Article TextThe process of change in psychotherapy, regardless of the clinician's orientation, lengt...

1. Conceptualizing Mental Health Care Utilization Using The
Health Belief Model
Article Text
The process of change in psychotherapy, regardless of the clinician's orientation, length of
treatment, or outcome measure, begins with this: The client must attend a first session. However,
several national surveys in the past decade converge on a rate of approximately one-third of
individuals diagnosed with a mental disorder receiving any professional treatment (AlegrÃa, Bijl,
Lin, Walters, & Kessler, 2000; Andrews, Issakidis, & Carter, 2001; Wang et al., 2005). A review of
the literature surrounding mental health utilization reveals evidence that a complex array of
psychological, social, and demographic factors influence a distressed individual's arrival to a mental
health clinic. Thus, developing effective strategies for decreasing barriers to care is a critical task
for clinicians and administrators. The
aim of this article was to review current research focused on appropriate utilization of mental health
services and to use the Health Belief Model (HBM; Becker, 1974) as a parsimonious model for
conceptualizing the current knowledge base, as well as predicting and suggesting future research
and implementation strategies in the field.
First, it is important to address whether increasing mental health service use is an appropriate
public health goal. A World Health Organization (WHO) survey comparing individuals with severe,
moderate, or mild disorder symptoms indicated that approximately half of those surveyed went
untreated in the past year (WHO World Mental Health Survey Consortium, 2004), with even less
treatment among those with more severe symptoms. Many costs are associated with untreated
mental disorders, including overuse of primary care services for a variety of reasons (Katon, 2003;
White et al., 2008), lost productivity for businesses and lost wages for employees (Adler et al., 2006),
as well as the negative impact of mental disorders on medical disorders, such as diabetes and
hypertension (Katon & Ciechanowski, 2002). These com
bined expenses have been calculated to rival some of the most common and costly physical
disorders, such as heart disease, hypertension, and diabetes (Druss, Rosenheck, & Sledge, 2000;
Katon et al., 2008).
The consequences of providing additional services to address unmet need may vary by the cost-effectiveness
of treatment, availability of providers, and the interaction of mental health symptoms
with other illnesses. Medical cost offset and cost-effectiveness research address these questions (for
further review, see Blount et al., 2007; Hunsley, 2003). Medical cost offset refers to the estimation of
cost savings produced by reduced use of services for primary care as a result of providing
psychological services. Reduced medical expenses could occur for several reasons: increased
adherence to lifestyle recommendation changes such as diet, exercise, smoking, or taking
medications; improved psychological and physical health; and reduction in unnecessary medical
visits which serve a secondary purpose (e.g
., making appointments to fill social needs; Hunsley, 2003). In comparison with the indirect costs to
society, the individual, and the health care system, costs for providing mental health treatment are
quite low (Blount et al., 2007).

2. However, debate continues regarding how to facilitate mental health care utilization. Identification
of mental health need through primary care screening for depression is one research area that
highlights the complexity of this issue. Palmer and Coyne (2003) point out several important issues
in developing a strategy for addressing this goal: First, several studies suggest that identification of
depression in primary care is not enough, as outcomes for depression are similar in primary care
patients who have detected depression and those who have not (e.g., Coyne, Klinkman, Gallo, &
Schwenk, 1997; Williams et al., 1999). This is supported by research indicating a large gap between
the number of individuals who are identified through screening and referred to care, and those who
actually receive care (Flynn, O'Mahen, Massey, & Marcus, 2006). Second, it is critical to evaluate
attempts to increase utilization, rather than to assume they will be successful, cost-effective, and
targeting the appropriate individuals. Therefore, a theoretical framework that addresses both
psychological and practical factors associated with treatment utilization will be a beneficial addition
to this literature.
Little systematic research has been conducted on the specific topic of psychological factors related
to seeking mental health services. However, extensive work has been conducted within two broad,
related areas of research: help-seeking behavior and health psychology. Many models have been
proposed to explain help-seeking and health-protecting behaviors, none of which has been accepted
as wholly superior to the rest. The HBM (Becker, 1974; Janz & Becker, 1984; Rosenstock, 1966) is
one of several commonly used social-cognitive theories of health behavior. This model will be
reviewed, followed by a brief discussion of several other models. A discussion of the strengths of the
HBM and its applicability to mental health treatment utilization research will follow.
