likely to receive treatment if they are minority group members (e.g., Marrast, Himmelstein, & Woolhandler, 2016).
Overall, the lack of available services for most people and systematic disparities among those services underlie the importance of delivering services in ways that can reach many more people and target special groups. I will return to the matter of disparities in mental health services later in the chapter. At this point, it is simply important to acknowledge that the lamentable fact that most people do not receive services is even worse for individuals of nonmajority cultural or ethnic minority status in the United States.
But what of the apparently elite group, namely, the people who did receive services? What exactly did they receive? In the WHO study, “receiving services” was based on whether respondents ever saw any one of a long list of caregivers, either as an outpatient or inpatient, for problems with emotions, nerves, mental health, or use of alcohol or drugs. Included were mental health professionals (e.g., psychiatrist, psychologist), general medical professionals (e.g., general practitioner, occupational therapist), religious counselors (e.g., minister, sheikh), and traditional healers (e.g., herbalist, spiritualist) (World Mental Health Survey Consortium, 2004). The list varied across countries depending on local circumstances where types of healers may vary. The precise service that was provided by these individuals was not identified. Also, the duration of the intervention was not known, but receiving services required at least one contact. This is a low and ambiguous criterion for what qualifies as receiving services. One visit with even a highly trained mental health professional, for someone with major depression, substance abuse, or severe anxiety, is not likely to accomplish very much. So when we say that 15 percent of individuals received treatment, the bar (p. 54) is low and could mean one contact with someone who has absolutely no mental health training.
In the United States, the National Comorbidity Survey Replication (NCS-R) study has provided data on who receives treatment as well as some further information about the nature of that treatment (Wang et al., 2005). More than 9,000 individuals with psychiatric disorders answered questions about their treatment that included who the service provider was (psychiatric, family physical, social worker, spiritual advisor, and others) and the type of treatment (self-help group, medication, hospital admission). Minimally adequate treatment was defined as receiving an intervention (e.g., medication, psychotherapy) that followed evidence-based guidelines for the specific disorder of the individual and included multiple contacts (rather than only one visit).
Overall, across the sample, 17.9 percent received some form of intervention. For individuals with a psychiatric disorder, 21.5 percent received treatment from a mental health specialist, but 41.7 percent received treatment if this is expanded to include contact with any health care person, in addition to those trained in mental health. Regarding individuals who did not meet criteria for a disorder (subclinical or subsyndromal), 4.4 percent received treatment from a mental health specialist and 10.1 percent received treatment if this is expanded to include any contact. Overall, across the entire sample, only 32.7 percent were classified as receiving at least minimally adequate treatment. The investigators concluded that only one-third of treatments provided met minimal standards of adequacy based on evidence-based treatment guidelines.
Other conclusions were noted from this survey. First, treatments were used that have unclear benefits. For example, complementary and alternative treatments accounted for 31.3 percent of all mental health visits despite the absence of evidence attesting to their effectiveness. Second, most services and mental health visits were consumed by individuals without meeting the criteria for disorders (subclinical). They account for almost one-third of all mental health visits. This is striking given the unmet need for services for individuals with well-defined mental disorders.
I have only sampled studies from large literatures on who receives treatment and what counts as treatment (e.g., Becker & Kleinman, 2013; Merikangas et al., 2011). A few points are worth reiterating. First, around the world, the majority of individuals with mental disorders do not receive treatment. Though studies vary and there is no one percentage to be held up as representative of those with unmet needs, it is nevertheless clear that we are not providing treatment to enough people in need of it.
Second, even when care is provided, we generally do not know whether it was a high-quality regimen of treatment specifically aimed at the clinical dysfunction in question. That is, “receiving care” includes basic “contact” and does not necessarily indicate a formalized treatment of any type (psychological treatment, medication, spiritual intervention).
Third, evidence-based treatments are used infrequently for mental disorders for those few individuals who receive care. Epidemiological surveys are not designed to probe precisely what the intervention was, for how long it was administered, (p. 55) whether the treatment was delivered in the way in which it was developed in research, or whether the persons administering the treatment were trained in its use. Beyond the surveys, we know that evidence-based interventions are not being used for mental and substance use disorders as a general rule. This situation has been referred to as a “quality chasm” and reflects the gap between what is known to be effective by researchers and what in fact is actually used in clinical practice. This chasm applies to mental health and substance use disorders as well as physical health and disease (Institute of Medicine [IOM], 2001, 2006). The ideal for individual patients and service providers should not just be to receive and provide any treatment, but rather to receive and provide the best treatments and specifically those that have an evidence base.
Fourth, none of the studies reporting on who receives treatment and what those treatments were evaluated the outcome of treatment. In the end, this is arguably the most critical index. Do people get better whether or not they receive treatment, and does the treatment they receive make any difference in their lives? We cannot even assume that if evidence-based treatment was provided that it actually helped; such treatments are often diluted in clinical work and do not achieve the touted effects proposed in research (Weisz et al., 2014). It is important to keep in mind that treatments, whether medical or psychological, can make people better, or can have no impact, or can make people worse. It would be useful, if not essential and ethical, to know what the outcomes are of the treatments we are using. Receiving treatment is critical, but whether treatments make any difference or actually help is hardly trivial.
There are limitations in the studies I have cited and in the research methods more generally. For instance, in some surveys (e.g., WHO Consortium, NCS-R) certain diagnoses are omitted (such as schizophrenia); whether treatment has been provided is usually examined in the context of a restricted period (often 12 months); and much of the data are based on self-report (and retrospective report at that). Self-report of having received services and actually receiving them could yield different results; people may be reluctant to report on clinical services or may have intended to go but did not. (Yet, in many surveys, self-report is confirmed by face-to-face interviews or phone interviews, so there is attention to this problem at least.) Even with limitations of individual studies and different methods of assessment, samples, time periods, and countries, the overall conclusions are quite similar: (1) most people in need of services are not receiving services, and (2) those who do are receiving an odd array of “services” provided by many people with no training in the care of mental disorders.
The absence of data on improvement and adaptive functioning in everyday life has its own set of ambiguities, namely: How many people improved whether or not they received services, and is the improvement greater (stronger effects, more people affected) among those who received treatment (controlling for severity of dysfunction, impairment, levels of stress, and so on for possible confounds)? It is important to raise these questions here; but later in the book they will be approached as challenges that can in fact be overcome to better provide services that reach people in need.
(p. 56) Barriers to Receiving Treatment Services
If we are going to reduce the burdens of mental illness, we will need to identify persons in need of treatment and provide services for them, ensure that care consists of more than one contact if needed, and ensure that the treatment has supportive evidence in its behalf, if any such treatment is available. These might be enough challenges for one day, or even constitute an insurmountable obstacle. So let us hold off on the solutions for a bit and instead fill out the picture of obstacles to be overcome.
