Obstacles \IEL\
B’
to Utilization IN
%. GLSSER.
of Prepaid
LL.l)..
TH0\IS
J.
Mental DUGGA\.
Health
PHI)..
Care \%ILLI%\I
S. HO1”F\I\,
\I.#{149}.
METHOI)
The co verage ofo health (are through
ut-of-hospital prepat’ment
ha.s been a mqjor barriers to ear/i’ mental disorders.
adsanee detection, However.
treatmen
many
help. the
t block
The
authors
United
A uto
roadblocks. perceptions toward
treatment,
in removing diagnosis. obstacles
eligible
conducted Workers
A niong oJneedJor
e.xpen.ce.s for and insurance
people
lack
from among
of awarenes.c
of
these
were differences and in attitudes
benefits among three key groups-consumers. agents. andproviders. The authors urge help in removing these obstacles.
of
receiving members
to identify
the obstacles treatment and
the economic and treatment to obtaining
a study union
mental program.s
in
of eligibility
for
refrrral psychiatry to
A DECADE A(IO the concept of widely available prepaid mental health care was thought to be little more than a speculation, especially for members of the working class. Currently well over 15 million workers and their dependents are eligible for such coverage as part of their basic private health insurance. This trend was accelerated by the United Auto Workers International Union (UAW), which negotiated the first nationwide collective bargaining agreements to add coverage for out-of-hospital mental health care. The program became effective in 1966. The moderate utilization rates seen during the first years of the UAW program (1,2) clearly demonstrated the program’s economic feasibility. However, these same utilization data further demonstrated that factory workers were not making as full use of mental health services as they might. Various estimates of the need for mental health care (3) were substantially higher than the observed utilization experiences. The program’s goal of early detection, referral, and psychiatric attention was not being fully achieved. Accordingly, the research reported in this paper was conducted to determine what factors operated to keep UAW workers and their families from more effectively utilizing mental health services.
The authors are all sith the Michigan Health and Social Security Research Institute. 8000 F. Jeflerson Ave., Detroit, Mich. 48214. Dr. Glasser is Secretar -Treasurer, Dr. Duggan is Senior Research Consultant, and Mr. Hoffman is Senior Research Associate. Dr. Duggan is also Associate Professor of Sociologs, Wayne State University, Dctroit. Mich. The research for this paper was 20373 from the National Institute
710
AmJ
Psychiatry
principally of Mental
/32:7,July
supported Health.
1975
by grant
MH-
The barriers to utilization of prepaid mental health care can be identified and examined within a model of a service delivery system that consists of three community elements. The potential consumer group within a community represents the first element ofthe system, and the community’s mental health practitioners comprise another. Occupying a position between these two groups is the segment of the community that consists of those mdividuals with whom the potential consumer group talk about their problems. The potential consumers, or workers and their families, relate to the sources of referral, or people workers confide in, who in turn relate to the providers of service, or mental health professionals. The effective operation of this process requires that each element have similar understandings of several phenomena. Potential systemic obstacles could derive from any lack of agreement, acceptance, definition, or awareness between any two of the system’s elements. In order to investigate barriers to treatment, a Michigan community that met two essential criteria was selected as a study site: it contained a large concentration of UAW members and a variety of mental health facilities. The 447 workers selected for this study represented a probability sample of active UAW members employed within the selected community. The 8 1 referral agents interviewed represented a sampling ofall community social agency personnel, school principals and counselors, clergy, nonpsychiatric physicians, local union officials, and court or police personnel whose specific duties might bring them into contact with people with mental health problems. The provider group (N = 72) included all of the community mental health practitioners and selected representatives of each of the treatment facilities within the community. Personal interviews were conducted between November 1972 and May 1973. The five following major areas were included in the investigation: I) knowledge of available outpatient mental health facilities, 2) knowledge of the workers’ eligibility for prepaid mental health care, 3) belief in the efficacy of mental health treatment, 4) perceptions of the inhibiting strength of selected potential barriers to treatment, and 5) attitudes toward mental health. Essentially parallel items were presented during the interviews conducted with members of each of the three groups.
GLASSER,
RESUI.TS
Workers
and
referral
agents
knew
little
about
avail-
The vast majority of providers (86. 1 percent) were able to name at least four of the local treatment facilities. In contrast, a large proportion of the workers (76.6 percent) were at best able to name no more than one facility; about two-thirds of these could not name even one. The responses of the referral agents (social agency and school personnel, clergy, nonpsychiatric physicians, union officials, and court or police staffs) placed them about midway between these two extremes. About one-third of the referral agents could at best name only one treatment resource, and over onefifth could not name even one. About 90 percent of the workers and over one-third of the referral agents were not able to offer the name of a single psychiatrist with a locally based private practice.
able
outpatient
Workers
treatment
and
resources.
referral
agents
were
largeR’
unaware
of
Awareness of the UAW mental health benefits does not necessarily mean that eligible workers will seek treatment or that referral agents will suggest that workers seek professional help. However, lack of awareness by either group could have a strong inhibiting influence on a worker’s decision to seek help or a referral agent’s decision to suggest that professional help be sought. In essence, not knowing that the benefits exist means that the cost of treatment remains a barrier to treatment, if not in reality then in the perception of those who are unaware of the benefits. All of those interviewed for the study were asked if UAW members were eligible for treatment by a psychiatrist in private practice, treatment at a mental health clinic or center, and psychological testing. Considering all three benefit provisions, which are available without initial coinsurance or deductibles, it was found that the providers of service were quite familiar with the major outpatient provisions of the UAW mental health benefits. However, the same could not be said for the workers themselves or for those who could potentially function in a referral role. Although no less than three-fourths of the providers were certain that the workers were eligible for each of the three benefit provisions, only about one-fifth of the workers and less than one-third of the referral agents were similarly aware of the benefits. It would appear that in many instances utilization of the professional mental health benefit occurred late in the development of emotional problems, when workers or members of their families exhibited behavior that made treatment imperative. On such occasions they then learned of their insurance coverage through their own sources or from providers. the
exi.stence
Workers
of
and,
the
to
benefits.