Health Belief Model
The HBM (Rosenstock, 1966, 1974), based in a socio-cognitive perspective, was originally developed
in the 1950s by social psychologists to explain the failure of some individuals to use preventative
health behaviors for early detection of diseases, patient response to symptoms, and medical
compliance (Janz & Becker, 1984 ; Kirscht, 1972; Rosenstock, 1974). The theory hypothesizes that
people are likely to engage in a given health-related behavior to the extent that they (a) perceive
that they could contract the illness or be susceptible to the problem (perceived susceptibility); (b)
believe that the problem has serious consequences or will interfere with their daily functioning
(perceived severity); (c) believe that the intervention or preventative action will be effective in
reducing symptoms (perceived benefits); and (d) perceive few barriers to taking action (perceived
barriers). All four variables are thought to be influenced by demographic variables such as race, age,
and socioeconomic status. A fifth original factor, cues to action, is frequently neglected in studies of
the HBM, but nevertheless provides an important social factor related to mental health care
utilization. Cues to action are incidents serving as a reminder of the severity or threat of an illness.
These may include personal experiences of symptoms, such as noticing the changing shape of a mole
that triggers an individual to consider his or her risk of skin cancer, or external cues, such as a
conversation initiated by a physician about smoking cessation. In addition, Rosenstock, Strecher,
and Becker (1988) added components of social cognitive theory (Ba ndura, 1977a, 1977b) to the
HBM. They proposed that one's expectation about the ability to influence outcomes (self-efficacy) is
an important component in understanding health behavior outcomes. Thus, believing one is capable
of quitting smoking (efficacy expectation) is as crucial in determining whether the person will
actually quit as knowing the individual's perceived susceptibility, severity, benefits, and barriers.
Other health care utilization theories
Other models for health care utilization have been proposed and used as a guide for research. In
general, these theories pull from a number of learning theories (e.g., Bandura, 1977a, 1977b; Lewin,

3. 1936; Watson, 1925). Two such models, the Theory of Planned Behavior (TPB; Ajzen, 1991) and the
Self-Regulation Model (SRM; Leventhal, Nerenz, & Steele, 1984), share many commonalities with
the HBM. Ajzen's TPB proposes that intentions to engage in a behavior predict an individual's
likelihood of actually engaging in the given behavior. Ajzen hypothesizes that intentions are
influenced by attitudes toward the usefulness of engaging in a behavior, perceived expectations of
important others such as family or friends, and perceived ability to engage in the behavior if desired
(Ajzen, 1991). This theory has been applied to a variety of health behaviors and has receiv
ed support for its utility in predicting health behaviors (Ajzen, 1991; Armitage & Conner, 2001;
Godin & Kok, 1996). However, its relevance in predicting mental health care utilization has received
relatively little attention (for two exceptions, see Angermeyer, Matschinger, & Riedel-Heller, 1999;
Skogstad, Deane, & Spicer, 2006). Similarly, the SRM (Leventhal et al., 1984) focuses on an
individual's personal representation of his or her illness as a predictor of mental health treatment
use. The SRM proposes that individuals' representation of their illness is comprised of how the
individual labels the symptoms he or she is experiencing, the perceived consequences and causes of
the symptoms for the individual, the expected time in which the individual would expect to be
relieved of symptoms, and the perceived control or cure of the illness (Lau & Hartman, 1983).
The HBM, TPB, and SRM are well-estab
lished socio-cognitive models with similar strengths and weaknesses. The models assume a rational
decision-making process in determining behavior, which has been criticized for not addressing the
emotional components of some health behaviors, such as using condoms or seeking psychotherapy
(Sheeran & Abraham, 1994). There is substantial overlap in the constructs of these three models.
For example, an individual's perception of the normative beliefs of others can be seen more
generally as a benefit of treatment (e.g., if I seek treatment my friends will support my decision) or
as a barrier (e.g., my family will think I am crazy if they know I am seeking professional help). The
SRM lacks a full description of the benefit and barrier aspects of decision making identified in the
HBM. However, the illness perceptions about timeline, identity, and consequences do provide a
more complete conceptualization of aspects of perceived severity, and in this way the SRM can
inform the HBM with these factors.