Receiving services for psychological dysfunction is a process of multiple steps:
1. Experiencing symptoms or some form of dysfunction;
2. Identifying those as symptoms or something in need of help;
3. Deciding whether action is needed to do something about the symptoms;
4. Identifying the options for intervention (e.g., a psychosocial “treatment,” medication, or something else);
5. Seeking and actually obtaining treatment if that is the option selected;
6. Beginning the treatment; and
7. Remaining in treatment as needed, with recurrent disorders traversing the process or abbreviated variants again.
There may be numerous obstacles at each of these steps that impede or prohibit a person from moving forward in the sequence and actually receiving care. These are often referred to as barriers to care or barriers to treatment.
Barriers to care vary in their sources. Two broad categories are often defined: system factors (financial costs, whether a service is available, and government, law, policy issues, and so on) and attitudinal factors (e.g., fear of stigmatization, views that treatment will not be of much help). Table 3.1 lists these two broad categories of barriers to treatment and some examples of each type.
Table 3.1 Barriers to Mental Health Care
Cost of mental health services
Treatment is not affordable because services are not covered by insurance of the client, services are not completely covered, or the out-of-pocket costs are too expensive. The complexity of understanding what is and is not covered or negotiating all of this (reimbursement forms, appealing after a claim has been refused) can be daunting.
Policy and legal constraints
Government policies (e.g., federal, state, province) and third-party payers may restrict what conditions can be treated and reimbursed or for how long treatment can be provided (e.g., number of sessions, days) and still be reimbursed. These constraints also include limited financial resources as a matter of budget, policy, or law that provides too few services and therefore less accessible services.
Too few providers to deliver services
Mental health professionals are not available in sufficient numbers to provide services to meet the need. This is a worldwide problem in developing (low- and middle-income) and developed (higher-income) countries as well. In the United States, trained professionals are insufficient in number to treat all those in need and are concentrated in urban areas. Too few meet the ethnic demographic of the nation or focus on clinical problems for which the need is the great.
Stigma refers to negative beliefs and practices by a group about a condition—in this case mental disorders. Concerns among potential clients or consumers of treatment are with being labeled (diagnosed) with a mental disorder or being associated with treatment for a mental disorder. Stigma can lead to genuine discriminatory practices and domains of rejection (e.g., employment, promotion). Also, individuals may view their own dysfunction with stigma (self-stigma), which can interfere with identifying themselves as having a mental disorder and seeking treatment.
Mental health literacy
Mental health literacy refers to information that individuals have and what they know about mental disorders, whether one has symptoms or a disorder that warrants treatment, what the options are for treatment, and how to pursue those options and obtain treatment.
Cultural and ethnic influences
Individuals of cultural and ethnic minorities have less access to services for health care in general, including mental health care. Views about whether psychological problems warrant treatment, about entry into any health care service, or about seeking treatment can vary widely. Some problems (e.g., anxiety, depression) may not be seen as a reason to seek “treatment” or to be involved with a health care system. This is not the same as mental health literacy, which is more about knowing, but rather is more firmly rooted in cultural practices and beliefs.
Not identifying individuals at risk early in their course toward dysfunction is another barrier to treatment. This includes the absence of systematic assessments early in life that would identify individuals who are at risk and the absence of follow-up with action to help them.
Model of intervention delivery
Psychosocial interventions for mental disorders usually are delivered one to one, in person, with a mental health professional. This inherently limits the number of individuals who can receive treatment and the reach of treatment to the range of populations that need to be served.
By system factors, I refer to factors outside of the individual that typically concern the services themselves and their availability. (The category of system factors is useful for presentation, but most efforts to define barriers outside of the individual and inside the individual are not sufficiently nuanced, as I will discuss shortly.)
Cost of Mental Health Services
Cost of mental health services can influence whether people receive treatment and generally amounts to the cost of providing and obtaining services. Consider a few cost considerations and how they create barriers to treatment. First, we begin with individuals and their families, and their ability to pay for services. In the United States, health care generally is covered (paid for) either through direct (p. 57) (p. 58) payment or partial payment (copay with some insurer) or by a policy provided by one’s employer. Even when mental health services are covered through one’s job, often payments are required (copayments) because only part of the cost is covered by insurance; often a small portion is paid by the patient. Whether insured or not, the cost of mental health services is for many people a barrier to enrolling in treatment (this goes, incidentally, for physical health treatment, too).
Many individuals in need of services do not have coverage, or the coverage they do have is restricted to services that are not conveniently available where they are living. For example, in the city in which I work, few mental health service providers accept insurance. (Among the reasons are that reimbursement is much lower than the going rates of therapy and that dealing with reimbursement plans can be onerous.) This means that having insurance is not necessarily very helpful, if many services will not accept it. Services that do accept one’s insurance plan might be more difficult to find. So, add availability of services as a related barrier.
But let us say a person with insurance has found an agency that will accept that insurance; it is not yet time for relief. Sometimes when insurance claims are submitted for reimbursement of a service, the claims are refused. Some feature of the problem that was treated (e.g., the precise diagnosis), the treatment (e.g., what the therapist used as the treatment), the service provider, or small print on the policy leads to rejection of the claim. These rejections come after the treatment sessions of course, so the patient must bear costs he or she thought were covered. The complexities and the uncertainties of insurance and reimbursement are huge barriers to receiving care.
Treatment even when reimbursed may have clear limits. Whether one can be treated and for how many sessions are all potential limitations, at least in the United States. In the usual case, one must meet criteria for a psychiatric disorder or be referred to treatment because of physical health problems exacerbated by mental health problems. Then, there might be some fixed number of sessions and some hoops or obstacles to go through to obtain additional treatment.
Treatment even when reimbursed may have unclear limits. For example, individuals who use a service covered by their plan may be surprised to learn that some part of their care was not part of the plan. A doctor or service may be called (p. 59) in or used that the patient mistakenly assumed would be covered, only to receive a big bill later (Cooper & Scott-Morton, 2016).
There is great unevenness in health insurance plans and coverage in the United States. For example, one’s status (citizen, immigrant, visitor on a visa, international student) can influence whether services are to be reimbursed. Within a given group (e.g., employees at a given company), insurance plans can vary tremendously, with those variations influencing whether or how much of a service will be reimbursed. All of these are barriers because individuals may refrain from services owing to the costs they will bear, the perceived costs they will bear (plans are not at all clear to many), and real or perceived challenges of negotiating the systems to receive services and reimbursement. System barriers (e.g., financial costs, service-providing constraints) can meld into attitudinal barriers (factors within the individual) when perceptions, beliefs, and worries about what care will be provided and reimbursed have an impact on seeking services. “Insurance is great until you need it,” goes the saying, which reflects the concern (at least in the United States) that not all care is covered as thoroughly as one may have imagined and that there are likely to be surprises when it comes to reimbursement.