a
somewhat
lesser
extent,
referral
agents primarily identtfied onh’ excess and unsubtle behavior as requiring professional help. To measure the similarity or diversity of the three groups’ views of the appropriateness of treatment, the respondents were asked to define eight hypothetical problem situations as either requiring or not requiring treatment. The eight situations were based upon the format developed by Star (4) and
AND
DUGGAN,
HOFFMAN
subsequently employed by others (5, 6). The items were modified to more closely reflect the workers’ life situations. The three groups’ perceptions of the need for mental health treatment in each situation are presented in table I. Excess viewing of television associated with lack of communication with the family, alcoholism, and constantly
getting
into
trouble
on
thejob
(situations
I, 7, and
8) were seen by a majority in all three groups as requiring treatment. Most workers and providers believed a man who talked constantly to his machine (situation 2) needed professional help. Referral agents were less certam. The responses to the remaining situations disclosed large discrepancies among the views of workers, referral agents, and providers. Roughly three-fourths of the workers and referral agents did not feel that a person who always refused to ride elevators (situation 5) or a working woman who felt unappreciated at home (situation 6) required professional help. Half of the providers believed such assistance was indicated. Considering the three groups’ response patterns in total, a form of polarization is evident. Those items involving some form of excess (fighting, drinking, and watching television) were viewed by similar proportions of each group as requiring treatment. However, the responses to the more subtle problems such as those of a married couple working different shifts and a working woman who feels unappreciated clearly differentiated the perceptions of the providers and the workers. The
stigma
associated
with
knowledge ofinsurance fi cact of treattilent were f actor.c adverse/v affecting
mental
health
care,
lack
of
benefits. and doubts about the efseen by all three groups as major decisions to seek help. Each of
the respondents was asked to evaluate the inhibiting strength of 15 items identified (6. pp. 126, 127) as potentially having a negative influence upon an individual’s decision to seek treatment (see table 2). Five of the items were viewed by at least a majority of each group as operating to “very much” prevent workers from seeking treatment. Three ofthese were indicators of the stigma associated with receiving treatment, one dealt with the efficacy of treatment, and the fifth involved the perceived costs of treatment among workers who were unaware that they were eligible for mental health benefits. The only factors that were viewed as not having much if any of an inhibiting effect were lack of transportation, the cost of a babysitter, and having to miss a favorite television program. These findings suggest that a number of factors have the potential for deterring workers from seeking treatment. It should also be recognized that it is unlikely that any of the factors would operate independently. Rather, it is probable that two or more factors would function together to inhibit seeking of treatment. Each of the factors identified as at least somewhat inhibiting, therefore, comprises only a portion of what must be considered a formidable set of obstacles to treatment. The provide
belief
of
the
appropriate
workers mental
Am
J Psychiatry
that
family
health
care
/32:7,
physicians and
July
the
1975
can concern
711
OBSTACLES
TABLE Perceptions
TO
UTILIZATION
I ofNeedfor
Mental
Health
Treatment
A mong
Worker.r
(N
-
447).
Referral
Agents
Situation I . A working man watches television from the time he gets home until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment? Workers Referral agents Providers 2. A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment? Workers Referral agents Providers 3. A husband and wife are having marital problems and seldom see each other because they both work and they work on different shifts. Do you think they need mental health treatment? Workers Referral agents Providers 4. A 12-year-old boy lies, steals. and skips school. Do you think he needs mental health treatment? Workers Referral agents Providers 5. A person always refuses to ride elevators. Do you think this person needs mental health treatment? Workers Referralagents Providers 6. A woman works at a job every day and goes home to cook and clean at night and feels no one appreciates what she does. Do you think she needs mental health treatment? Workers Referral agents Providers 7. A man cannot seem to hold ajob very long because he drinks so much. Do you think he needs mental health treatment? Workers Referralagents Providers 8. A young man is always getting into trouble on thejob. Do you think he needs mental health treatment? Workers Referral agents Providers
of referral agents with were potential obstacles.
the
‘The items included replicate associates (6, pp. 124 127).
several
stigma
of
being
mental/v
ill
The response patterns for several of the attitude and opinion items’ demonstrate a degree of disparity among the three groups that could hinder the delivery of mental health care to the eligible consumers (see table 3). Perhaps one of the more important response variations reflected the perception of the family doctor as an appropriate source of mental health care by the eligible consumers (attitude I in table 3). This view was reinforced by the referral agents and suggests that self-directed referral to a psychiatrist was less than likely. It would follow that the workers would expect to receive appropriate care
7 I2
A m J Psychiatry
132:7,
of the statements
July
1975
of Elinson
and
(N
=
8/ ). and
Providers
(N
=
72 ).
in Percents
Don’t
Know
No
Response
Yes
No
65.8 65.4 70.8
30.8 27.2 11.1
3.4 7.4 18.1
63.6 49.4 62.5
30.2 43.2 26.4
6.2 7.4 1 I .1
16.2 49.4 66.7
80.9 44.4 30.6
2.9 6.2 2.7
58.2 69.1 93.1
37.6 23.5 6.9
4.2 7.4 0.0
22.4 23.5 50.0
73.7 72.8 43.1
4.9 3.7 6.9
17.4 22.2 54.2
78.7 70.4 40.3
3.9 7.4 5.5
83.0 81.5 95.8
13.4 13.6 4.2
3.6 4.9 0.0
72.2 79.0 84.7
21.9 13.6 7.0
5.9 7.4 8.3
or
from their family physicians; this expectation might interfere with family doctors’ subsequently suggesting referral to a mental health professional. Attitudes 2, 3, and 4 in table 3 are measures of the stigma associated with receiving care for mental or emotional problems. The response variations among the three groups for these items indicate a tendency for the referral agents to be overly concerned with the problems inherent in the stigmatization process. These findings suggest a potential obstacle in the referral process. Since referral agents tended to be more concerned with the negative effects of stigma than either of the other two groups, they might have hesitated to suggest that a troubled worker seek treatment or they might have transmitted their negative impressions when approached by workers for advice.