Andersen's Sociobehavioral Model (Andersen, 1995) and Pescosolido's Network Episode Model
(Pescosolido, 1992; Pescosolido, Brooks Gardner, & Lubell, 1998) emphasize the role of the health
care and social network system in influencing patterns of health care use, while Cramer's (1999)
Help Seeking Model highlights the role of self-concealment and social support in decisions to seek
counseling. In particular, the Network Episode Model hypothesizes that clear, independent choice is

4. only one of seve
ral ways that clients enter treatment, along with coercion and passive, indirect pathways to care.
According to Cramer's model, individuals who habitually conceal personally distressing information
tend to have lower social support, higher personal distress, and more negative attitudes toward
seeking psychological help. Thus, according to this model, self-concealment creates high distress,
which pushes an individual toward seeking treatment, but also creates negative attitudes toward
treatment, pushing an individual away from treatment. The HBM includes system-level benefits and
barriers to utilization, but these three models more fully emphasize the social-emotional context of
decision making.
Critiques and limitations of the HBM
The HBM has received some criticism regarding its utility for predicting health behaviors. Ogden
(2003), in a review of articles from 1997 to 2001 using social cognition models, questions whether
the theory is disconfirmable. She found that two-thirds of the studies reviewed found one or more
variables within the model to b
e insignificant, and explained variance accounted for by the model ranged from 1% to 65% when
predicting actual behavior. Yet, Ogden writes, rather than rejecting the model, the majority of
authors offer alternative explanations for their weak findings and claim that the theory is supported.
While authors' conclusions about their findings may be overstated in many cases, some explanations
of insignificant findings are valid limitations of the model. For example, some (e.g., Castle, Skinner,
& Hampson, 1999) point out that construct operationalization could be improved for the particular
health behavior being studied. However, insignificant results should not be explained away without
considering alternative models as well. Certainly, the HBM has received strong support in predicting
some health behaviors (Aiken, West, Woodward, & Reno, 1994; Gillibrand & Stevenson, 2006), but
questions remain as to its ability to predict all preventative health situations. The usefulnes
s of the HBM in predicting mental health utilization has not adequately been tested to our
knowledge.
The HBM may be limited further by its ability to predict more long-term health-related behaviors.
For example, from an early review of preventive health behavior models including the HBM by
Kirscht (1983), we can anticipate that the factors associated with initiating treatment, as discussed
here, may differ from the factors that predict mental health treatment adherence and engagement.
Thus, these outcomes--attending one therapy appointment versus completing a full course of
psychotherapy treatment--should be clearly distinguished from each other.
Strengths of the HBM
Researchers have not explicitly investigated mental health utilization patterns using the HBM
framework; however, much of the
existing literature can be conceptualized as dimensions of severity, benefits, and barriers, indicating
that the model may be a useful framework for guiding research in this area. For example, cultural
researchers often examine barriers to treatment and perceived severity of symptoms and benefits of
treatment in various ethnic populations (e.g., Constantine, Myers, Kindaichi, & Moore, 2004; Zhang,
Snowden, & Sue, 1998). In general, the focus of these studies has been to examine cultural
differences in beliefs about symptom causes (Chadda, Agarwal, Singh, & Raheja, 2001), changing
perceptions of mental health stigma among various ethnic groups (Schnittker, Freese, & Powell,

5. 2000), and cultural mistrust or perceived cultural insensitivity of mental health providers as a
barrier to effective treatment (Poston, Craine, & Atkinson, 1991). These studies lay the groundwork
for using the HBM as a framework for understanding mental health care utilization for all
populations.
Parsimonious and Clear
The model's use of benefits and barriers opposing each other provides a dynamic representation of
the decision-making process. In this "common sense" presentation, the impact of each positive
aspect is considered in the context of the
negative aspects. The model in this way provides a parsimonious explanation of a variety of
constructs within one clear framework.
Useful and Applicable
One strength of focusing on attitudes and perceptions related to treatment seeking is the clinical
utility of such models. By identifying attitudes that may inhibit appropriate help seeking,
psychologists can then use research findings to develop interventions for addressing maladaptive
attitudes or inaccurate beliefs about mental health and its treatment. Therefore, socio-cognitive
theory provides a useful focus for research that ultimately may result in programmatic changes to
benefit clients. Once developed, perception-change interventions can be evaluated through changes
in observed treatment utilization.