In short, there are all sorts of nuances, limits, and escape clauses for various reimbursement policies. In the United States, that means that even if one has coverage one might need to be cautious in assuming treatment will be fully covered. And people who enter treatment without insurance are at increased risk for dropping out early (Enlund et al., 2002).
Many of these reimbursement issues are likely to be less evident with medications as treatment rather than psychosocial interventions. For medications, doctors and pharmacies have reasonably informed ideas of what is covered and know the set of plans in a given area. Consequently, patients can be assured more explicitly about what is and is not covered and what their contribution will need to be if anything. Although individuals filling a prescription are surprised by little exceptions here and there (e.g., “I thought there was no copay”), this is not close to the mystery of insurance plans and how they handle mental health reimbursement.
Policy and Legal Constraints
Several barriers to care pertain to laws, policies, and regulations (e.g., McGowan et al., 2016). Within the United States these can be a maze of factors, and among different countries there are varied and rich options pertaining to what services are provided and to whom, as well as the extent to which patients are charged. Let us consider the category generally. Many of the issues are also related to financial barriers and are worth distinguishing.
Government spending has direct implications for whom receives care and ease of access to care. States and cities often cannot afford even to provide services in many areas of the community. For example, in the United States, each of the 50 states has areas classified as rural (often defined as <3,500 residents). Rural areas have very limited access to care. Less dramatic instances can occur in urban cities where care is not evenly provided among sections within the city. One can ask whether services or treatments are available in a given area (e.g., (p. 60) inner city) and if they readily accessible (e.g., known about, welcoming) for prospective clients.
Policy and changes in policy can greatly introduce barriers and do so routinely. In the United States, many mental health services are funded and provided by the individual states and are subject to budget fluctuations. A major evaluation of cuts in mental health services revealed that the need and requests for mental health services in the United States have been rising, but many state governments have cut back on the amount of funds allocated for mental health services (Honberg et al., 2011). Services that are either eliminated or downsized include
• Emergency and long-term hospital treatment;
• Crisis intervention teams;
• Intensive case management services (for children, adolescents, or adults);
• A team approach with home visits to treat and monitor functioning, as needed; and
• Psychiatric medication.
In the United States, Medicaid is a federal source of funding and is the most important source of funding for public mental health services for youth and adults. Added to reductions in state budgets for mental health are reductions in Medicaid for such services (Honberg et al., 2011). Reduced funds mean that treatment is available to fewer people in need of services. A particular service may be eliminated or greatly reduced. Individuals simply would not have access to a service that previously had been available.
The number of hospital beds (inpatient care) for mental disorders is a dramatic illustration of reduction and elimination of services over the past few decades (Bastiampillai, Sharfstein, & Allison, 2016; Sisti, Segal, & Emanuel, 2015). A large movement going back 50 years focused on placing individuals in community settings rather than hospitals and maintaining them with services and medication that had the stigma but not the cost of psychiatric hospitalization. The number of hospital beds has continued to decline, and of those provided, many are for incarcerated people with mental disorders. Of course, the need for inpatient care has not magically declined.
Overall, we have a “perfect storm” in which the need for services is on the rise, most people in need already receive nothing, and services are routinely cut back in times when budgets are strained. The cutback is reflected in cost in another way, with businesses cutting back ever so slightly on health benefits or requiring larger contributions of employees when they seek services.1 The cutbacks are designed to decrease expenditures, but in fact reduced social services in general are known to be associated with increases in physical health care costs (e.g., from adult obesity, asthma, days with limitations of activity, mortality rates for lung cancer, heart attack, and diabetes) (e.g., Bradley et al., 2016; Bradley & Taylor, 2013).
The paucity of services provided by local and state governments and insurance coverage plans combine to convey the impediments to receiving care. It is quite possible that services are available, but many individuals do not have (p. 61) reimbursement plans to make those accessible. It is also possible that people have adequate reimbursement plans and coverage but services are not readily available. The perfect situation in which services are readily available and individuals in need of care have adequate coverage is not likely to emerge very often. It is important also to keep in mind that in negotiating services, presumably we are talking about a person with mental health problems (e.g., depression, anxiety, suicidality). These conditions are not optimal for negotiating anything, let alone the intricacies of the mental health system and its reimbursement challenges. And if a family member without mental illness is taking up the challenges, there probably is desperation to get help as soon as possible. Here, too, we want access to be as easy as possible when in fact there is a steeplechase of hurdles.
Too Few Providers to Deliver Services
If one wants services, providers are not as readily available as one would imagine. On the world stage, especially in low- or middle-income countries (where 85 percent of the world population resides), there is only a fraction of care professionals needed for providing services (e.g., Bruckner et al., 2011). Perhaps the situation is fine in a developed country such as the United States? Not at all.
There are many mental health professionals but not enough to meet the need for treatment, at least in the way treatment is provided. There is no single definitive survey, method of sampling, or even definition of “mental health professional” in the United States. But as an instructive guide, two estimates have yielded figures of 550,000 and 700,000 individuals providing mental health services (see Health Resources and Services Administration, 2010; Hoge et al., 2007; Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). These figures may be underestimates given the range of providers not usually included, such as other professionals (e.g., nurses, pastoral counselors, art therapists, school counselors) and individuals with various titles (e.g., counselor, personal coach, life coach, healer, therapist). Some of the terms (e.g., counselor, therapist) are only partially and inconsistently regulated, which means they can be used by anyone without special training. In short, the number of individuals who provide therapy with or without formal training in the mental health professions would be hard to count. Even with all of these qualifiers and caveats in mind, it is difficult to envision that a number within this range of the two figures I presented, or indeed less than 1 million service providers, would help sufficiently if 25 percent (or approximately 81 million) of the United States population in any given year or 50 percent over the course of one’s life (or approximately 163 million people) meet criteria for a psychiatric disorder, leaving aside the added group of individuals outside of these percentages who evince subclinical disorders.
An initial obvious reaction is that we just need more trained mental health professionals who can provide treatment. That is, this is a “person-power” problem. Actually not. Having more mental health professionals might be valuable but cannot be expected to have a significant impact on reaching palpably more people. The main reasons relate to the geographical distribution, interests, and composition of the professional workforce and a latter barrier I discuss regarding (p. 62) how they usually provide treatment. Consider the limits of delivering care just pertaining to the providers.
