Aging & Mental Health, 2015 Vol. 19, No. 2, 182191, http://dx.doi.org/10.1080/13607863.2014.920300
Attitudes towards seeking mental health services among older adults: personal and contextual correlates Eva-Marie Kesslera,b*, Sabrina Aginesa and Catherine E. Bowenc a
Network Aging Research, Heidelberg University, Heidelberg, Germany; bDepartment of Psychological Ageing Research, Institute of Psychology, Heidelberg University, Heidelberg, Germany; cAge and Cohort Change Project of the World Population Program, International Institute for Applied Systems Analysis (IIASA), Wittgenstein Centre for Demography and Global Human Capital (IIASA, € VID/OAW, WU), Laxenburg, Austria (Received 7 February 2014; accepted 21 April 2014) Objectives: Especially older adults underutilize professional mental health services. However, little is known about the factors associated with older adults’ attitudes towards seeking mental health services (ATSMHS). We therefore investigated a wide range of contextual (e.g. physical access, residence) and personal (e.g. perceived social support, life satisfaction, openness to experience) predictors of ATSMHS in a sample of older community-dwelling adults in Germany. We predicted that representations of old age as well as perceptions of (younger) psychotherapists would be uniquely important for determining ATSMHS. Method: A diverse sample of N ¼ 156 older adults (Mage ¼ 71.5 years, SD ¼ 6.4, range: 6092) completed questionnaire measures. We used hierarchical linear regression analyses to identify predictors of ATSMHS. Results: In the final saturated model, female gender, urban residence, personal and vicarious experience with psychotherapy, and higher perceived social support were each associated with more positive ATSMHS. In addition, more positive representations of old age and less negative perceptions of (younger) psychotherapists explained unique variance in ATSMHS over and above the other predictors. The overall model was significant and explained 49% of the variance in ATSMHS. Conclusion: Our findings can be used to inform interventions to improve older adults’ ATSMHS. Interventions that seek to improve older adults’ representations of their own aging as well as of psychotherapists may be useful for reducing the treatment gap. Keywords: psychotherapy; attitudes towards seeking mental health services; treatment gap; age stereotypes; older adults
Introduction Older adults disproportionately underutilize professional mental health services relative to younger adults (e.g. Bogner, de Vries, Maulik, & Un€ utzer, 2009; Crabb & Hunsley, 2006; Wang et al., 2005). Attitudes towards seeking mental health services (ATSMHS) are one factor that influences actual mental health help-seeking behavior (Cramer, 1999; ten Have et al., 2010). Thus, identifying correlates of older adults’ ATSMHS is one critical part of remedying the ‘treatment gap’. To date, however, little is known about the factors underlying individual differences in older adults’ ATSMHS, as most studies have focused exclusively on younger adults, investigated only a limited range of potential predictors, and/or taken a ‘group differences’ approach (i.e. compared older adults’ attitudes to younger adults’ attitudes in terms of overall attitude valence). In the current cross-sectional study, we investigate predictors of older adults’ ATSMHS using a heterogeneous sample of older community-dwelling adults in Germany. We integrate previous research on factors associated with (primarily younger adults’) ATSMHS as well as consider additional factors that, from a geropsychological perspective, we believe are uniquely important for determining older adults’ ATSMHS. In particular, this study is the first to investigate older adults’ subjective representations of old *Corresponding author. Email: [email protected] All authors contributed equally to this work. Ó 2014 Taylor & Francis
age and aging and age-based perceptions of mental health professionals who are usually younger as potential predictors of older adults’ ATSMHS. Predictors of older adults’ mental health treatment attitudes: previous research With regards to demographic characteristics, previous cross-sectional studies have revealed an inconsistent relationship between chronological age and ATSMHS. Despite common assumptions to the contrary, older age has been associated with more positive (Mackenzie, Gekoski, & Knox, 2006) or similarly positive (James & Buttle, 2008; Jang, Chiriboga, & Okazaki, 2009; Robb, Haley, Becker, Polivka, & Chwa, 2003; Segal, Coolidge, Mincic, & O’Riley, 2005) ATSMHS when older samples have been compared with younger samples (though see Yamawaki, Pulsipher, Moses, Rasmuse, & Ringger, 2011 for an exception). Relative to the ‘youngold’, ‘oldold’ participants have reported either similar (Woodward & Pachana, 2009) or more negative ATSMHS as well as less willingness to seek psychological help (Park, Jang, Lee, Schonfeld, & Molinari, 2012; Zank, 2002). Two studies have investigated the relationship between age and more specific subfacets of ATSMHS. According to the results of these two studies, older age seems to be associated
Aging & Mental Health with a greater propensity to seek help in general (‘help-seeking propensity’), but age does not seem to be associated with concerns about being stigmatized for seeking professional mental health help (‘indifference to stigma’) (James & Buttle, 2008; Mackenzie et al., 2006). Results with regards to the relationship between age and openness to acknowledging psychological problems (‘psychological openness’) are mixed. One study found that older people were less psychologically open (James & Buttle, 2008), but another study did not find evidence of a relationship between age and psychological openness (Mackenzie et al., 2006). Women of all ages typically report more positive ATSMHS (Mackenzie et al., 2006; Nam et al., 2010; Yamawaki et al., 2011; see James & Buttle, 2008 for an exception) as well as receive treatment more frequently in old age (65þ years) (Maercker, Enzler, Grimm, Helfenstein, & Ehlert, 2005) relative to men. In younger samples, higher education tends to be associated with more positive ATSMHS and mental health service use (Jagdeo, Cox, Stein, & Sareen, 2009; Jang et al., 