GLASSER,
DUGGAN,
AND
HOFFMAN
2
TABLE
Perceptions
of Potential
Obstacles
to Treatment
Among
Workers
(N = 447),
Referral
Agents
IdentifIcation of Am Potential
Obstacle
Very
knowing that services are available Workers Referralagents Providers Not knowing that one is covered by insurance Workers Referral agents Providers Worrying about what might happen Workers Referral agents Providers Feeling that asking for help is a sign of weakness for men Workers Referral agents Providers Fear that others will learn about it Workers
Much
Somewhat
and Providers
(N = 8/),
(N = 72), in Percents
ount of Impediment Very
Little
Not
Don No
at All
t Know or Response
Not
Referral agents Providers Feeling that just talking will do no good Workers Referral agents Providers Fear that it will affect one’s job Workers Referral agents Providers No transportation available Workers Referral agents Providers Would miss favorite television program Workers Referral agents Providers Fear that people will think one is crazy Workers Referral agents Providers Cost of a babysitter Workers Referral agents Providers Feeling that one can handle one’s Workers Referral agents Providers Fear of talking to a psychiatrist Workers Referral agents Providers Not knowing one needs help Workers Referral agents Providers Embarrassment Workers
own
38.3 33.3 30.5
25.9 49.4 52.8
20.8 13.6 13.9
14.6 2.5 1.4
0.4 1.2 1.4
67.1 65.4 54. 1
19.7 30.9 38.9
8.3 3.7 5.6
4.0 0.0 1.4
0.9 0.0 0.0
43.2 59.3 45.8
33.8 35.8 47.2
15.7 1.2 5.6
6.7 3.7 1.4
0.6 0.0 0.0
41.2 56.8 55.6
30.6 32. 1 36.1
17.5 1 1. I 6.9
10.0 0.0 0.0
0.7 0.0 1.4
58.8
27.1
8.7
4.7
0.6
66.7 63.9
28.4 31.9
1 .2 2.8
3.7 1.4
0.0 0.0
29.9 32.1 30.6
41.2 49.4 54.1
20.6 18.5 12.5
7.4 0.0 2.8
0.9 0.0 0.0
34.5 43.3 37.5
29.8 44.4 40.3
20.1 4.9 20.8
15.4 7.4 1.4
0.2 0.0 0.0
11.6
16.3
43.2
28.9
0.0
12.3 8.3
23.5 25.0
43.2 47.2
21.0 18.1
0.0 1.4
7.2 7.4 2.8
11.1 27.2 18.1
30.9 38.3 41.7
50.1 27.2 33.3
0.7 0.0 4.1
60.6
22.8
8.7
7.4
0.4
80.2 73.6
12.4 23.6
2.5 2.8
3.7 0.0
1.2 0.0
5.6 4.9 2.8
21.7 44.4 56.9
45.7 34.6 37.5
26.6 16.0 2.8
49.2 71.6 56.9
30.4 21.0 37.6
13.0 3.7 4.1
6.3 2.5 1.4
1.1 1.2 0.0
48.8 58.1 58.3
29.8 33.3 34.7
11.1 3.7 5.6
9.6 3.7 1.4
0.7 1.2 0.0
62.4 70.4 45.8
22.6 22.3 47.3
8.7 4.9 6.9
4.7 1.2 0.0
1.5 1.2 0.0
0.4 0.0 0.0
problems
56.6
31.3
9.2
2.2
0.6
Referral agents
69.1
24.7
3.7
2.5
0.0
Providers
50.0
44.4
5.6
0.0
0.0
Am
J Psychiatry
/32:7.
July
1975
713
OBSTACLES
TO
TABLE
3
Attitudes
Toward
UTILIZATION
Mental
Health
Among
Workers
(N
-
447). Referral
Agents
(N
8//. and Providers
Attitude I. Most family doctors can help patients with emotional problems. Workers Referral agents Providers 2. Most people would not like to work next to a person who had been a mental Workers Referral agents Providers 3. If a mental patient is treated in a general hospital or clinic instead of a mental hospital, there will he less of a stigma against the person. \xorkers Referral agents Providers 4. Mental illness tends to repel most people. Workers Referral agents Providers
DISC’
USS
ION
The
The relatively low utilization of mental health services in spite ofthe removal ofa substantial portion of the economic barriers to such care has been demonstrated to be related to the obstacles that exist in the pathways to prepaid mental health care. The differences among the three groups reported in this study indicate the lack ofan effectively functioning system of mental health care in which problems are detected early. appropriate referral is made, and professional attention is received. Specifically, workers are not aware of professional resources. This situation inhibits self-referrals and indicates that the burden for directing workers to appropriate sources of treatment rests with those who have the potential to function in a referral role. However, the referral agents, especially the union officials and clergy, are also less than fully aware of the various treatment sources available. This in turn suggests the need for better informing the referral group about the available professional treatment resources. Despite the fact that each year since 1966, when 1 percent of those eligible used the mental health insurance benefit, there has been a modest increase in the percentage of utilizers, the evidence of this study indicates that workers are still largely unaware of mental health benefits available to them through their union contracts. Therefore, while economic barriers to early diagnosis and treatment have been largely eliminated, they probably continue to act as deterrents for those workers who are unaware of these benefits. Many of the problems that were identified by mental health professionals as requiring treatment were not so identified by the workers. Unless influenced to change their views, the workers would not be likely to seek professional intervention early in the course of a problem episode. Further, unless modified, the workers’ negative attitudes toward mental health care would continue to act as strong deterrents to treatment.
