16.1 Treatment: Getting Help to Those Who Need It

Estimates suggest that 46.4% of people in the United States suffer from some type of mental disorder at some point in their lifetime (Kessler, Berglund, et al., 2005), and 26.2% suffer from at least one disorder during a given year (Kessler, Chiu, et al., 2005). The personal costs of these disorders involve anguish to the sufferers as well as interference in their ability to carry on the activities of daily life. Think about Christine from the example above. If she did not (or could not) seek treatment, she would continue to be crippled by her OCD, which was causing major problems in her life. She had to quit her job at the local coffee shop because she was no longer able to touch money or anything else that had been touched by other people without washing it first. Her relationship with her boyfriend was in trouble because he was growing tired of her constant reassurance seeking regarding cleanliness (hers and his). All of these problems were in turn increasing her anxiety and depression, making her obsessions even stronger. She desperately wanted and needed some way to break out of this vicious cycle. She needed an effective treatment.

The personal and social burdens associated with mental disorders are also enormous. Mental disorders typically have earlier ages of onset than physical disorders and are associated with significant impairments in the form of an inability to carry out daily activities, such as days out of school or work or problems in family and personal relationships. Impairments associated with mental disorders are as severe, and in many cases more severe, than those associated with physical disorders such as cancer, chronic pain, and heart disease (Ormel et al., 2008). For instance, a person with severe depression may be unable to hold down a job or even get organized enough to collect a disability check, and people with many disorders stop getting along with family, caring for their children, or trying to help.

There are financial costs too. Depression is the fourth leading cause of disability worldwide, and it is expected to rise to the second leading cause of disability by 2020 (Murray & Lopez, 1996a, 1996b). People with severe depression often are unable to make it into work due to their disorder, and even when they make it into work they often suffer from poor work performance. Recent estimates suggest that depression-related lost work productivity costs somewhere from $30 to $50 billion per year (Kessler, 2012). If we add in similar figures for anxiety disorders, psychotic disorders, substance disorders, and all the other psychological problems, the overall costs are astronomical. In addition to the personal benefits of treatment, then, society also stands to benefit from the effective treatment of psychological disorders.

Do all people with a mental disorder receive treatment? Not by a long shot. Only about 18% of people in the United States with a mental disorder in the past 12 months received treatment during the same time frame. Treatment rates are even lower elsewhere around the world, especially in low-income or developing countries (Wang et al., 2007). Treatment rates are higher for those with more severe mental disorders. Approximately 40% of those in the United States with a serious mental disorder (one that substantially interferes with major life activities) have received treatment in the past year (Wang, Demler, & Kessler, 2002). However, it is clear from these numbers that most people with a mental disorder do not receive treatment, and among those who do, the average delay from onset until treatment is first received is over a decade (Wang et al., 2004)!

Why Many People Fail to Seek Treatment

A physical symptom such as a toothache would send most people to the dentist—a trip that usually results in a successful treatment. The clear source of pain and the obvious solution make for a quick and effective response. In contrast, the path from a mental disorder to a successful treatment is often far less clear and many people are less familiar with when they should seek treatment for a mental disorder or where they should go. In the case of mental disorders, people may fail to get treatment for a number of reasons. Here are three of the most often reported:

1. People may not realize that they have a mental disorder that could be effectively treated. Approximately 45% of those with a mental disorder who do not seek treatment report that they did not do so because they didn’t think that they needed to be treated (Mojtabai et al., 2011). Mental disorders often are not taken nearly as seriously as physical illness, perhaps because the origin of mental illness is “hidden” and usually cannot be diagnosed by a blood test or X-ray. Moreover, although most people know what a toothache is and that it can be successfully treated, far fewer people know when they have a mental disorder and what treatments might be available.
2. There may be barriers to treatment, such as beliefs and circumstances that keep people from getting help. Individuals may believe that they should be able to handle things themselves. In fact, this is the primary reason that people with a mental disorder give for not seeking treatment (72.6%) and for dropping out of treatment prematurely (42.2%; Mojtabai et al., 2011). Other attitudinal barriers for not seeking treatment include believing that the problem was not that severe (16.9% of nontreatment seekers), the belief that treatment would be ineffective (16.4%), and perceived stigma from others (9.1%).
   