2009; Vasiliadis, Tempier, Lesage, & Kates, 2009). Use of mental health services is generally lower in rural areas relative to urban areas (Judd, Jackson, Komiti, Murray, & Fraser, 2007; Karlin, Duffy, & Gleaves, 2008). Being married has been related to past use of psychological help (Jagdeo et al., 2009; Judd et al., 2007) as well as ATSMHS (Yamawaki et al., 2011), though the results have been inconsistent with regards to the valence of the relationship. To the best of our knowledge, the relationship between having children and ATSMHS has not been investigated. With regards to the accessibility of services, physical accessibility of mental health services may also be related to ATSMHS. Proximity may breed familiarity with mental health services, and hence, more positive attitudes. The physical accessibility of mental health services may be especially important for older adults due to the increased likelihood of reduced mobility (Pepin, Segal, & Coolidge, 2009). A further accessibility factor for older adults is their contact with physicians. Research has consistently indicated that older people with psychological symptoms tend to turn first to their physician as opposed to a psychotherapist (e.g. James & Buttle, 2008; Mackenzie et al., 2006). It thus seems plausible that more frequent contact with physicians goes along with more negative ATSMHS, as older people who visit their physician more frequently may expect that physicians are able to adequately respond to their mental health issues. Previous research has found that knowledge about and previous experience with psychotherapy is generally related to more positive ATSMHS. Older people who recognized a need for mental health support but did not seek help identified not knowing how to seek help as the reason why they did not seek help (Karlin et al., 2008). People with personal experience with psychotherapy tend to have more positive ATSMHS (James & Buttle, 2008; Woodward & Pachana, 2009). Because personal experience with psychotherapy is low in current older cohorts (Imai, Telger, Wolter, & Heuft, 2008; Institut f€ ur Sozialmedizin, Epidemiologie und Gesundheitsforschung [ISEG], 2007),
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vicarious experience with mental health services through significant others might be an important predictor of older adults’ ATSMHS. Perceived social support that is, the subjective perception of social resources (Barrera, 1986; Sommer & Fydrich, 1989) is an important variable for predicting attitudes towards mental health services. On the one hand, people who perceive less social support might tend to have more psychological problems, which may explain why less social support has been associated with higher willingness to seek psychological help (Park et al., 2012). On the other hand, a meta-analysis suggested that for younger adults, more social support is related to more positive ATSMHS (Nam et al., 2013). Consistent with this latter finding, older adults with psychological problems who reported higher social support were more likely to seek professional help (Vasiliadis et al., 2009). Presumably, older people who perceive more social support are more used to accepting help and trusting people, which may be reflected in more positive attitudes towards accepting help from mental health professionals. Previous research with younger samples has indicated that personality traits also predict ATSMHS. In particular, higher neuroticism (among men; Kakhnovets, 2011) and higher openness (Franz, Schiessl, Manz, & Fellhauer, 1990; Kakhnovets, 2011) have been associated with higher tendencies to use mental health services and more positive ATSMHS. Finally, previous research with younger samples has indicated that while low subjective wellbeing is related to higher use of psychological help (Vasiliadis et al., 2009), life satisfaction is generally not related to ATSMHS (Nam et al., 2013). To the best of our knowledge, no study has investigated the relationship between life satisfaction and ATSMHS in older samples. Images of aging as predictors of older people’s attitudes towards mental health services Images of aging that is, mental representations of specific age groups and/or the aging process may play a role in older peoples’ ATSMHS. Part of having a positive image of old age and aging is recognition that old age is not synonymous with poor health. Recognizing mental health symptoms as an illness as opposed to a normal part of aging has been related to more positive ATSMHS (Sarkisian, Lee-Henderson, & Mangione, 2003) as well as higher use of psychotherapy (Pepin et al., 2009). People with more positive images of aging also believe that it is never too late to change one’s life for the better and tend to have higher self-efficacy beliefs (Levy, Slade, & Kasl, 2002; Wurm, Tesch-R€omer, & Tomasik, 2007). It therefore seems likely that older people with more positive representations of old age will also have more positive ATSMHS as they are more likely to (1) recognize psychological symptoms in old age as a health problem as opposed to a normal part of aging and (2) see utility in seeking help from mental health professionals. In addition to older people’s representation of their own aging, older adults’ perceptions of psychotherapists who are generally younger (i.e. middle-aged) may also
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be related to their ATSMHS. Since most adults expect to grow in wisdom in later adulthood (Heckhausen & Krueger, 1993), some older people may question whether younger therapists can truly offer meaningful support to an older patient due to a lack of life experience and/or experience with aging. Some older people might also expect that a younger therapist would not be able to relate to an older client due to generational differences in lifestyle, norms, and values (Harwood, McKee, & Lin, 2000). Indeed, several ‘intergenerational barriers’ to older adults’ help seeking have been narratively described in the literature (e.g. Evans, 2007; Knight & Poon, 2008). To the best of our knowledge, however, the relationship between older people’s ATSMHS and their perceptions of psychotherapists as members of both a younger age group and a different generation has not yet been empirically tested.