First, in the United States mental health professionals are concentrated in highly populated, affluent urban areas and in cities with major universities (Health Resources and Services Administration, 2010). As I mentioned previously, all of the states include rural areas where the concentration of people to square miles of land is low (www.hrsa.gov/ruralhealth/aboutus/definition.html). For these areas and small towns more generally, very few, or more commonly, no mental health professionals may be available.
Second, the majority of mental health professionals do not provide care to populations and clinical problems for which there is an especially great demand (e.g., children and older adults, individuals of minority groups, special populations in need such as victims of violence, single-mothers living below or near the poverty line, and more generally individuals of lower income). Most psychiatric disorders have their onset in childhood and adolescence, but most individuals in the mental health professions are trained in the treatment of adults. At the other end of the age spectrum, the proportion of older adults is expanding rapidly in the United States (and worldwide); this group is underserved and, in light of the expansion, increasingly underserved by mental (and physical) health services (IOM, 2012). Too few mental health professionals are trained to provide services to older adults, even if this group were not expanding so rapidly. Indeed, it would be very unusual for a graduate training program (e.g., clinical psychology, social work) to train therapists specifically in treatment of older adults. Similarly, few internships offer options, let alone supervised training, in the treatment of older adults. Older adults are merely an example of the more general problem; where need is great, services are often especially sparse
Finally, disproportionately few mental health professionals reflect the cultural and ethnic characteristics of many of those in need of care. Individuals do not necessarily have to be treated by persons of the same ethnic and cultural group with which they identify. Yet entering into treatment, forming an alliance with the therapist, being able to communicate in one’s primary language, and having a shared view of psychological problems can all depend on a good match of therapist and patient in relation to ethnicity and culture. A mismatch of ethnicity and culture between prospective client and therapist at minimum adds another barrier for receiving services. A mismatch can have a variety of deleterious influences, including not remaining in treatment, lower quality of the therapeutic alliance, and less therapeutic change (e.g., Kim, Ng, & Ahn, 2005; Zane et al., 2005). Even obtaining diagnostic information could be influenced by a mismatch. For example, when interviews are conducted in the native language of the client, rather than their secondary language (e.g., English), clients report more and more severe symptoms (Brown & Weisman de Mamani, 2017). The effects of treatment can also be influenced. In one review, treatment was more effective when ethnically adapted and placed in the native language of the client (i.e., two to four times more effective, as measured by effect size) (Griner & Smith, 2006). In short, having poor ethnic and cultural representation among mental health professionals (p. 63) who can provide services maintains and fosters huge disparities among groups and obstacles for entering treatment.
Overall, adding more mental health professionals to do what they are doing now, including how they provide services, to whom, and where, will not palpably (if at all) reduce the burdens of mental illness. We could use more person-power (and more to come on that topic), but having more people providing the usual treatment to mostly majority-group individuals and mostly in urban areas perpetuates rather than solves a problem.
By attitudinal factors here I refer to influences within the individual that provide obstacles in obtaining or seeking care. These factors are readily distinguished from system factors at the margins, but they can also blend. For instance, services may be available to those in need of care, but perhaps people do not believe they will be reimbursed or reimbursed completely. Beliefs about the system of care are deterrents, too. Attitudinal issues are not minor and indeed are considered to be the main source of barriers to receiving care. Here are salient barriers within this category.
Attitudes and perceptions of the public serve as major barriers to providing mental health services. These attitudes encompass views about several aspects of mental illness, including perceptions of psychiatric disorders (what they are and what it means to “have” one), concerns about acceptance by other individuals if they admit to having a disorder, the value of interventions designed to treat mental disorders, views about mental health professionals and others who provide services, and more generally a reluctance to get involved in mental health treatment. Stigma is the most familiar barrier that comprises an attitudinal factor. Stigma means that mental illness tends to be associated with negative attributes such as disgrace, shame, weakness, lack of control, irrationality, and others. Stigma can result in people with mental illness being rejected, shunned, and treated in a discriminatory fashion (Hinshaw & Stier, 2008). Stigma is not limited to mental illness and is also associated with various physical characteristics (disabilities, disease), culture and ethnicity, varied gender identity, homelessness, poverty, and use of illicit substances, to mention major contenders. Regrettably, rejection, discrimination, and attribution of pejorative characteristics have many victims.
Separate facets of stigma can be delineated. First, there are the negative effects on the person who is stigmatized. Stigma includes prejudice, stereotypes, and discrimination against people with mental disorders. That discrimination can be expressed in many ways, including limited opportunities for work, housing, and insurance coverage (because of a preexisting condition). At school and in the workplace, bullying, physical violence, and harassment may result from the stigma against mental illness and any symptoms that suggest psychological (p. 64) problems. Most of us have seen rejection of individuals with seemingly odd emotional, cognitive, or behavioral characteristics.
Second, the stigma individuals hold against themselves can affect their attitudes toward their own mental health problems. This is known as self-stigma, or the internalization of the broader view one might hold toward others. Because of self-stigma, individuals may be unlikely to acknowledge a possible mental illness or symptoms, or to seek treatment. Even if one acknowledges symptoms, one would want to avoid certain stereotypic attributes such as being “crazy” or unable to handle everyday life commonly associated with mental illness or treatment.
Stigma is so pervasive that even health care professionals are susceptible to it and can display numerous negative reactions, prejudice, and stereotypes (e.g., about dangerousness) in relation to individuals with mental illness (e.g., Ahmead, Rahhal, & Baker, 2010; Lauber et al., 2004; Nordt, Rössler, & Lauber, 2006; Reavley, Mackinnon et al., 2014; Van Boekel et al., 2013). This is instructive because it demonstrates that education and information do not necessarily protect people from harboring stigma.
Stigma related to mental illness is well studied, with theory and research going back several decades and spanning many different countries (Corrigan et al., 2012; Pescosolido, 2013). National surveys and laboratory studies have evaluated various negative responses to psychiatric disorders and the people who have them. These views include stereotypes about how dangerous people with mental illness are likely to be and the need for coercive and restrictive treatments to contain or control individuals labeled as mentally ill. Efforts to inform the public that mental illness is a disease, with biological bases (in the brain, genetics), were made in part to reduce stigma. Unfortunately, such educational approaches have generally failed to reduce stigma—indeed, they have occasionally increased it—because they introduced a more fatalistic view, namely that not much can be done for individuals with a disorder (e.g., Phelan, 2005; Schnittker, 2008; Stuart et al., 2012).