714
Am J Psychiatry
/32:7,
July
/975
(N
72/.
in Percents
Yes
No
Don’t Know or No Response
74.1 65.5 48.6
22.4 33.3 43.1
3.5 1.2 8.3
43.4 51.9 43.1
54.1 43.2 48.6
2.5 4.9 8.3
71.8 84.0 83.4
25.1 14.8 8.3
3.1 1.2 8.3
86.6 91.1 81.9
11.9 9.9 9.8
1.5 0.0 8.3
patient.
Referral
Group
The key element here is the referral group. The members of this group have the potential to influence workers to modify their beliefs regarding the efficacy of treatment and to overcome workers’ apprehension or fear of seeking professional help. However, the referral agents are themselves not in agreement with the mental health professionals’ identification of problem situations that require treatment. Therefore, before the referral group can influence workers to have a more positive beliefin the efficacy of treatment, they must modify their own views. Nearly all of the individuals in the referral group acknowledged that workers seek their advice about personal problems. They were therefore presented with opportunities to make referrals to mental health professionals. However, when given these opportunities, a large proportion of the referral group, especially the clergy, union officials, and court or police personnel, only offered general advice. In fact, about one-third of all referral agents had never even suggested that an individual seek help from a psychiatrist. Among those who did, the suggestions frequently did not involve any actual referral activities. Furthermore, nearly one-third of the nonpsychiatric physicians, social agency personnel, and school personnel had never even suggested to anyone asking their advice that he or she should seek help at a mental health clinic. The providers reported that nonpsychiatric physicians, social agencies, and school personnel were among their most frequent sources of referral. Yet the providers also viewed these same sources as not recognizing problems early enough and frequently attempting to provide treatment themselves. These actions, of course, impede the early detection of problems and referral to an appropriate mental health professional. It is clear that the major obstacles to utilizing mental health benefits center on the potential referral group. They are not well informed about the benefits for and ap-
GLASSER,
propriate sources of professional help. They do not recognize problems amenable to treatment and, in sum, are not performing the requisite functions ofthe referral role. Implications
of the
Study
The findings ofour study have widespread implications for the current scene. In recent years there has been a tremendous growth in the number of Americans who are eligible for mental health services under some form of prepayment or private insurance plan. Mental health benefits are, however, not like general medical benefits. They cover services that potential users may and frequently do consider nonessential or at least postponable. Employers and unions representing workers therefore have an obligation to do more than negotiate collective bargaining agreements that include coverage for mental health services. With a few notable exceptions, employers providing these benefits have done nothing to conduct information programs to inform their employees ofthem. In normal economic times, turnover among blue collar workers is high. New employees are almost never informed about these benefits, except through a few sentences in a multipaged booklet on all employee benefits. Unions whose members are concentrated in relatively few locations where word of mouth information and interpretation is possible have been able, as the Amalgamated Clothing Workers Union has demonstrated, to achieve widespread understanding and acceptance of the program. On the other hand, large international unions like the UAW, with members located in 34 states and 77 principal cities, have much greater communications problems. Their efforts to communicate through printed materials, films, and orientation sessions for union referral agents have at best provided relatively thin coverage. Information programs on mental health coverage must also compete with those of hundreds of other union-negotiated benefits. The insurance carriers (Blue Cross and Blue Shield and the commercial insurance companies) have apparently felt no responsibility for any special activity either to inform their subscribers of the benefits to which they are entitled or to interpret how the benefits might be used. To our knowledge no insurance company that writes these benefits for national union contracts has done anything about explaining them to covered employees. It is evident that the mental health professions, particularly psychiatry, also have an obligation to become more actively involved in community-wide systems of detection, referral, and treatment. However, American psychiatry does not appear to be clear about either its role or its responsibility in this regard. After an initial spurt in
1966 with terest
DUGGAN,
AND
HOFFMAN
and 1967, when a number of psychiatrists helped UAW information and interpretation sessions, inappeared to flag. There has been relatively little
evidence
in recent
years
that
organized
psychiatry
is pre-
pared to take the initiative on or put the necessary time and effort into information and interpretation programs for those covered for psychiatric insurance benefits. In at least one instance, a state psychiatric society decided that it would not participate in union efforts to onent members about mental health services unless the physicians were paid their usual fees for time spent in these activities. These attitudes are not usually evident among the psychiatrists and other mental health personnel associated with community mental health centers and other organized mental health programs. It appears clear that by taking a leadership role in efforts designed to better inform the general public and particularly referral agents, the psychiatric profession can be of immense help in removing many of the obstades in the pathways to effective use of prepaid mental health care identified in this study. Finally, in the view of most informed observers, the United States will within a relatively short time adopt some form of national health insurance. Most proposals now before the Congress include some form of mental health coverage. In a few of the hills the benefits are substantial. However, the fact that more people will be coyered will be less meaningful if the benefits are used minimally or, as is more likely, if groups of prospective beneficiaries like blue collar workers are blocked from making effective use of them. The organizational and attitudinal obstacles as well as the lack ofawareness of coyerage identified in this study may provide the basis of an attempt at their reduction. Such an effort, undertaken at an early date, would appear to be imperative if the goal of providing
equal
achieved
through
access
to
national
mental
health
health
services
is to be
insurance.
REFERENCES I. Glasser MA, Duggan Ti: Prepaid psychiatric care experience with UAW members. Am J Psychiatry 126:675 681, 1969 2. Blue Cross and Blue Shield: Utilization rates, outpatient psychiatric benefit, in Big Three Data Reports: Auto National Account Program. Chicago. Ill,BlueCrossand BlueShield, Nov l’ull,p2 3. Srole L, Langner T, Michael S. et al: Mental Health in the Metropolis. The Midtown Manhattan Study, vol. I. New York, McGrawHill Book Co. 1962 4. Star SA: The public ideas about mental health. Read at the fifth annual meeting of the National Association for Mental Health, Indianapolis, Nov 4, 1955 5. Cumming F, Cumming J: Closed Ranks. Cambridge. Mass, Harvard University Press, 957 6. Elinson JE, Padilla E. Perkins ME: Public Image of Mental Health Services. New York, Mental Health Materials Center, 1967
Am
J Psychiatry
132:7,
July
1975
715
B’
to Utilization IN
%. GLSSER.
of Prepaid
LL.l)..