Current study We investigated a wide range of predictors of ATSMHS as described above using a heterogeneous sample of older community-dwelling adults in Germany. German statutory health insurance covers psychoanalytic and behavioral psychotherapy. Therefore, it can be assumed that the relationships between predictors and ATSMHS in the current sample are less confounded by financial status relative to samples in countries with self-paying patients. In addition to the potential predictors of ATSMHS included in previous research (mostly with younger age groups), we investigated representations of old age and aging and perceptions of (younger) psychotherapists as two potential predictors of older people’s ATSMHS. To gain more detailed knowledge about the relationship between age and ATSMHS, we also analyzed the relationship between age and three subfacets of ATSMHS (see ‘Methods’ section).
Methods Procedure Participants completed a questionnaire study (3045 minutes). They were informed that the study concerned attitudes and beliefs about aging and that data would be treated anonymously. A stamped and addressed envelope was enclosed so that questionnaires could be returned by mail.
Sample We recruited a convenience sample of non-institutionalized older German adults (60þ years). Specifically, the authors and associated research assistants distributed questionnaires to members of their larger social networks via personal contact or by mail. Of the distributed questionnaires, 162 were returned (response rate: 72.6%). Six (3.7%) questionnaires were excluded from analysis because major parts of the questionnaires had not been completed, resulting in a sample size of N ¼ 156. The sample included individuals from a variety of occupational groups such as business owners, farmers, teachers,
Table 1. Sample characteristics. Variable
M (SD) or %
Age (years) Gender (female) Partner (yes) Residence (rural) Children (yes) Education Less than secondary level Lower secondary level Higher secondary level University level Experience with counseling (yes) Personal Vicarious Accessible psychotherapeutic office (yes) Physician consultations (last 12 months) Once 26 times 46 times 712 times More often
71.50 (6.42) 57.1 75.0 52.3 90.4 2.6 23.7 43.6 30.1 16.6 37.1 48.0 21.6 47.7 15.7 10.5 4.5
actors, carpenters, and architects and was equally distributed across urban and rural environments. The average age of the participants was M ¼ 71.50 years (SD ¼ 6.42; range: 6092 years) and 57.1% were female. Table 1 displays the characteristics of the sample in more detail. Overall, the sample was heterogeneous with regards to sociodemographic characteristics and comparable to their age peers in the general German population with regards to having a partner and retirement status, with a bias towards well-educated individuals and a slight overrepresentation of women (European Social Survey Round 6 Data, 2012). With approximately nine participants for each predictor variable, the sample size had more than adequate statistical power according to the minimum ‘five cases per independent variable’ rule of thumb for regression (e.g. Tabachnick & Fidell, 1989).
Measures Attitudes towards seeking mental health services ATSMHS were assessed with a German version of the Inventory of Attitudes Towards Seeking Mental Health Services (IASMHS; Mackenzie, Knox, Gekoski, & Macaulay, 2004), a modified version of Fischer and Turner’s (1970) Attitudes Towards Seeking Professional Psychological Help Scale. The German version of the original English-language questionnaire was constructed through front and back translation. Previous studies have confirmed the convergent validity of the IASMHS (Mackenzie et al., 2004) and the scale has been previously used with age-heterogeneous samples (James & Buttle, 2008; Mackenzie et al., 2006). Within the measure, ‘professional psychological help’ was defined as support from psychologists and psychiatrists. The IASMHS
Aging & Mental Health assesses three subfacets of ATSMHS, each measured with eight items: (1) psychological openness, the extent to which individuals recognize psychological problems and are open to the possibility of seeking professional help; (2) help-seeking propensity, the extent to which individuals are willing and able to seek professional psychological help; and (3) indifference to stigma, the extent to which individuals are concerned about what important others might think if they were to find out that he or she was receiving professional psychological help. Example items include: ‘There are certain problems which should not be discussed outside of one’s immediate family’ (psychological openness), ‘If I believed I were having a mental breakdown, my first inclination would be to get professional attention’ (help-seeking propensity), and ‘Having been mentally ill carries with it a burden of shame’ (indifference to stigma). Answers could range from disagree (0) to agree (4). In line with the purpose of the scale (Mackenzie et al., 2004), a sum of scores across items within each subscale (a ¼ .67.84) and across all items (a ¼ .79) were used as indicators of the subfacets and overall ATSMHS, respectively. Higher scores indicate more positive attitudes.