Stigma and self-stigma can be influenced (moderated) by several other variables, including culture, country, age of the target patient (child, adult), type of disorder, and descriptors used to portray mental illness (e.g., Pescosolido, 2013). These nuances are important, but for present purposes the overall concern is more critical, namely, stigma presents a huge barrier in seeking and providing services. The degree of perceived stigma is inversely related to the likelihood of seeking treatment (Clement et al., 2015).
Many people because of stigma are reticent to label their conditions as mental illness and to enter into mental health systems and services. Obtaining effective treatment and overcoming some impairing condition are weighed against risking stigma and discrimination. The stigma and discrimination risks are real and are associated with all sorts of discriminatory acts, including not being hired, being denied loans, being treated with discourtesy, and being seen as dishonest (e.g., Kessler et al., 1999). Individuals with mental illness or a history of illness may be restricted in other ways, such as the ability to obtain or renew a driver’s license, vote, serve on a jury, hold elected office, or maintain custody of children. The discrimination associated with mental illness has its own consequences in terms (p. 65) of emotional and stress reactions that can exacerbate mental health problems (e.g., Capezza et al., 2012). In short, stigma and self-stigma go beyond “beliefs and attitudes.” Disclosing one’s mental illness or symptoms can have untoward consequences, and even in situations in which there might not be “real” negative consequences, the perception alone that these consequences could or will occur are more than enough to keep people from seeking treatment.
Real or perceived risks of disclosing mental illness are likely to outweigh any gain of disclosing for at least two reasons. First (and as discussed in the next section), public views of psychological treatments and mental health services are not very positive or hopeful. Many people do not see treatment as a viable or effective option, so the advantages of treatment seem paltry when weighed against the seemingly greater costs of stigma and discrimination.
Second, as a general rule, we humans tend to avoid risk—it seems to be a feature of our neurobiological makeup as a species even when there might be a benefit, or greater benefit than can be quantified (e.g., more money earned than money at risk to be lost). Even the neurobiological underpinnings of this risk-averse style have begun to be unraveled (e.g., Macoveanu et al., 2013). One can understand the reticence of participating in any mental health service to minimize the perceived risk that is associated with stigma.
Mental Health Literacy
Another pervasive and multifaceted barrier to seeking treatment is mental health literacy, which refers to “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention” (Jorm et al., 1997, p. 182). Mental health literacy includes knowledge about disorders and their treatment and prevention, recognition of the emergence and presence of disorders, and awareness of help-seeking options, including self-help strategies and professional treatment options. Literacy in this context goes beyond simple knowledge but instead indicates the likelihood of actually following through and acting on that knowledge (Jorm, 2012).
Lack of mental health literacy is a barrier to receiving treatment and affects multiple facets of entering treatment. To begin, individuals with a mental disorder may not immediately recognize there is a problem nor seek treatment right away when the problem is recognized. One study found an average total delay of 8.2 years, with 6.9 years passing before recognition of the problem and 1.3 years before obtaining treatment (Thompson, Issakidis, & Hunt, 2008). Similarly, a large-scale survey of people in 28 developed and developing countries revealed that only a fraction of individuals in need of treatment received any (Wang et al., 2007); among those who did receive treatment, the delay in seeking treatment was long (e.g., 1–14 years for mood disorders, 3–30 years for anxiety disorders, and 6–18 years for substance use disorders).2
Delays in identifying the need for treatment are due in part to the human tendency to use more normalizing terms (e.g., stress, life problems) rather than more clinically informed and more severe labels (e.g., depression) when referring to symptoms and clinical dysfunction. Of course, such terms tend to minimize (p. 66) the significance of the problem while also classifying it as not requiring professional mental health services. When individuals are given descriptions of mental disorders, they often do not identify them as problems at all (for a review, see Jorm, 2012). Outside of the laboratory, a large percentage of those with a disorder (44.8 percent) do not perceive the need for treatment (Mojtabai et al., 2011). Simply put, people often just prefer to handle their problems on their own.
Mental health literacy may be all the more difficult because of obstacles of identifying disorders in childhood and adolescence. The majority of mental disorders arise during these periods. Yet childhood and adolescence are periods that can show marked changes in emotions, thought processes, and behaviors that are normative. Consequently, in childhood and adolescence, it may not be so easy to distinguish whether something is a problem or signs of a problem and whether that sign is transient or permanent and worthy of intervention. Many problems that can indeed be significant (e.g., tics, stuttering, language delays) often emerge and then just as quickly disappear in childhood. Thus the transient nature of some clinical problems and the fluctuations of “normative” child behavior can make clinical dysfunction difficult to identify unless it is extreme (for instance, the extremes of autism spectrum disorder or intellectual disabilities) and there is clear impairment in key areas (like self-care and school functioning).
With so many mental health disorders, with ambiguity in terms of what is and is not a problem, and with the huge variation in personality and social behaviors among individuals, one might say that identifying mental health problems is inherently difficult. That might well be the case, but a larger problem is worth noting here. When it comes to other types of health issues, including hearing problems, vision problems, and obesity, individuals are not all that good at identifying problems and seeking interventions (Davis et al., 2007; Lydecker & Grilo, 2016; Noertjojo et al., 2006). So, the problem of health literacy is not limited to mental disorders.
Mental health literacy also includes knowing what the range of treatment options are and how to access and enter treatment.3 Limits in people’s views about what viable treatment options exist and attitudes toward the various options provide barriers to obtaining professional help. One study found that in general adults consider parents and family to be their primary sources of support and help, and view these sources more positively than they do a mental health professional (Jorm, 2012). Apart from family and friends, many people consider certain self-help strategies (vitamins, special diets, physical activity, getting out of the house more, and courses on stress management) to be effective means of addressing their mental health problems (sometimes more so than professional mental health treatment). In short, mental health care is not necessarily the first resource people consider. People may question the effectiveness of mental health care. Indeed, a survey in six European countries indicated that one-third of individuals believed that professional mental health care is worse than or equal to no help at all for mental disorders (ten Have et al., 2010).
Educational efforts clearly are needed to inform individuals of the process of identification and how to move from identification to obtaining effective help (p. 67) (Perry et al., 2014; Reavley, McCann et al., 2014). Yet, by themselves, educational efforts may not be sufficient. Evidence shows that knowledge of mental health is improved after intervention, but it is not clear that this shift would have any impact on actual identification of problems in everyday life, change how the problems are labeled, or be followed by action in obtaining treatment. Knowledge and attitudes on self-report measures are rather easily changed; behavior change usually is much more difficult.