TH0\IS
J.
Mental DUGGA\.
Health
PHI)..
Care \%ILLI%\I
S. HO1”F\I\,
\I.#{149}.
METHOI)
The co verage ofo health (are through
ut-of-hospital prepat’ment
ha.s been a mqjor barriers to ear/i’ mental disorders.
adsanee detection, However.
treatmen
many
help. the
t block
The
authors
United
A uto
roadblocks. perceptions toward
treatment,
in removing diagnosis. obstacles
eligible
conducted Workers
A niong oJneedJor
e.xpen.ce.s for and insurance
people
lack
from among
of awarenes.c
of
these
were differences and in attitudes
benefits among three key groups-consumers. agents. andproviders. The authors urge help in removing these obstacles.
of
receiving members
to identify
the obstacles treatment and
the economic and treatment to obtaining
a study union
mental program.s
in
of eligibility
for
refrrral psychiatry to
A DECADE A(IO the concept of widely available prepaid mental health care was thought to be little more than a speculation, especially for members of the working class. Currently well over 15 million workers and their dependents are eligible for such coverage as part of their basic private health insurance. This trend was accelerated by the United Auto Workers International Union (UAW), which negotiated the first nationwide collective bargaining agreements to add coverage for out-of-hospital mental health care. The program became effective in 1966. The moderate utilization rates seen during the first years of the UAW program (1,2) clearly demonstrated the program’s economic feasibility. However, these same utilization data further demonstrated that factory workers were not making as full use of mental health services as they might. Various estimates of the need for mental health care (3) were substantially higher than the observed utilization experiences. The program’s goal of early detection, referral, and psychiatric attention was not being fully achieved. Accordingly, the research reported in this paper was conducted to determine what factors operated to keep UAW workers and their families from more effectively utilizing mental health services.
The authors are all sith the Michigan Health and Social Security Research Institute. 8000 F. Jeflerson Ave., Detroit, Mich. 48214. Dr. Glasser is Secretar -Treasurer, Dr. Duggan is Senior Research Consultant, and Mr. Hoffman is Senior Research Associate. Dr. Duggan is also Associate Professor of Sociologs, Wayne State University, Dctroit. Mich. The research for this paper was 20373 from the National Institute
710
AmJ
Psychiatry
principally of Mental
/32:7,July
supported Health.
1975
by grant
MH-
The barriers to utilization of prepaid mental health care can be identified and examined within a model of a service delivery system that consists of three community elements. The potential consumer group within a community represents the first element ofthe system, and the community’s mental health practitioners comprise another. Occupying a position between these two groups is the segment of the community that consists of those mdividuals with whom the potential consumer group talk about their problems. The potential consumers, or workers and their families, relate to the sources of referral, or people workers confide in, who in turn relate to the providers of service, or mental health professionals. The effective operation of this process requires that each element have similar understandings of several phenomena. Potential systemic obstacles could derive from any lack of agreement, acceptance, definition, or awareness between any two of the system’s elements. In order to investigate barriers to treatment, a Michigan community that met two essential criteria was selected as a study site: it contained a large concentration of UAW members and a variety of mental health facilities. The 447 workers selected for this study represented a probability sample of active UAW members employed within the selected community. The 8 1 referral agents interviewed represented a sampling ofall community social agency personnel, school principals and counselors, clergy, nonpsychiatric physicians, local union officials, and court or police personnel whose specific duties might bring them into contact with people with mental health problems. The provider group (N = 72) included all of the community mental health practitioners and selected representatives of each of the treatment facilities within the community. Personal interviews were conducted between November 1972 and May 1973. The five following major areas were included in the investigation: I) knowledge of available outpatient mental health facilities, 2) knowledge of the workers’ eligibility for prepaid mental health care, 3) belief in the efficacy of mental health treatment, 4) perceptions of the inhibiting strength of selected potential barriers to treatment, and 5) attitudes toward mental health. Essentially parallel items were presented during the interviews conducted with members of each of the three groups.
GLASSER,
RESUI.TS
Workers
and
referral
agents
knew
little
about
avail-
The vast majority of providers (86. 1 percent) were able to name at least four of the local treatment facilities. In contrast, a large proportion of the workers (76.6 percent) were at best able to name no more than one facility; about two-thirds of these could not name even one. The responses of the referral agents (social agency and school personnel, clergy, nonpsychiatric physicians, union officials, and court or police staffs) placed them about midway between these two extremes. About one-third of the referral agents could at best name only one treatment resource, and over onefifth could not name even one. About 90 percent of the workers and over one-third of the referral agents were not able to offer the name of a single psychiatrist with a locally based private practice.
able
outpatient
Workers
treatment
and
resources.
referral
agents
were
largeR’
unaware
of
Awareness of the UAW mental health benefits does not necessarily mean that eligible workers will seek treatment or that referral agents will suggest that workers seek professional help. However, lack of awareness by either group could have a strong inhibiting influence on a worker’s decision to seek help or a referral agent’s decision to suggest that professional help be sought. In essence, not knowing that the benefits exist means that the cost of treatment remains a barrier to treatment, if not in reality then in the perception of those who are unaware of the benefits. All of those interviewed for the study were asked if UAW members were eligible for treatment by a psychiatrist in private practice, treatment at a mental health clinic or center, and psychological testing. Considering all three benefit provisions, which are available without initial coinsurance or deductibles, it was found that the providers of service were quite familiar with the major outpatient provisions of the UAW mental health benefits. However, the same could not be said for the workers themselves or for those who could potentially function in a referral role. Although no less than three-fourths of the providers were certain that the workers were eligible for each of the three benefit provisions, only about one-fifth of the workers and less than one-third of the referral agents were similarly aware of the benefits. It would appear that in many instances utilization of the professional mental health benefit occurred late in the development of emotional problems, when workers or members of their families exhibited behavior that made treatment imperative. On such occasions they then learned of their insurance coverage through their own sources or from providers. the
exi.stence
Workers
of
and,
the
to
benefits.