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yes) and whether any significant other had experience with counseling (no/yes). Perceived social support Perceived social support was assessed with a widely used German questionnaire (F-SozU; Fydrich, Sommer, Tydecks, & Br€ahler, 2009) (14 items; a ¼ .91, M ¼ 4.49, SD ¼ 0.49). Answers could range from strongly disagree (1) to strongly agree (5). Higher scores indicate more perceived social support. Personality The German version of the NEO-Five Factor Inventory (NEO-FFI-30; K€orner et al., 2008) was used to measure neuroticism (6 items; a ¼ .85, M ¼ 1.27, SD ¼ 0.78) and openness to experience (6 items; a ¼ .70, M ¼ 2.56, SD ¼ 0.69). Participants used a 5-point scale ranging from strongly disagree (0) to strongly agree (4) to indicate their agreement with each statement. Life satisfaction
Sociodemographic variables Participants indicated their age, gender (male/female), whether they had children (yes/no), highest completed educational level (less than secondary/lower secondary/ higher secondary/university), if they had a partner (yes/ no) and residence (urban > 20,000 inhabitants /rural < 20,000 inhabitants). Access to mental health services As a measure of physical accessibility, participants indicated whether they were aware of a psychotherapist whose office they could reach easily by foot, with public transportation or by car (yes/no). Participants also indicated the frequency of physician consultations (not specific to mental health problems) in the past 12 months (once/ 26 times/46 times/712 times/more often). Knowledge about and experience with psychotherapy Participants answered five true or false items about mental health services in Germany. The facts covered in the scale were culled from the facts on psychotherapy that the German Federal Chamber of Psychotherapists communicates in its public health information (German Federal Chamber of Psychotherapists, 2012). The items were: ‘Psychotherapy is covered by health insurance (true)’; ‘Only physicians can operate as psychotherapists (false); Behavior therapy is a form of psychotherapy (true)’; ‘All psychotherapeutic treatment involves checking in to a hospital on an in-patient basis (false)’; and ‘Psychotherapist is not a protected label. Anyone can call himself or herself a psychotherapist (false).’ Participants got one point for each correct answer (M ¼ 3.95, SD ¼ 0.96). Higher scores indicate more knowledge about psychotherapy. Participants also indicated whether they had personal experience with counseling (no/
Participants used a 7-point scale ranging from very unsatisfied (1) to very satisfied (7) to answer the question: ‘All things considered, how satisfied are you with life as a whole these days?’ The validity of the single-item life satisfaction item has been convincingly demonstrated within the literature and has been used across central studies regarding subjective well-being across the life span (e.g. Baird, Lucas, & Donnellan, 2010). Average life satisfaction in the current sample was M ¼ 5.53 (SD ¼ 1.17). Subjective representation of aging and old age The Expectations Regarding Aging Survey-12 (ERA-12; Sarkisian, Steers, Hays, & Mangione, 2005) was used to assess representations of old age and aging. The ERA-12 includes four items concerning mental health (e.g. ‘It’s normal to be depressed when you are old’), four items concerning physical health (e.g. ‘Having more aches and pains is an accepted part of aging’), and four items concerning cognitive functioning (e.g. ‘I expect that as I get older I will become more forgetful’). Answers could range from definitely true (1) to definitely false (4). Answers across all items were averaged with higher scores indicating a more positive representation of old age and aging (a ¼ .84, M ¼ 28.62, SD ¼ 5.29). Perceptions of (younger) psychotherapists Participants used a 5-point scale ranging from strongly disagree (0) to strongly agree (4) to indicate agreement with four items based on ‘intergenerational barriers’ to older peoples’ mental health help seeking described within the geropsychological literature (Evans, 2007; Knight & Poon, 2008). Participants were instructed that the following statements referred to psychotherapists treating older adults: ‘Psychotherapists treat older people
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less well than younger people’; ‘Psychotherapists lack life experience’; ‘Psychotherapists do not know what kind of problems accompany old age’; and ‘Psychotherapists have different fundamental values and attitudes in comparison to older people (e.g. the understanding of marriage, the allocation of roles in society, technology).’ Answers were averaged with higher scores indicating more negative perceptions (a ¼ .85, M ¼ 5.24, SD ¼ 3.54). Data analysis strategy To investigate the raw relationship between age and ATSMHS and to be able to compare our results with the results of previous studies (e.g. James & Buttle, 2008; Mackenzie et al., 2006), we separately analyzed the zeroorder correlations between age and overall ATSMHS as well as between age and each of the three subfacets of ATSMHS (psychological openness, help-seeking propensity, indifference to stigma). Associations between the predictor variables and overall ATSMHS were then tested with a series of hierarchical linear regression analyses after confirming that the dependent variable was distributed normally and that there were no problems with multicollinearity. Variables were entered in eight steps: first, demographic variables (age, gender, partner, children, education, residence); second, accessibility variables (accessible psychotherapist, physician consultations); third, knowledge and experience with psychotherapy variables (knowledge about psychotherapy, personal and vicarious experience with psychotherapy); fourth, perceived social support; fifth, personality variables (neuroticism, openness); and sixth, life satisfaction. In the seventh and eighth steps, we entered perceptions of (younger) psychotherapists and subjective representation of aging and old age. We used the results of the saturated regression model to interpret the relationship between ATSMHS and each of the predictor variables. In addition, we ran a commonality analysis to determine the unique variance in ATSMHS associated with each of the eight variable sets. Specifically, we ran a separate series of hierarchical linear regressions with each variable set entered in the final step. The change in R2 in the last step represents the unique variance explained by the last entered variable set. We used the change in R2 from the hierarchical regression analyses and the proportion of unique variance from the commonality analysis to determine the ‘added value’ of the variable sets. There was a low level of missing data (