Cultural and Ethnic Influences
In the United States, cultural and ethnic identity can serve as a barrier to receiving services. Well documented is the lower likelihood of receiving mental (or physical) health care for individuals of ethnic minority status (e.g., McGuire et al., 2006; Nelson, Smedley, & Stith, 2002; US Department of Health and Human Services [USDHHS], 2001). This is frequently discussed and referred to as disparities in health care and reflects the differences among various groups and their access to care (not attributable to differences in health status, e.g., prevalence of dysfunction) or preferences of the group. For example, if 25 percent of every ethnic and cultural group experienced dysfunction and 20 percent of each group received treatment, there would be no disparities. It is when this proportion varies among groups that disparities arise. In the United States, certain minority groups (e.g., African American, Hispanic American, and Native American) are victims of these disparities.
The factors that contribute to these disparities are many and include characteristics of the services themselves, cultural views of mental health care, and attitudes and bias based on cultural and ethnic stereotypes among those who deliver services (Smedley et al., 2003). Let us consider a few of these factors in more detail. To begin, the availability of services places a limit on receiving care. Minority groups are disproportionately living in poverty in the United States, and services (e.g., clinics, hospitals) for mental health care are less available to the poor (Anderson, 2012). People living in poverty are not likely to have insurance or other sources of funds for physical or mental health care. So, even if one lived next door to an outpatient mental health service (very unlikely), being able to pay for services also is unlikely.
Second, services are not available that are culturally or ethnically congruent with the population in need. For example, treatment rarely is provided in the United States in different languages (e.g., Native American languages, Spanish, Chinese), so individuals with primary fluency in one of these languages might not seek treatment, even if they could communicate sufficiently in English. Those who are not fluent or less fluent in English in the United States might feel even less comfortable discussing psychological problems and participating in the entire process (e.g., intake assessment, therapy of some kind). Too few mental health professionals are available who reflect the cultural and ethnic characteristics of those in need of care (see Commission on Ethnic Minority Recruitment, Retention, and Training, 2008). Finding a practitioner of a given ethnicity who specializes in the problem at hand is difficult; most practitioners in the United (p. 68) States are European American. In principle, a perfect ethnic match of a therapist and client is not a prerequisite for effective treatment (Miranda et al., 2005), but the lack of available services and professionals that do match one’s culture could certainly deter one from seeking and entering into treatment.
Above and beyond the nature of services and providers themselves, key values and characteristics of individual cultures also can derail the processes of defining disorders, identifying what suitable interventions are, and seeking treatment. For example, cultures that emphasize self-reliance and spirituality as a health care option, or that see the family or community as a source of care, would be less likely to pursue “mainstream” (European American) health care or even to consider it relevant. As an example, exorcism and spiritual worship are major and, in some cases, primary means of addressing mental health problems in some non-Western cultures (e.g., Nguyen, 2014; Sabry & Vohra, 2013). Recall that earlier I mentioned that mental health treatments are not the first line of attack for many of those in need of care, and mainstream Western treatments often are not seen as likely to be effective anyway.
The notion of mental health literacy, discussed previously, itself is culturally based because it is based on the view that there is a fixed objective condition that some people can or cannot identify an once identified seek or do not seek treatment for that condition. Yet, many individuals, based on cultural traditions and personal beliefs, do not identify impairment in emotions, thinking, or behaviors as a psychological problem or a “problem” necessarily at all. For people who do not see their problems as psychological, mental health literacy is an irrelevant concept. If one does not see the problem from within the same cultural context in which mental health services have been devised, understandably one would not seek out such services. Overall, there are enormous cultural barriers in diagnosis, assessment, and treatment (Constantine & Sue, 2005; Paniagua & Yamada, 2013).
Providing public information and increasing knowledge are important but less likely to have a direct impact on our goal of reducing the burdens of mental disorders. An assumption of mental health literacy, as with stigma, is that more information and education will reduce that barrier, open the gate, and allow individuals to go to treatment. This remains largely an assumption, with mixed findings at best. Knowing more does not translate to doing something about it or doing something differently. This is not an argument against knowledge, information, or education. Indeed, all options for improving mental health should be pursued to bring treatment to individuals. Some ways of delivering interventions, noted in later chapters, can circumvent many of the usual barriers and do not need to assume that batting down illiteracy or stigma is a precondition to getting people into treatment.
I have designated a third broad category of barriers that are not easily placed elsewhere, barriers that greatly influence whether care is and can be provided to all (p. 69) those in need of services. They are highlighted here but raise critical issues to which we return later in the book.
Mental health literacy usually concerns people in the community and the extent to which they are able to identify clinical problems and resources for treatment. This might be referred to as self-identification given the focus on clients, potential clients, and communities of clients (e.g., by cultural or ethnic groups). Consider case identification as a separate barrier to providing services with a shift in focus from potential clients to systems of care.
Case identification refers to the ability to identify cases (individuals who might be in need of care) as a function of various systems within society, such as the schools, the workplace, and the community. That is, we know individuals with problems exist in large numbers. To what extent can they be identified by systems within the community and directed to potential treatment or other interventions? The difficulty in identifying cases in need of attention is a barrier to providing services. We might call this system mental health literacy, the ability of systems to identify clinical problems and direct individuals to the services that would help them.4
Case identification can be explained using, as an example, shootings in public places (schools, movie theaters, churches, shopping malls, and so on). In these shootings, multiple people have been killed and wounded. In many such cases, news articles report that the shooter had some form of mental illness, undiagnosed or poorly treated, or otherwise not detected. The implication is that something could have and should have been done differently to prevent the crime.5 Using a case identification approach, we ask what might be done to identify such individuals. Invariably following such violent incidents there are numerous calls and perhaps even some allocation of funds for increases in mental health services (e.g., Mueller, 2014). But even if implemented, the effect of such action is likely to be very small to nonexistent. This is because more services will not help in identifying people who need those services nor in bringing those people to the services that exist. More broadly, adding more funds to a system that is not very effective in providing services is of uncertain value, at best.
Case identification is a barrier to care because we have no systematic way of identifying cases in a proactive fashion. Because we know that most psychiatric disorders begin in childhood and in adolescence, those periods of life would be one place to begin to focus on case identification. Systems and settings in which many or most children are seen would be a logical place to implement systematic means to identify cases that might warrant attention. For example, elementary schools could conduct routine monthly evaluations of each child that focus on age-related functioning in social spheres (e.g., friends, interacting with others, victims or bullies or both), academic spheres (e.g., not so much achievement oriented but overall doing alright in role requirements), and other domains. Measures could be brief, and the resulting huge data sets could be used by researchers to refine items and their utility in predicting later problems and to address variations in (p. 70) region, ethnicity, and culture. All the measures would alert screeners to children who might be in need of supports (and not necessarily just from a mental health professional—this could mean volunteers, Big Brothers and Sisters, and the like).