a
somewhat
lesser
extent,
referral
agents primarily identtfied onh’ excess and unsubtle behavior as requiring professional help. To measure the similarity or diversity of the three groups’ views of the appropriateness of treatment, the respondents were asked to define eight hypothetical problem situations as either requiring or not requiring treatment. The eight situations were based upon the format developed by Star (4) and
AND
DUGGAN,
HOFFMAN
subsequently employed by others (5, 6). The items were modified to more closely reflect the workers’ life situations. The three groups’ perceptions of the need for mental health treatment in each situation are presented in table I. Excess viewing of television associated with lack of communication with the family, alcoholism, and constantly
getting
into
trouble
on
thejob
(situations
I, 7, and
8) were seen by a majority in all three groups as requiring treatment. Most workers and providers believed a man who talked constantly to his machine (situation 2) needed professional help. Referral agents were less certam. The responses to the remaining situations disclosed large discrepancies among the views of workers, referral agents, and providers. Roughly three-fourths of the workers and referral agents did not feel that a person who always refused to ride elevators (situation 5) or a working woman who felt unappreciated at home (situation 6) required professional help. Half of the providers believed such assistance was indicated. Considering the three groups’ response patterns in total, a form of polarization is evident. Those items involving some form of excess (fighting, drinking, and watching television) were viewed by similar proportions of each group as requiring treatment. However, the responses to the more subtle problems such as those of a married couple working different shifts and a working woman who feels unappreciated clearly differentiated the perceptions of the providers and the workers. The
stigma
associated
with
knowledge ofinsurance fi cact of treattilent were f actor.c adverse/v affecting
mental
health
care,
lack
of
benefits. and doubts about the efseen by all three groups as major decisions to seek help. Each of
the respondents was asked to evaluate the inhibiting strength of 15 items identified (6. pp. 126, 127) as potentially having a negative influence upon an individual’s decision to seek treatment (see table 2). Five of the items were viewed by at least a majority of each group as operating to “very much” prevent workers from seeking treatment. Three ofthese were indicators of the stigma associated with receiving treatment, one dealt with the efficacy of treatment, and the fifth involved the perceived costs of treatment among workers who were unaware that they were eligible for mental health benefits. The only factors that were viewed as not having much if any of an inhibiting effect were lack of transportation, the cost of a babysitter, and having to miss a favorite television program. These findings suggest that a number of factors have the potential for deterring workers from seeking treatment. It should also be recognized that it is unlikely that any of the factors would operate independently. Rather, it is probable that two or more factors would function together to inhibit seeking of treatment. Each of the factors identified as at least somewhat inhibiting, therefore, comprises only a portion of what must be considered a formidable set of obstacles to treatment. The provide
belief
of
the
appropriate
workers mental
Am
J Psychiatry
that
family
health
care
/32:7,
physicians and
July
the
1975
can concern
711
OBSTACLES
TABLE Perceptions
TO
UTILIZATION
I ofNeedfor
Mental
Health
Treatment
A mong
Worker.r
(N
-
447).
Referral
Agents
Situation I . A working man watches television from the time he gets home until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment? Workers Referral agents Providers 2. A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment? Workers Referral agents Providers 3. A husband and wife are having marital problems and seldom see each other because they both work and they work on different shifts. Do you think they need mental health treatment? Workers Referral agents Providers 4. A 12-year-old boy lies, steals. and skips school. Do you think he needs mental health treatment? Workers Referral agents Providers 5. A person always refuses to ride elevators. Do you think this person needs mental health treatment? Workers Referralagents Providers 6. A woman works at a job every day and goes home to cook and clean at night and feels no one appreciates what she does. Do you think she needs mental health treatment? Workers Referral agents Providers 7. A man cannot seem to hold ajob very long because he drinks so much. Do you think he needs mental health treatment? Workers Referralagents Providers 8. A young man is always getting into trouble on thejob. Do you think he needs mental health treatment? Workers Referral agents Providers
of referral agents with were potential obstacles.
the
‘The items included replicate associates (6, pp. 124 127).
several
stigma
of
being
mental/v
ill
The response patterns for several of the attitude and opinion items’ demonstrate a degree of disparity among the three groups that could hinder the delivery of mental health care to the eligible consumers (see table 3). Perhaps one of the more important response variations reflected the perception of the family doctor as an appropriate source of mental health care by the eligible consumers (attitude I in table 3). This view was reinforced by the referral agents and suggests that self-directed referral to a psychiatrist was less than likely. It would follow that the workers would expect to receive appropriate care
7 I2
A m J Psychiatry
132:7,
of the statements
July
1975
of Elinson
and
(N
=
8/ ). and
Providers
(N
=
72 ).
in Percents
Don’t
Know
No
Response
Yes
No
65.8 65.4 70.8
30.8 27.2 11.1
3.4 7.4 18.1
63.6 49.4 62.5
30.2 43.2 26.4
6.2 7.4 1 I .1
16.2 49.4 66.7
80.9 44.4 30.6
2.9 6.2 2.7
58.2 69.1 93.1
37.6 23.5 6.9
4.2 7.4 0.0
22.4 23.5 50.0
73.7 72.8 43.1
4.9 3.7 6.9
17.4 22.2 54.2
78.7 70.4 40.3
3.9 7.4 5.5
83.0 81.5 95.8
13.4 13.6 4.2
3.6 4.9 0.0
72.2 79.0 84.7
21.9 13.6 7.0
5.9 7.4 8.3
or
from their family physicians; this expectation might interfere with family doctors’ subsequently suggesting referral to a mental health professional. Attitudes 2, 3, and 4 in table 3 are measures of the stigma associated with receiving care for mental or emotional problems. The response variations among the three groups for these items indicate a tendency for the referral agents to be overly concerned with the problems inherent in the stigmatization process. These findings suggest a potential obstacle in the referral process. Since referral agents tended to be more concerned with the negative effects of stigma than either of the other two groups, they might have hesitated to suggest that a troubled worker seek treatment or they might have transmitted their negative impressions when approached by workers for advice.