Attitudes towards seeking mental health services among older adults: personal and contextual correlates Eva-Marie Kesslera,b*, Sabrina Aginesa and Catherine E. Bowenc a
Network Aging Research, Heidelberg University, Heidelberg, Germany; bDepartment of Psychological Ageing Research, Institute of Psychology, Heidelberg University, Heidelberg, Germany; cAge and Cohort Change Project of the World Population Program, International Institute for Applied Systems Analysis (IIASA), Wittgenstein Centre for Demography and Global Human Capital (IIASA, € VID/OAW, WU), Laxenburg, Austria (Received 7 February 2014; accepted 21 April 2014) Objectives: Especially older adults underutilize professional mental health services. However, little is known about the factors associated with older adults’ attitudes towards seeking mental health services (ATSMHS). We therefore investigated a wide range of contextual (e.g. physical access, residence) and personal (e.g. perceived social support, life satisfaction, openness to experience) predictors of ATSMHS in a sample of older community-dwelling adults in Germany. We predicted that representations of old age as well as perceptions of (younger) psychotherapists would be uniquely important for determining ATSMHS. Method: A diverse sample of N ¼ 156 older adults (Mage ¼ 71.5 years, SD ¼ 6.4, range: 6092) completed questionnaire measures. We used hierarchical linear regression analyses to identify predictors of ATSMHS. Results: In the final saturated model, female gender, urban residence, personal and vicarious experience with psychotherapy, and higher perceived social support were each associated with more positive ATSMHS. In addition, more positive representations of old age and less negative perceptions of (younger) psychotherapists explained unique variance in ATSMHS over and above the other predictors. The overall model was significant and explained 49% of the variance in ATSMHS. Conclusion: Our findings can be used to inform interventions to improve older adults’ ATSMHS. Interventions that seek to improve older adults’ representations of their own aging as well as of psychotherapists may be useful for reducing the treatment gap. Keywords: psychotherapy; attitudes towards seeking mental health services; treatment gap; age stereotypes; older adults
Introduction Older adults disproportionately underutilize professional mental health services relative to younger adults (e.g. Bogner, de Vries, Maulik, & Un€ utzer, 2009; Crabb & Hunsley, 2006; Wang et al., 2005). Attitudes towards seeking mental health services (ATSMHS) are one factor that influences actual mental health help-seeking behavior (Cramer, 1999; ten Have et al., 2010). Thus, identifying correlates of older adults’ ATSMHS is one critical part of remedying the ‘treatment gap’. To date, however, little is known about the factors underlying individual differences in older adults’ ATSMHS, as most studies have focused exclusively on younger adults, investigated only a limited range of potential predictors, and/or taken a ‘group differences’ approach (i.e. compared older adults’ attitudes to younger adults’ attitudes in terms of overall attitude valence). In the current cross-sectional study, we investigate predictors of older adults’ ATSMHS using a heterogeneous sample of older community-dwelling adults in Germany. We integrate previous research on factors associated with (primarily younger adults’) ATSMHS as well as consider additional factors that, from a geropsychological perspective, we believe are uniquely important for determining older adults’ ATSMHS. In particular, this study is the first to investigate older adults’ subjective representations of old *Corresponding author. Email: [email protected] All authors contributed equally to this work. Ó 2014 Taylor & Francis
age and aging and age-based perceptions of mental health professionals who are usually younger as potential predictors of older adults’ ATSMHS. Predictors of older adults’ mental health treatment attitudes: previous research With regards to demographic characteristics, previous cross-sectional studies have revealed an inconsistent relationship between chronological age and ATSMHS. Despite common assumptions to the contrary, older age has been associated with more positive (Mackenzie, Gekoski, & Knox, 2006) or similarly positive (James & Buttle, 2008; Jang, Chiriboga, & Okazaki, 2009; Robb, Haley, Becker, Polivka, & Chwa, 2003; Segal, Coolidge, Mincic, & O’Riley, 2005) ATSMHS when older samples have been compared with younger samples (though see Yamawaki, Pulsipher, Moses, Rasmuse, & Ringger, 2011 for an exception). Relative to the ‘youngold’, ‘oldold’ participants have reported either similar (Woodward & Pachana, 2009) or more negative ATSMHS as well as less willingness to seek psychological help (Park, Jang, Lee, Schonfeld, & Molinari, 2012; Zank, 2002). Two studies have investigated the relationship between age and more specific subfacets of ATSMHS. According to the results of these two studies, older age seems to be associated
Aging & Mental Health with a greater propensity to seek help in general (‘help-seeking propensity’), but age does not seem to be associated with concerns about being stigmatized for seeking professional mental health help (‘indifference to stigma’) (James & Buttle, 2008; Mackenzie et al., 2006). Results with regards to the relationship between age and openness to acknowledging psychological problems (‘psychological openness’) are mixed. One study found that older people were less psychologically open (James & Buttle, 2008), but another study did not find evidence of a relationship between age and psychological openness (Mackenzie et al., 2006). Women of all ages typically report more positive ATSMHS (Mackenzie et al., 2006; Nam et al., 2010; Yamawaki et al., 2011; see James & Buttle, 2008 for an exception) as well as receive treatment more frequently in old age (65þ years) (Maercker, Enzler, Grimm, Helfenstein, & Ehlert, 2005) relative to men. In younger samples, higher