Within the HBM framework, three general approaches can be used to increase appropriate
utilization: increasing perceptions of individual susceptibility to illness and severity of symptoms,
decreasing the psychological or physical barriers to treatment, or increasing the perceived benefits
of treatment. The following discussion will highlight how each perception can be increased or
decreased, and the implic
ations for such intensification of the perceptions. Examples of intervention strategies that can serve
as individual or system-level "cues to action" will be reviewed within each domain of the model. In
addition, where appropriate, the discussions will highlight how sociodemographic factors such as
age, sex, and ethnicity impact the perceived threat from the disorder and the expectations for the
benefits of therapy. The model we discuss assumes that the individual seeking therapy is
autonomous in this decision making. That is, it is not directly applicable to those who are required to
seek therapy by the judicial system, a spouse, or their place of employment, nor does it address
children's mental health care utilization. We will address some of these issues briefly later in our
discussion.
Figure 1 is a visual representation of the model we propose for conceptualizing mental health care
utilization using the HBM as a framework. The studies reviewed in each section below were
designed primarily without use of the HBM framework. However, the model is a useful heuristic tool
to organize and draw in research from a variety of disciplines--marketing, public health, psychology,
medicine, etc.
Sociodemographic variables in the HBM

6. Several demographic variables consistently predict utilization of mental health services. Despite
similar levels of distress, some groups are less likely to seek professional treatment than others,
creating a gap between need and actual use of outpatient mental health services. Groups identified
as consistently underutilizing services include men, adults aged 65 and older, and ethnic minority
groups in the United States (Wang et al., 2005). Within the HBM framework, these demographic
variables are hypothesized to influence clients' perceptions of severity, benefits, and barriers to
seeking professional mental health services. Studies exploring the relationship between
demographic variables and HBM constructs will be highlighted throughout this article.
Systems approaches to addressing perceived susceptibility and severity
According to the HBM, individuals vary in how vulnerable they believe they are to contracting a
disorder (susceptibility). Once diagnosed with the disorder, this dimension of the HBM has been
reformulated to include acceptance of the diagnosis (Becker & Maiman, 1980). In addition,
increasing an individual's perception of the severity of his or her symptoms increases the likelihood
that he or she will seek treatment. In relation to mental health, perceived susceptibility goes hand in
hand with perceived severity (i.e., Do I have the disorder and how bad is it?), and so they will be
discussed together. In health-related decisions, the majority of consumers are dependent upon the
expertise and referral of the medical professional, usually the trusted general practitioner
(Lipscomb, Root, & Shelley, 2004; Thompson, Hunt, & Issakidis, 2004). Unlike decisions about the
need for a new vehicle or a firmer mattress, determining whether or not feelings of sadness should
be interpreted as normal emotional fluctuation or as indicators of depression is a decision often left
to an expert in the area of mental health or a primary care physician. This places a great
responsibility on practitioners, psychiatrists, psychologists, and other mental health service
providers when discussing the severity of a client's symptoms and options for treatment.
Ethical Considerations in Increasing Perceived Severity and Symptom Awareness
The American Psychological Association (APA) provides ethical guidelines for clinicians about how to
inform the public appropriately about mental health services. According to the 2002 Ethics Code
(American Psychological Association, 2002), psychologists are prohibited from soliciting testimonials
from current therapy clients for the purpose of advertising, as individuals in such circumstances may
be influenced by the therapist-client relationship they experience. Additionally, psychologists are
prohibited from soliciting business from those who are not seeking care, whether a current or
potential client. This may include a psychologist suggesting treatment services to a person who has
just experienced a car accident or handing out business cards to individuals at a funeral home.
However, disaster or community outreach services are not prohibited, as these are services to the
community. Psychologists are prohibited from making false statements knowingly about their
training, credentials, services, and fees, and are also prohibited from making knowingly deceptive or
exaggerated statements about the success or scientific evidence for their services. In this way, limits
are placed on the influence of practitioners on those in vulnerable situations.