GLASSER,
DUGGAN,
AND
HOFFMAN
2
TABLE
Perceptions
of Potential
Obstacles
to Treatment
Among
Workers
(N = 447),
Referral
Agents
IdentifIcation of Am Potential
Obstacle
Very
knowing that services are available Workers Referralagents Providers Not knowing that one is covered by insurance Workers Referral agents Providers Worrying about what might happen Workers Referral agents Providers Feeling that asking for help is a sign of weakness for men Workers Referral agents Providers Fear that others will learn about it Workers
Much
Somewhat
and Providers
(N = 8/),
(N = 72), in Percents
ount of Impediment Very
Little
Not
Don No
at All
t Know or Response
Not
Referral agents Providers Feeling that just talking will do no good Workers Referral agents Providers Fear that it will affect one’s job Workers Referral agents Providers No transportation available Workers Referral agents Providers Would miss favorite television program Workers Referral agents Providers Fear that people will think one is crazy Workers Referral agents Providers Cost of a babysitter Workers Referral agents Providers Feeling that one can handle one’s Workers Referral agents Providers Fear of talking to a psychiatrist Workers Referral agents Providers Not knowing one needs help Workers Referral agents Providers Embarrassment Workers
own
38.3 33.3 30.5
25.9 49.4 52.8
20.8 13.6 13.9
14.6 2.5 1.4
0.4 1.2 1.4
67.1 65.4 54. 1
19.7 30.9 38.9
8.3 3.7 5.6
4.0 0.0 1.4
0.9 0.0 0.0
43.2 59.3 45.8
33.8 35.8 47.2
15.7 1.2 5.6
6.7 3.7 1.4
0.6 0.0 0.0
41.2 56.8 55.6
30.6 32. 1 36.1
17.5 1 1. I 6.9
10.0 0.0 0.0
0.7 0.0 1.4
58.8
27.1
8.7
4.7
0.6
66.7 63.9
28.4 31.9
1 .2 2.8
3.7 1.4
0.0 0.0
29.9 32.1 30.6
41.2 49.4 54.1
20.6 18.5 12.5
7.4 0.0 2.8
0.9 0.0 0.0
34.5 43.3 37.5
29.8 44.4 40.3
20.1 4.9 20.8
15.4 7.4 1.4
0.2 0.0 0.0
11.6
16.3
43.2
28.9
0.0
12.3 8.3
23.5 25.0
43.2 47.2
21.0 18.1
0.0 1.4
7.2 7.4 2.8
11.1 27.2 18.1
30.9 38.3 41.7
50.1 27.2 33.3
0.7 0.0 4.1
60.6
22.8
8.7
7.4
0.4
80.2 73.6
12.4 23.6
2.5 2.8
3.7 0.0
1.2 0.0
5.6 4.9 2.8
21.7 44.4 56.9
45.7 34.6 37.5
26.6 16.0 2.8
49.2 71.6 56.9
30.4 21.0 37.6
13.0 3.7 4.1
6.3 2.5 1.4
1.1 1.2 0.0
48.8 58.1 58.3
29.8 33.3 34.7
11.1 3.7 5.6
9.6 3.7 1.4
0.7 1.2 0.0
62.4 70.4 45.8
22.6 22.3 47.3
8.7 4.9 6.9
4.7 1.2 0.0
1.5 1.2 0.0
0.4 0.0 0.0
problems
56.6
31.3
9.2
2.2
0.6
Referral agents
69.1
24.7
3.7
2.5
0.0
Providers
50.0
44.4
5.6
0.0
0.0
Am
J Psychiatry
/32:7.
July
1975
713
OBSTACLES
TO
TABLE
3
Attitudes
Toward
UTILIZATION
Mental
Health
Among
Workers
(N
-
447). Referral
Agents
(N
8//. and Providers
Attitude I. Most family doctors can help patients with emotional problems. Workers Referral agents Providers 2. Most people would not like to work next to a person who had been a mental Workers Referral agents Providers 3. If a mental patient is treated in a general hospital or clinic instead of a mental hospital, there will he less of a stigma against the person. \xorkers Referral agents Providers 4. Mental illness tends to repel most people. Workers Referral agents Providers
DISC’
USS
ION
The
The relatively low utilization of mental health services in spite ofthe removal ofa substantial portion of the economic barriers to such care has been demonstrated to be related to the obstacles that exist in the pathways to prepaid mental health care. The differences among the three groups reported in this study indicate the lack ofan effectively functioning system of mental health care in which problems are detected early. appropriate referral is made, and professional attention is received. Specifically, workers are not aware of professional resources. This situation inhibits self-referrals and indicates that the burden for directing workers to appropriate sources of treatment rests with those who have the potential to function in a referral role. However, the referral agents, especially the union officials and clergy, are also less than fully aware of the various treatment sources available. This in turn suggests the need for better informing the referral group about the available professional treatment resources. Despite the fact that each year since 1966, when 1 percent of those eligible used the mental health insurance benefit, there has been a modest increase in the percentage of utilizers, the evidence of this study indicates that workers are still largely unaware of mental health benefits available to them through their union contracts. Therefore, while economic barriers to early diagnosis and treatment have been largely eliminated, they probably continue to act as deterrents for those workers who are unaware of these benefits. Many of the problems that were identified by mental health professionals as requiring treatment were not so identified by the workers. Unless influenced to change their views, the workers would not be likely to seek professional intervention early in the course of a problem episode. Further, unless modified, the workers’ negative attitudes toward mental health care would continue to act as strong deterrents to treatment.
714
Am J Psychiatry
/32:7,
July
/975
(N
72/.
in Percents
Yes
No
Don’t Know or No Response
74.1 65.5 48.6
22.4 33.3 43.1
3.5 1.2 8.3
43.4 51.9 43.1
54.1 43.2 48.6
2.5 4.9 8.3
71.8 84.0 83.4
25.1 14.8 8.3
3.1 1.2 8.3
86.6 91.1 81.9
11.9 9.9 9.8
1.5 0.0 8.3
patient.