education tends to be associated with more positive ATSMHS and mental health service use (Jagdeo, Cox, Stein, & Sareen, 2009; Jang et al., 2009; Vasiliadis, Tempier, Lesage, & Kates, 2009). Use of mental health services is generally lower in rural areas relative to urban areas (Judd, Jackson, Komiti, Murray, & Fraser, 2007; Karlin, Duffy, & Gleaves, 2008). Being married has been related to past use of psychological help (Jagdeo et al., 2009; Judd et al., 2007) as well as ATSMHS (Yamawaki et al., 2011), though the results have been inconsistent with regards to the valence of the relationship. To the best of our knowledge, the relationship between having children and ATSMHS has not been investigated. With regards to the accessibility of services, physical accessibility of mental health services may also be related to ATSMHS. Proximity may breed familiarity with mental health services, and hence, more positive attitudes. The physical accessibility of mental health services may be especially important for older adults due to the increased likelihood of reduced mobility (Pepin, Segal, & Coolidge, 2009). A further accessibility factor for older adults is their contact with physicians. Research has consistently indicated that older people with psychological symptoms tend to turn first to their physician as opposed to a psychotherapist (e.g. James & Buttle, 2008; Mackenzie et al., 2006). It thus seems plausible that more frequent contact with physicians goes along with more negative ATSMHS, as older people who visit their physician more frequently may expect that physicians are able to adequately respond to their mental health issues. Previous research has found that knowledge about and previous experience with psychotherapy is generally related to more positive ATSMHS. Older people who recognized a need for mental health support but did not seek help identified not knowing how to seek help as the reason why they did not seek help (Karlin et al., 2008). People with personal experience with psychotherapy tend to have more positive ATSMHS (James & Buttle, 2008; Woodward & Pachana, 2009). Because personal experience with psychotherapy is low in current older cohorts (Imai, Telger, Wolter, & Heuft, 2008; Institut f€ ur Sozialmedizin, Epidemiologie und Gesundheitsforschung [ISEG], 2007),
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vicarious experience with mental health services through significant others might be an important predictor of older adults’ ATSMHS. Perceived social support that is, the subjective perception of social resources (Barrera, 1986; Sommer & Fydrich, 1989) is an important variable for predicting attitudes towards mental health services. On the one hand, people who perceive less social support might tend to have more psychological problems, which may explain why less social support has been associated with higher willingness to seek psychological help (Park et al., 2012). On the other hand, a meta-analysis suggested that for younger adults, more social support is related to more positive ATSMHS (Nam et al., 2013). Consistent with this latter finding, older adults with psychological problems who reported higher social support were more likely to seek professional help (Vasiliadis et al., 2009). Presumably, older people who perceive more social support are more used to accepting help and trusting people, which may be reflected in more positive attitudes towards accepting help from mental health professionals. Previous research with younger samples has indicated that personality traits also predict ATSMHS. In particular, higher neuroticism (among men; Kakhnovets, 2011) and higher openness (Franz, Schiessl, Manz, & Fellhauer, 1990; Kakhnovets, 2011) have been associated with higher tendencies to use mental health services and more positive ATSMHS. Finally, previous research with younger samples has indicated that while low subjective wellbeing is related to higher use of psychological help (Vasiliadis et al., 2009), life satisfaction is generally not related to ATSMHS (Nam et al., 2013). To the best of our knowledge, no study has investigated the relationship between life satisfaction and ATSMHS in older samples. Images of aging as predictors of older people’s attitudes towards mental health services Images of aging that is, mental representations of specific age groups and/or the aging process may play a role in older peoples’ ATSMHS. Part of having a positive image of old age and aging is recognition that old age is not synonymous with poor health. Recognizing mental health symptoms as an illness as opposed to a normal part of aging has been related to more positive ATSMHS (Sarkisian, Lee-Henderson, & Mangione, 2003) as well as higher use of psychotherapy (Pepin et al., 2009). People with more positive images of aging also believe that it is never too late to change one’s life for the better and tend to have higher self-efficacy beliefs (Levy, Slade, & Kasl, 2002; Wurm, Tesch-R€omer, & Tomasik, 2007). It therefore seems likely that older people with more positive representations of old age will also have more positive ATSMHS as they are more likely to (1) recognize psychological symptoms in old age as a health problem as opposed to a normal part of aging and (2) see utility in seeking help from mental health professionals. In addition to older people’s representation of their own aging, older adults’ perceptions of psychotherapists who are generally younger (i.e. middle-aged) may also
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be related to their ATSMHS. Since most adults expect to grow in wisdom in later adulthood (Heckhausen & Krueger, 1993), some older people may question whether younger therapists can truly offer meaningful support to an older patient due to a lack of life experience and/or experience with aging. Some older people might also expect that a younger therapist would not be able to relate to an older client due to generational differences in lifestyle, norms, and values (Harwood, McKee, & Lin, 2000). Indeed, several ‘intergenerational barriers’ to older adults’ help seeking have been narratively described in the literature (e.g. Evans, 2007; Knight & Poon, 2008). To the best of our knowledge, however, the relationship between older people’s ATSMHS and their perceptions of psychotherapists as members of both a younger age group and a different generation has not yet been empirically tested.