Identification of Symptoms
What, then, does an ethical symptom awareness intervention look like? It would involve clearly
differentiating between clinical and nonclinical levels of distress, with an indication of what types of
intervention strategies may be most effective for each. For example, in cases of mild
symptomatology, individuals may be encouraged to use a stepped care approach beginning with
bibliotherapy, psychoeducation, and increases in social support. Also important is the provision of
accurate, research-based information regarding symptoms of psychological disorders and treatment
options. This may call for challenging our assumptions that psychotherapy is helpful for all

7. psychological distress. Recent studies of grief counseling and postdisaster crisis counseling, for
example, suggest there may be an iatrogenic effect of therapy for some individuals (Bonanno &
Lilienfeld, 2008). On the other hand, some research indicates that individuals with subclinical levels
of distress who receive treatment early may avoid developing more severe pathology (e.g.,
prodromal psychosis; Killackey & Yung, 2007). In programming for all components of health beliefs,
not just severity, the credibility of psychotherapy is dependent upon ethical, appropriate public
health statements and service marketing.
Many examples of mental health education campaigns have been discussed in the literature, often
focusing simultaneously on increasing awareness of mental illness, destigmatizing individuals with
mental illness, and increasing awareness of mental health resources. The Defeat Depression
Campaign of the UK was designed with these goals in mind, and results of nationally representative
polls before, during, and after the campaign indicated positive changes in public attitude toward
depression and recognition of personal experiences of symptoms (Paykel, Tylee, & Wright, 1997).
Similarly, more recent national campaigns in Australia have provided some evidence that education
increases public accuracy in identifying mental illness (Jorm & Kelly, 2007). National screening day
initiatives for depression, substance abuse, and other psychological disorders also aim to increase
awareness of illness severity for individuals who may not recognize symptoms as signs of illness
warranting treatment.
Approximately 71% (Lipscomb et al., 2004; Thompson et al., 2004) of individuals report looking to
their primary care physician for mental health information, treatment, and referrals. However, many
physicians lack the appropriate knowledge to identify mental health problems (Hodges, Inch, &
Silver, 2001). After examining five decades (1950-2000) of articles evaluating the adequacy of
physician training in detecting, diagnosing, and treating mental health, Hodges et al. (2001) offer
several suggestions for improving primary care physicians' training to effectively identify patients
with mental health issues. Beyond learning the diagnostic criteria for the major disorders and
providing appropriate medications when needed, however, physicians also need to be aware that
they can act as a "cue to action" in the patient seeking psychotherapy. Such cues would alert the
patient that his or her symptoms of distress or depression had reached severe levels and that the
trusted family physician believes additional treatment is needed.
Influence of Demographic Variables on Perceived Severity
An individual's personal label of the symptoms and illness are thought to contribute to perceived
severity. In a study of four large-scale surveys of psychiatric help seeking, Kessler, Brown, and
Broman (1981) found that women more often labeled feelings of distress as emotional problems than
men did, a factor thought to help explain the consistent finding that men seek mental health services
less often than women even when experiencing similar emotional problems. Similarly, Nykvist,
Kjellberg, and Bildt (2002) found that among men and women reporting neck and stomach pains,
women were more likely to attribute pains to psychological distress, while men were more likely to
indicate no significant cause and little concern regarding the somatic symptoms.
Relatively little research has been conducted regarding how individuals of diverse backgrounds
perceive the severity of their mental illness symptoms. However, some evidence suggests that
individuals of different ethnic backgrounds appraise the severity of their illness symptoms
differently, such that individuals from minority cultures are more influenced by their own culture's
norms about mental illness symptoms than White Americans (Dinges & Cherry, 1995; Okazaki &
Kallivayalil, 2002). Cues to action from providers may be more effective if they are framed in a way
that is congruent with individuals' attributions about symptoms. In other cases, education about
symptoms, provided in a culturally sensitive manner, may be necessary. This is an area where

8. additional research is needed to determine practice.
Older adults are more likely to seek treatment when they perceive a strong need for treatment
(Coulton & Frost, 1982). However, some aspects of aging may influence whether or not older adults
perceive ambiguous symptoms as psychological in nature or due to physical ailments. For example,
among older adults, particularly those experiencing chronic pain or illness, somatic symptoms of
mental illness may be interpreted as symptoms of physical illness or part of a natural aging process,
rather than as symptoms of depression or anxiety (Smallbrugge, Pot, Jongenelis, Beekman, &
Eefsting, 2005). In this way, some depression symptoms may be overlooked by older individuals and
the physicians who see them (Gatz & Smyer, 1992).