Not all sources of dysfunction emerge in childhood and adolescence. We should have means of identifying people in need of services over the course of life through the school system, the workplace, and public service (such as the military). We need not begin with the daunting task of identifying all psychological disorders (>400 in contemporary diagnosis) and revamping multiple systems (elementary, middle, and high school; workplaces). Currently, we do not have procedures in place that are convenient, user-friendly, and brief and that could be used on a large-scale basis for even one or two disorders. Consequently, systematic efforts to identify cases in any setting and on almost any scale (e.g., school district) would be a good start.
Currently, when someone with undiagnosed or untreated psychological impairment commits a crime or completes suicide, we are led to wonder how the individual could have slipped through the cracks. There are no cracks—there are huge gorges. We do not look for individuals who are on the path toward needing care. In addition to increasing mental health literacy so that clients and their relatives can better identify who might be in need of treatment and what to do, we also need to have in place complementary, systemic procedures to identify such individuals as early in life as possible. Also, we want to identify dysfunction (subclinical) early in its progression because the longer the dysfunction goes untreated the more likely it will become a more serious disorder (or disorders). Thus some case identification is likely to be appropriate at multiple points early in life (e.g., pediatric visits, schools), but it has to be done quite systematically and in an ongoing way. I mentioned that there are obstacles in identifying dysfunction in childhood because of variation and the transient nature of many “symptoms.” Yet these need not be a deterrent to case identification as we collect data systematically, looking for possible outliers or “profiles” that increase the risk for clinical dysfunction. Assessment is arguably as important as developing interventions.
Model of Intervention Delivery
An enormous but often overlooked barrier in reducing the burdens of mental illness is how we routinely deliver psychological treatment. Consider as a key distinction the difference between interventions and how they are delivered. We have evidence-based psychosocial interventions (EBPIs), which are the interventions; how they are provided to individuals is the model of intervention delivery. The vast majority of psychosocial interventions in various forms of cognitive behavioral, traditional, and other therapies are delivered in a common way (or model of delivery) that dominants mental health. That dominant model has three interrelated characteristics:
1. Treatment sessions are provided in person and one-to-one with a client (individual, couple, family);
(p. 71) 2. Treatment is administered by a highly trained (e.g., master’s or doctoral level) mental health professional; and
3. Sessions are held at a clinic, private office, or health care facility.
This model is so pervasive that it is usually seen as the way of administering treatment when in fact it is only one way (with many options as will be elaborated in later chapters). I mention here that the dominant model is a barrier because it is available to so few people in the United States and in other developed and developing countries. If we are interested in reducing the burdens of mental illness, this model can play a role, but it should be very different from the one in current use. Later I will engage in a more extended discussion of the model, why and how it limits access to mental health care for people in need, and how to surmount that (see Chapter 6). Here, it is important to mention the dominant model as a professional-system barrier: “professional” because the model is dictated by the professions that provide mental health services and “system” because this barrier is not inherent in the attitudes or perceptions of clients. Therapy almost always means individual psychotherapy of one sort or another. That is fine if you are fortunate enough to have access, but it is not viable as a means of helping a large number of people in need.
Addressing and Surmounting Barriers to Treatment
These barriers must be addressed if we are to provide mental health services on a large scale and reach the vast majority of individuals in need of services. There are two broad strategies for addressing these barriers. First, one can combat individual barriers directly. For example, to address financial considerations and cost as a barrier, we can make affordable insurance available for a larger number of people and also simplify the process of charging insurance for mental health services (though no small task, that). Providing reimbursement for treatment sessions is a step in the right direction for reducing cost as a barrier. In the United States, insurance programs are still not the same as providing free as-needed care, enabling clients to walk into a clinic or health care facility and not worry about payment, coverage, or an interrogation about one’s insurance. In many other countries (e.g., some within the European Union), treatment is free, although of course it is paid for by taxes. In any case, better insurance coverage is an attempt to address cost as a barrier and obviously constitutes a direct assault on an important barrier.
Another example relates to mental health literacy. This barrier is addressed by ongoing efforts to distribute information and educational materials about disorders and their treatment. For example, in the United States, the Centers for Disease Control and Prevention (2016a) play a pivotal role in providing updated information on physical and mental health issues. Information and educational materials are provided in multiple languages. Moreover, there is a major effort (p. 72) to ensure that information about health care is presented in plain language (free from jargon) to improve health care literacy.6
Despite having provided two examples of direct efforts to reduce or eliminate barriers, it must be acknowledged that there will be no single way to overcome any individual barrier, and hence multiple efforts at multiple levels (federal, state, local) are important to continue and expand. In the vast majority of efforts, education is seen as the path to reducing barriers. If people knew more, they would behave differently, goes the thinking (this of course has so many counter-instances in research and everyday life, such as our diet and exercise behaviors). Nevertheless, the impact of an effort to reduce barriers is an empirical question. We need more trials to test different strategies to determine whether (1) a given barrier in fact was reduced; (2) the reduction led to more people being treated or taking care of themselves; and, arguably most important, (3) one could see palpable improvements in health as a result. Also, education and better understanding may be essential as part of a larger package that includes multiple ways of directly combatting the barriers.
A second and complementary strategy is to sidestep barriers entirely rather than addressing them directly and individually. By sidestepping, I mean making the barrier less relevant or irrelevant rather than trying to surmount it. For example, a barrier in physical health care has been getting people to treatment settings (clinics and hospitals). A breakthrough here was making the setting less relevant; many treatments can now be brought to patients by setting up clinics to do limited work in shopping malls, drug stores, and other settings (these include vaccinations, screens for cardiovascular disease, and much more). Referrals can be made from these settings when serious medical conditions are evident. Reducing the need to travel to clinics (with obstacles being transportation, parking, and scheduling appointments) increases the likelihood of receiving services. A related effort has been to set up small urgent-care centers. These are walk-in services often in fairly unassuming and nonmedicalized store fronts. The centers bring medical care closer to patients’ lives and also alleviate the ordeal of going to a doctor or to a hospital. They help get people to treatment by getting treatment centers closer to people.
Mobile mammography has served as a model for bringing care to individuals. Busses equipped with diagnostic tests, materials, and information visit communities where people live and can provide services in the neighborhood. The model has been adopted to address all sorts of health issues (general health, cardiovascular health, oral health, and others; I do not provide citations here because most of these are commercial enterprises and can be found on the Web). In any case, bringing treatment and diagnostic services to people to some extent sidesteps the barrier of accessibility. Similarly, in mental health care there are ways to sidestep some of the barriers. This model of delivering treatment (through technology, social policy changes) provides several opportunities that I will take up later in the book.