Current study We investigated a wide range of predictors of ATSMHS as described above using a heterogeneous sample of older community-dwelling adults in Germany. German statutory health insurance covers psychoanalytic and behavioral psychotherapy. Therefore, it can be assumed that the relationships between predictors and ATSMHS in the current sample are less confounded by financial status relative to samples in countries with self-paying patients. In addition to the potential predictors of ATSMHS included in previous research (mostly with younger age groups), we investigated representations of old age and aging and perceptions of (younger) psychotherapists as two potential predictors of older people’s ATSMHS. To gain more detailed knowledge about the relationship between age and ATSMHS, we also analyzed the relationship between age and three subfacets of ATSMHS (see ‘Methods’ section).
Methods Procedure Participants completed a questionnaire study (3045 minutes). They were informed that the study concerned attitudes and beliefs about aging and that data would be treated anonymously. A stamped and addressed envelope was enclosed so that questionnaires could be returned by mail.
Sample We recruited a convenience sample of non-institutionalized older German adults (60þ years). Specifically, the authors and associated research assistants distributed questionnaires to members of their larger social networks via personal contact or by mail. Of the distributed questionnaires, 162 were returned (response rate: 72.6%). Six (3.7%) questionnaires were excluded from analysis because major parts of the questionnaires had not been completed, resulting in a sample size of N ¼ 156. The sample included individuals from a variety of occupational groups such as business owners, farmers, teachers,
Table 1. Sample characteristics. Variable
M (SD) or %
Age (years) Gender (female) Partner (yes) Residence (rural) Children (yes) Education Less than secondary level Lower secondary level Higher secondary level University level Experience with counseling (yes) Personal Vicarious Accessible psychotherapeutic office (yes) Physician consultations (last 12 months) Once 26 times 46 times 712 times More often
71.50 (6.42) 57.1 75.0 52.3 90.4 2.6 23.7 43.6 30.1 16.6 37.1 48.0 21.6 47.7 15.7 10.5 4.5
actors, carpenters, and architects and was equally distributed across urban and rural environments. The average age of the participants was M ¼ 71.50 years (SD ¼ 6.42; range: 6092 years) and 57.1% were female. Table 1 displays the characteristics of the sample in more detail. Overall, the sample was heterogeneous with regards to sociodemographic characteristics and comparable to their age peers in the general German population with regards to having a partner and retirement status, with a bias towards well-educated individuals and a slight overrepresentation of women (European Social Survey Round 6 Data, 2012). With approximately nine participants for each predictor variable, the sample size had more than adequate statistical power according to the minimum ‘five cases per independent variable’ rule of thumb for regression (e.g. Tabachnick & Fidell, 1989).
Measures Attitudes towards seeking mental health services ATSMHS were assessed with a German version of the Inventory of Attitudes Towards Seeking Mental Health Services (IASMHS; Mackenzie, Knox, Gekoski, & Macaulay, 2004), a modified version of Fischer and Turner’s (1970) Attitudes Towards Seeking Professional Psychological Help Scale. The German version of the original English-language questionnaire was constructed through front and back translation. Previous studies have confirmed the convergent validity of the IASMHS (Mackenzie et al., 2004) and the scale has been previously used with age-heterogeneous samples (James & Buttle, 2008; Mackenzie et al., 2006). Within the measure, ‘professional psychological help’ was defined as support from psychologists and psychiatrists. The IASMHS
Aging & Mental Health assesses three subfacets of ATSMHS, each measured with eight items: (1) psychological openness, the extent to which individuals recognize psychological problems and are open to the possibility of seeking professional help; (2) help-seeking propensity, the extent to which individuals are willing and able to seek professional psychological help; and (3) indifference to stigma, the extent to which individuals are concerned about what important others might think if they were to find out that he or she was receiving professional psychological help. Example items include: ‘There are certain problems which should not be discussed outside of one’s immediate family’ (psychological openness), ‘If I believed I were having a mental breakdown, my first inclination would be to get professional attention’ (help-seeking propensity), and ‘Having been mentally ill carries with it a burden of shame’ (indifference to stigma). Answers could range from disagree (0) to agree (4). In line with the purpose of the scale (Mackenzie et al., 2004), a sum of scores across items within each subscale (a ¼ .67.84) and across all items (a ¼ .79) were used as indicators of the subfacets and overall ATSMHS, respectively. Higher scores indicate more positive attitudes.