Systems approaches to addressing perceived benefits
Even if clients do view their symptoms as warranting attention, they are unlikely to seek treatment if
they do not believe they will benefit from professional services. Thus, increasing perceived benefits
of treatment is a second approach to increasing appropriate utilization.
Public Perceptions of Psychotherapy
In response to changing health care markets, the 1996 APA Council of Representatives called for the
creation of a public education campaign to inform consumers about psychological care, research,
services, and the value of psychological interventions (Farberman, 1997). Results of preprogram
focus group assessments indicated that participants were frustrated with changes in health care
service delivery in the United States and many participants did not know whether their health
insurance policy included mental health benefits. Participants indicated that they did not know when
it was appropriate to seek professional help, and often cited lack of confidence in mental health
outcomes, lack of coverage, and shame associated with help seeking as main reasons for not seeking
treatment. Participants reported that the best way to educate the public about the value of
psychological services was to show life stories of how they helped real people with real-life issues.
Informed by the focus groups and telephone interviews, APA launched a pilot campaign in two states
using television, radio, and print advertisements depicting individuals who have benefited from
psychotherapy, as well as an 800 telephone number, a consumer brochure, and a consumer
information website. During the first six months of the campaign, over 4,000 callers contacted the
campaign service bureau for a referral to the state psychological association to request campaign
literature, with over 3,000 people visiting the Internet site weekly (Farberman, 1997). In sum,
addressing perceived benefits of treatment means answering the question, "What good would it do?"
When individuals are made aware of how treatment could improve their daily functioning, they may
be more motivated to overcome the perceived barriers to treatment. Especially for individuals who
have not previously sought mental health treatment, describing realistic expectations for treatment
may be an essential first step in orienting individuals to make informed treatment decisions.
Public Preference for Providers of Care
Many different types of professionals serve as mental health service providers, and individuals'
beliefs about the relative benefit of seeking help from various lay and professional sources likely
impact decisions to seek help. Roles have shifted in treatment over time, with the introduction of
managed care and the increased role of the PsyD, master's-level psychologist or counselor, and
MSW as treatment providers. Counseling has been considered a primary role of clergy for many
decades; however, specificity of counseling training has changed over time, with some clergy
receiving specific training as counselors within seminary education. Primary care physicians have
been relied upon for treatment through pharmacotherapy with the development of improved

9. medications for depression, anxiety, and attention deficit hyperactivity disorder, among others.
While few primary care physicians conduct traditional therapy sessions, many individuals report that
they first share mental health concerns with their primary care physician, making this profession an
important potential gateway for psychotherapy (Mickus, Colenda, & Hogan, 2000).
Level of distress may also influence where individuals seek help: Consumer Reports' popular survey
of over 4,000 participants found that individuals tend to see a primary care physician for less severe
emotional distress and seek a mental health professional for more severe distress (Consumer
Reports, 1995), while Jorm, Griffiths, and Christensen (2004) found that individuals with depressive
symptoms were most likely to use self-help strategies in mild to moderate levels of severity and to
seek professional help at high levels of severity.
Some support has been found for the importance of a match between individuals' perceptions of the
cause of symptoms and the type of treatment they seek. In a German national survey, perceptions of
the cause of depression and schizophrenia significantly predicted preferences for professional or lay
help. Those who endorsed a biological cause of illness reported they would be more likely to advise
an ailing friend to seek help from a psychiatrist, family physician, or psychotherapist, and less likely
to advise seeking help from a confidant. Perceptions of social-psychological causes of illness, such as
family conflict, isolation, or alcohol abuse, were related to advising a confidant, self-help group, or
psychotherapist rather than a psychiatrist or physician (Angermeyer et al., 1999).
Demographic Variables and Perceived Benefits
Perceptions of mental health treatment as beneficial are likely shaped by cultural influences as well
as an individual's personal experience. In a subset of randomly selected individuals from a nationally
representative survey, Schnittker et al. (2000) compared Black and White respondents' beliefs about
the etiology of mental illnesses and their attitudes toward using professional mental health services.