Much of contemporary psychosocial research has focused on identifying EBPIs, a topic addressed in Chapter 4. Having treatments that are effective and (p. 73) with firm science behind them is pivotal. With piles of effective interventions in hand, now one looks to the other hand with a pile of barriers. Can we get all of these effective treatments to people in need? Devising effective treatments is only a part of what is needed if all of the barriers discussed here remain in place. That is why any discussion of reducing the burden of mental disorders requires at least a two-pronged approach: not only the development of treatments but also efforts to ensure that they can be delivered on a large scale.
Summary and Conclusions
We have learned that the vast majority of individuals in need of care actually receive nothing at all. And the proportion that does receive care gets a wide range of “interventions” that can involve any contact or even just one contact with a variety of individuals (counselors, healers, health but not mental health professionals), few of whom are directly trained in mental health care.
In this chapter I also discussed barriers to receiving care and highlighted several impediments. System factors were discussed, which refer to barriers outside of the individual that can impede receiving treatment. The financial cost of treatment in the United States is clearly a deterrent. When a person has insurance coverage, it is not always so clear what will be reimbursed. Policy and legal regulations were also noted as a systems barrier, and these reflect a panoply of influences dictating whether service facilities are available and whether various groups and clinical problems will be treated based on budgetary constraints. Also, trained mental health professionals are too few in number and are concentrated in places that limit their reach among the many who need services. Other limits (too few professionals to reflect the ethnicity and culture of the population, and too few trained to address problems where need is great, such as with children and older adults) provide further barriers.
Attitudinal barriers are considered to have an even greater impact in keeping individuals from treatment. I began with discussing stigma associated with symptoms of mental illness, including self-stigma or views individuals have about themselves and acknowledging symptoms as such. Mental health literacy was discussed and shown to relate to delays in identifying whether one has a mental disorder and is in need of treatment, as well as delays in action to obtain treatment. The lack of information and ability to recognize a disorder alone prevents individuals from seeking appropriate care, leaving aside barriers such as stigma.
Case identification and model of intervention delivery were two barriers rarely discussed that greatly limit providing services. The dominant model of treatment delivery has been and continues to be some form of individual psychotherapy, delivered in person, by a mental health professional and in a clinic or private practice setting. Evidence-based and non–evidence-based therapies are of this model. The dominant model of providing treatment and viable alternatives will be taken up in later chapters. (p. 74)
1. In passing, let me note the well-known consequences associated with cutting mental health budgets by government agencies. Many individuals in need of mental health care often end up in other systems (e.g., homeless shelters, jails and prisons, medical hospital services) or in no systems at all (e.g., the streets) and use other services more frequently (e.g., emergency department visits for psychiatric and neglected physical health problems, social services for homeless care). Rather than saving states and communities money, these cuts to mental health services simply shift financial responsibility and costs to other services, agencies, or settings. The funding insight in any program is to be concerned not only with the cost of providing services but also with the cost of not providing them. Sometimes it is costlier to ignore or undertreat a problem than to provide adequate services.
2. Delays in seeking treatment are not at all unique to mental illness. For example, people with hearing loss take approximately 10 years before they seek assessment and intervention (Davis et al., 2007). This is an interesting example because hearing loss shares some features with mental illness, including the stigma many people experience with the loss and the fact that far more individuals are in need of services than there are professionals and facilities to serve them. Also, hearing loss often leads to social isolation and has been associated with serious psychological problems, including depression, anxiety, and, dementia (Battey, 2016).
3. Knowing what the treatment options are is part of mental health literacy and might be out of reach for all of us. For example, there are hundreds of forms of psychotherapy and all sorts of other psychosocial programs and interventions advocated for mental disorders and substance use and abuse disorders (e.g., Bellack & Hersen, (p. 289) 1985; Kazdin, 2000; Substance Abuse and Mental Health Service Administration, 2017b; https://en.wikipedia.org/wiki/List_of_psychotherapies). It is unlikely that trained mental health professionals (e.g., me) could identify any more than a very small percentage of the treatments in these categories. This is not the same challenge in relation to mental health literacy for the public, which is identifying that treatment is needed and what a viable treatment would be in general terms, and then engaging in the actions necessary to obtain a form of that treatment. Even so, it does not help literacy to have a baffling array of options without any clear way to sort through them.
4. I have designated this in a separate category of barriers as “other factors.” It might well fit into system barriers because it is the system rather than attitudinal facets that serves as a barrier. Yet this is worth distinguishing because it is not usually included in lists of barriers and will emerge later in the book with the discussion of novel models that address barriers.
5. When an individual commits a heinous crime, invariably there is interest in going back into the person’s history to identify if there was mental disorder or subclinical symptoms. If such a past is found, an implication is that the crime was related to that prior history. There might well be a connection. However, the usual accounts in the media are not a suitable way to find these connections. Among the reasons is that the base rate of mental disorder (ignoring subclinical) in the general population is fairly high (25 percent of individuals in the United States, as elaborated previously). So, we do not know whether the rate of the disorders among individuals who committed the type of crime in question exceeds that rate in the general population and among people who did not commit that type of crime. Also, on the same day of the horrible crime, there were many individuals who helped older adults through the crosswalks, who gave money to charity, and who volunteered at homeless shelters to help individuals in need. For individuals who did such laudable acts, we do not know their rate of mental disorder to help discern if the violent crime perpetrators have a higher rate of disorder. Perhaps more pertinent than abstract argument are the data. Most of the public (approximately 75 percent) considers people with mental illness as dangerous (Link et al., 1999). Actually, individuals with mental disorder are not any more dangerous than others in the general population. An exception is when individuals have both a mental disorder and substance abuse disorder; then the risk for engaging in violent behavior is much higher (Elbogen & Johnson, 2009). However, people with mental illness are much more likely to be victims than perpetrators of a dangerous crime (Hinshaw & Stier, 2008).
6. In the United States, a law was passed referred to as the Plain Writing Act of 2010 (H.R. 946/Public Law 111-274). The law requires that federal agencies use “clear Government communication that the public can understand and use.” In 2011, a new Executive Order, “Improving Regulation and Regulatory Review” (E.O. 13563) was issued, which stated that “[our regulatory system] must ensure that regulations are accessible, consistent, written in plain language, and easy to understand” (www.plainlanguage.gov/plLaw/index.cfm). Guidelines are provided and periodically revised (www.plainlanguage.gov/index.cfm) and serve as a critical effort to improve literacy in health care more generally.