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yes) and whether any significant other had experience with counseling (no/yes). Perceived social support Perceived social support was assessed with a widely used German questionnaire (F-SozU; Fydrich, Sommer, Tydecks, & Br€ahler, 2009) (14 items; a ¼ .91, M ¼ 4.49, SD ¼ 0.49). Answers could range from strongly disagree (1) to strongly agree (5). Higher scores indicate more perceived social support. Personality The German version of the NEO-Five Factor Inventory (NEO-FFI-30; K€orner et al., 2008) was used to measure neuroticism (6 items; a ¼ .85, M ¼ 1.27, SD ¼ 0.78) and openness to experience (6 items; a ¼ .70, M ¼ 2.56, SD ¼ 0.69). Participants used a 5-point scale ranging from strongly disagree (0) to strongly agree (4) to indicate their agreement with each statement. Life satisfaction
Sociodemographic variables Participants indicated their age, gender (male/female), whether they had children (yes/no), highest completed educational level (less than secondary/lower secondary/ higher secondary/university), if they had a partner (yes/ no) and residence (urban > 20,000 inhabitants /rural < 20,000 inhabitants). Access to mental health services As a measure of physical accessibility, participants indicated whether they were aware of a psychotherapist whose office they could reach easily by foot, with public transportation or by car (yes/no). Participants also indicated the frequency of physician consultations (not specific to mental health problems) in the past 12 months (once/ 26 times/46 times/712 times/more often). Knowledge about and experience with psychotherapy Participants answered five true or false items about mental health services in Germany. The facts covered in the scale were culled from the facts on psychotherapy that the German Federal Chamber of Psychotherapists communicates in its public health information (German Federal Chamber of Psychotherapists, 2012). The items were: ‘Psychotherapy is covered by health insurance (true)’; ‘Only physicians can operate as psychotherapists (false); Behavior therapy is a form of psychotherapy (true)’; ‘All psychotherapeutic treatment involves checking in to a hospital on an in-patient basis (false)’; and ‘Psychotherapist is not a protected label. Anyone can call himself or herself a psychotherapist (false).’ Participants got one point for each correct answer (M ¼ 3.95, SD ¼ 0.96). Higher scores indicate more knowledge about psychotherapy. Participants also indicated whether they had personal experience with counseling (no/
Participants used a 7-point scale ranging from very unsatisfied (1) to very satisfied (7) to answer the question: ‘All things considered, how satisfied are you with life as a whole these days?’ The validity of the single-item life satisfaction item has been convincingly demonstrated within the literature and has been used across central studies regarding subjective well-being across the life span (e.g. Baird, Lucas, & Donnellan, 2010). Average life satisfaction in the current sample was M ¼ 5.53 (SD ¼ 1.17). Subjective representation of aging and old age The Expectations Regarding Aging Survey-12 (ERA-12; Sarkisian, Steers, Hays, & Mangione, 2005) was used to assess representations of old age and aging. The ERA-12 includes four items concerning mental health (e.g. ‘It’s normal to be depressed when you are old’), four items concerning physical health (e.g. ‘Having more aches and pains is an accepted part of aging’), and four items concerning cognitive functioning (e.g. ‘I expect that as I get older I will become more forgetful’). Answers could range from definitely true (1) to definitely false (4). Answers across all items were averaged with higher scores indicating a more positive representation of old age and aging (a ¼ .84, M ¼ 28.62, SD ¼ 5.29). Perceptions of (younger) psychotherapists Participants used a 5-point scale ranging from strongly disagree (0) to strongly agree (4) to indicate agreement with four items based on ‘intergenerational barriers’ to older peoples’ mental health help seeking described within the geropsychological literature (Evans, 2007; Knight & Poon, 2008). Participants were instructed that the following statements referred to psychotherapists treating older adults: ‘Psychotherapists treat older people
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less well than younger people’; ‘Psychotherapists lack life experience’; ‘Psychotherapists do not know what kind of problems accompany old age’; and ‘Psychotherapists have different fundamental values and attitudes in comparison to older people (e.g. the understanding of marriage, the allocation of roles in society, technology).’ Answers were averaged with higher scores indicating more negative perceptions (a ¼ .85, M ¼ 5.24, SD ¼ 3.54). Data analysis strategy To investigate the raw relationship between age and ATSMHS and to be able to compare our results with the results of previous studies (e.g. James & Buttle, 2008; Mackenzie et al., 2006), we separately analyzed the zeroorder correlations between age and overall ATSMHS as well as between age and each of the three subfacets of ATSMHS (psychological openness, help-seeking propensity, indifference to stigma). Associations between the predictor variables and overall ATSMHS were then tested with a series of hierarchical linear regression analyses after confirming that the dependent variable was distributed normally and that there were no problems with multicollinearity. Variables were entered in eight steps: first, demographic variables (age, gender, partner, children, education, residence); second, accessibility variables (accessible psychotherapist, physician consultations); third, knowledge and experience with psychotherapy variables (knowledge about psychotherapy, personal and vicarious experience with psychotherapy); fourth, perceived social support; fifth, personality variables (neuroticism, openness); and sixth, life satisfaction. In the seventh and eighth steps, we entered perceptions of (younger) psychotherapists and subjective representation of aging and old age. We used the results of the saturated regression model to interpret the relationship between ATSMHS and each of the predictor variables. In addition, we ran a commonality analysis to determine the unique variance in ATSMHS associated with each of the eight variable sets. Specifically, we ran a separate series of hierarchical linear regressions with each variable set entered in the final step. The change in R2 in the last step represents the unique variance explained by the last entered variable set. We used the change in R2 from the hierarchical regression analyses and the proportion of unique variance from the commonality analysis to determine the ‘added value’ of the variable sets. There was a low level of missing data (