Black respondents were more likely than White respondents to endorse views of mental illness as
God's will or due to bad character, and less likely to attribute mental illness to genetic variation or
poor family upbringing. These beliefs predicted less positive views of mental health services, and the
authors found that more than 40% of the racial difference in attitudes toward treatment was
attributable to differences in beliefs about the cause of mental illness.
Older adults' reluctance to seek psychological services has been connected with more negative
attitudes toward psychological services (Speer, Williams, West, & Dupree, 1991). Attitudes toward
psychotherapy appear to improve by aging cohort, however. Currin, Hayslip, Schneider, and Kooken
(1998) assessed dimensions of mental health attitudes among two different cohorts of older adults
and found that younger cohorts of older adults hold more positive attitudes toward mental health
services. Thus, attitudes among older adults may be less attributable to age than to changing
cultural acceptance of mental illness over time. Older adults who have engaged in professional
psychological treatment tend to see mental health treatment as more beneficial than their
counterparts who have never sought treatment (Speer et al., 1991).
Across diverse religious orientations, beliefs in a spiritual cause of mental illness have been
associated with preference for treatment from a religious leader rather than a mental health
professional (Chadda et al., 2001; Cinnirella & Loewenthal, 1999). For individuals who interpret
psychological distress symptoms as spiritually based, a religious leader may be viewed as a more
beneficial provider than a traditional mental health professional. Some clients prefer to see clergy
for mental health concerns. Some psychologists have formed relationships between religious
organizations and mental health providers to foster collaboration and access to many care options
for community members (McMinn, Chaddock, & Edwards, 1998). Benes, Walsh, McMinn,

10. Dominguez, and Aikins (2000) describe a model of clergy-psychology collaboration. Using Catholic
Social Services as a medium through which collaboration took place, psychologists, priests, religious
school teachers, and parishioners collaborated through a continuum of care beginning with
prevention (public speaking about mental health topics, parent training workshops) through
intervention (1-800 access numbers, support groups, and counseling services). The authors note that
bidirectional referrals--not simply clergy referring to clinicians--and a sharing of techniques and
expertise are keys to the success of such programs. Providing care to individuals through the source
that they consider most credible or accessible is an innovative strategy for increasing perceived
treatment benefits and decreasing barriers
Marketing Psychological Services
While the idea of marketing psychological services may seem unappealing to some psychologists,
marketing strategies designed to encourage appropriate utilization may serve as both a strategy for
the field of psychology as well as an outreach service to improve public health. In order to benefit
from psychotherapy, individuals must view it as a legitimate way to address their problems.
Strategies may include marketing psychological services at a national level, such as the APA's 1996
public education campaign (Farberman, 1997); at a group level, such as a community mental health
system providing rationale for increased funding; or at an individual level, such as an independent
private practitioner seeking to increase referrals. Two theories, social marketing theory and
problem-solution marketing, are useful models for developing effective mental health campaigns.
Social Marketing Theory
Rochlen and Hoyer (2005) identify social marketing theory as a framework for identifying strategies
specifically aimed at changing social behaviors. Three principles define social marketing: negative
demand, sensitive issues, and invisible preliminary benefits (Andreason, 2004). Negative demand
describes the challenge of selling a product (psychotherapy, in this case) that the individual does not
want to buy. In the case of individuals who see therapy as unhelpful or a frightening experience,
addressing negative demand would include considering the viewpoint of a reluctant audience and
perhaps utilizing the Stages of Change model (Prochaska & DiClemente, 1984), in which the goal of
the marketing campaign would be to move an individual from the precontemplation stage to the
contemplation stage of change. Social marketing theory also takes into account the degree of
sensitivity in the task being encouraged; that is, seeking psychotherapy requires a greater amount of
mental energy and vulnerability than less sensitive purchases, such as a new motorcycle. The
principle of invisible preliminary benefit reminds those marketing psychological services that the
benefits of choosing to seek psychological help are often not seen immediately, as they are when
receiving a pain medication. Therefore, marketing strategies for mental health must make
consumers aware of psychotherapy's benefits and the long-term prospect of improving quality of life.

11. By: waluyo
Article Directory: http://www.articledashboard.com
1stpsychologyarticles.blogspot.com/2009/12/conceptualizing-mental-health-care.html