Referral
Group
The key element here is the referral group. The members of this group have the potential to influence workers to modify their beliefs regarding the efficacy of treatment and to overcome workers’ apprehension or fear of seeking professional help. However, the referral agents are themselves not in agreement with the mental health professionals’ identification of problem situations that require treatment. Therefore, before the referral group can influence workers to have a more positive beliefin the efficacy of treatment, they must modify their own views. Nearly all of the individuals in the referral group acknowledged that workers seek their advice about personal problems. They were therefore presented with opportunities to make referrals to mental health professionals. However, when given these opportunities, a large proportion of the referral group, especially the clergy, union officials, and court or police personnel, only offered general advice. In fact, about one-third of all referral agents had never even suggested that an individual seek help from a psychiatrist. Among those who did, the suggestions frequently did not involve any actual referral activities. Furthermore, nearly one-third of the nonpsychiatric physicians, social agency personnel, and school personnel had never even suggested to anyone asking their advice that he or she should seek help at a mental health clinic. The providers reported that nonpsychiatric physicians, social agencies, and school personnel were among their most frequent sources of referral. Yet the providers also viewed these same sources as not recognizing problems early enough and frequently attempting to provide treatment themselves. These actions, of course, impede the early detection of problems and referral to an appropriate mental health professional. It is clear that the major obstacles to utilizing mental health benefits center on the potential referral group. They are not well informed about the benefits for and ap-
GLASSER,
propriate sources of professional help. They do not recognize problems amenable to treatment and, in sum, are not performing the requisite functions ofthe referral role. Implications
of the
Study
The findings ofour study have widespread implications for the current scene. In recent years there has been a tremendous growth in the number of Americans who are eligible for mental health services under some form of prepayment or private insurance plan. Mental health benefits are, however, not like general medical benefits. They cover services that potential users may and frequently do consider nonessential or at least postponable. Employers and unions representing workers therefore have an obligation to do more than negotiate collective bargaining agreements that include coverage for mental health services. With a few notable exceptions, employers providing these benefits have done nothing to conduct information programs to inform their employees ofthem. In normal economic times, turnover among blue collar workers is high. New employees are almost never informed about these benefits, except through a few sentences in a multipaged booklet on all employee benefits. Unions whose members are concentrated in relatively few locations where word of mouth information and interpretation is possible have been able, as the Amalgamated Clothing Workers Union has demonstrated, to achieve widespread understanding and acceptance of the program. On the other hand, large international unions like the UAW, with members located in 34 states and 77 principal cities, have much greater communications problems. Their efforts to communicate through printed materials, films, and orientation sessions for union referral agents have at best provided relatively thin coverage. Information programs on mental health coverage must also compete with those of hundreds of other union-negotiated benefits. The insurance carriers (Blue Cross and Blue Shield and the commercial insurance companies) have apparently felt no responsibility for any special activity either to inform their subscribers of the benefits to which they are entitled or to interpret how the benefits might be used. To our knowledge no insurance company that writes these benefits for national union contracts has done anything about explaining them to covered employees. It is evident that the mental health professions, particularly psychiatry, also have an obligation to become more actively involved in community-wide systems of detection, referral, and treatment. However, American psychiatry does not appear to be clear about either its role or its responsibility in this regard. After an initial spurt in
1966 with terest
DUGGAN,
AND
HOFFMAN
and 1967, when a number of psychiatrists helped UAW information and interpretation sessions, inappeared to flag. There has been relatively little
evidence
in recent
years
that
organized
psychiatry
is pre-
pared to take the initiative on or put the necessary time and effort into information and interpretation programs for those covered for psychiatric insurance benefits. In at least one instance, a state psychiatric society decided that it would not participate in union efforts to onent members about mental health services unless the physicians were paid their usual fees for time spent in these activities. These attitudes are not usually evident among the psychiatrists and other mental health personnel associated with community mental health centers and other organized mental health programs. It appears clear that by taking a leadership role in efforts designed to better inform the general public and particularly referral agents, the psychiatric profession can be of immense help in removing many of the obstades in the pathways to effective use of prepaid mental health care identified in this study. Finally, in the view of most informed observers, the United States will within a relatively short time adopt some form of national health insurance. Most proposals now before the Congress include some form of mental health coverage. In a few of the hills the benefits are substantial. However, the fact that more people will be coyered will be less meaningful if the benefits are used minimally or, as is more likely, if groups of prospective beneficiaries like blue collar workers are blocked from making effective use of them. The organizational and attitudinal obstacles as well as the lack ofawareness of coyerage identified in this study may provide the basis of an attempt at their reduction. Such an effort, undertaken at an early date, would appear to be imperative if the goal of providing
equal
achieved
through
access
to
national
mental
health
health
services
is to be
insurance.
REFERENCES I. Glasser MA, Duggan Ti: Prepaid psychiatric care experience with UAW members. Am J Psychiatry 126:675 681, 1969 2. Blue Cross and Blue Shield: Utilization rates, outpatient psychiatric benefit, in Big Three Data Reports: Auto National Account Program. Chicago. Ill,BlueCrossand BlueShield, Nov l’ull,p2 3. Srole L, Langner T, Michael S. et al: Mental Health in the Metropolis. The Midtown Manhattan Study, vol. I. New York, McGrawHill Book Co. 1962 4. Star SA: The public ideas about mental health. Read at the fifth annual meeting of the National Association for Mental Health, Indianapolis, Nov 4, 1955 5. Cumming F, Cumming J: Closed Ranks. Cambridge. Mass, Harvard University Press, 957 6. Elinson JE, Padilla E. Perkins ME: Public Image of Mental Health Services. New York, Mental Health Materials Center, 1967
Am
J Psychiatry
132:7,
July
1975
715