   When your tooth hurts, you go to a dentist. But how do you know when to see a psychologist?

   ALLISON LEACH/GETTY IMAGES
3. Structural barriers prevent people from physically getting to treatment. Like finding a good lawyer or plumber, finding the right psychologist can be more difficult than simply flipping through the yellow pages or searching online. This confusion is understandable given the plethora of different types of treatments available (see the Real World box, Types of Psychotherapists). Once you find the therapist for you, you may encounter structural barriers related to not being able to afford treatment (15.3% of nontreatment seekers), lack of clinician availability (12.8%), inconvenience of attending treatment (9.8%), and trouble finding transportation to the clinic (5.7%; Mojtabai et al., 2011).

Even when people seek and find help, they sometimes do not receive the most effective treatments, which further complicates things. For starters, most of the treatment of mental disorders is not provided by mental health specialists, but by general medical practitioners (Wang et al., 2007). And even when people make it to a mental health specialist, they do not always receive the most effective treatment possible. In fact, only a small percentage of those with a mental disorder (< 40%) receive what would be considered minimally adequate treatment, and only 15.3% of those with serious mental illness receive treatment that is considered minimally adequate. Inadequate treatment is especially a problem among those who are younger, African American, living in the Southern United States, diagnosed with a psychotic disorder, and treated in a general medical setting (Wang et al., 2002). Clearly, before choosing or prescribing a therapy, we need to know what kinds of treatments are available and understand which treatments are best for particular disorders.

THE REAL WORLD: Types of Psychotherapists

What do you do if you’re ready to seek the help of a mental health professional? To whom do you turn? Therapists have widely varying backgrounds and training, and this affects the kinds of services they offer. Before you choose a therapist, it is useful to have an understanding of a therapist’s background, training, and areas of expertise. There are several major “flavors.”

• Psychologist A psychologist who practices psychotherapy holds a doctorate with specialization in clinical psychology (a PhD or PsyD). This degree takes about 5 years to complete and includes extensive training in therapy, the assessment of psychological disorders, and research. The psychologist will sometimes have a specialty, such as working with adolescents or helping people overcome sleep disorders, and will usually conduct therapy that involves talking. Psychologists must be licensed by the state, and most states require candidates to complete about 2 years of supervised practical training and a competency exam. If you look for a psychologist in the Yellow Pages or through a clinic, you will usually find someone with this background.

  

  WAVEBREAKMEDIA LTD./GETTY IMAGES

• Psychiatrist A psychiatrist is a medical doctor who has completed an M.D. with specialized training in assessing and treating mental disorders. Psychiatrists can prescribe medications, and some also practice psychotherapy. General practice physicians can also prescribe medications for mental disorders and often are the first to see people with such disorders because people consult them for a wide range of health problems. However, general practice physicians do not typically receive much training in the diagnosis or treatment of mental disorders, and they do not practice psychotherapy.

  

  ZIGY KALUZNY/GETTY IMAGES

• Social worker Social workers have a master’s degree in social work and have training in working with people in dire life situations such as poverty, homelessness, or family conflict. Clinical or psychiatric social workers also receive special training to help people in these situations who have mental disorders. Social workers often work in government or private social service agencies and may also work in hospitals or have a private practice.

• Counselor Counselors have a wide range of training. To be a counseling psychologist, for example, requires a doctorate and practical training—the title uses that key term psychologist and is regulated by state laws. But states vary in how they define counselor. In some cases, a counselor must have a master’s degree and extensive training in therapy, whereas in others, a counselor may have minimal training or relevant education. Counselors who work in schools usually have a master’s degree and specific training in counseling in educational settings.

BSIP/UIG/GETTY IMAGES

Some people offer therapy under made-up terms that sound professional—“mind/body healing therapist,” for example, or “marital adjustment adviser.” Often these terms are simply invented to mislead clients and avoid licensing boards, and the “therapist” may have no training or expertise at all. And, of course, there are a few people who claim to be licensed practitioners who are not: Louise Wightman, who had once worked as stripper “Princess Cheyenne,” was convicted of fraud in 2007 after conducting psychotherapy as a psychologist with dozens of clients. She claimed she didn’t know the PhD degree she had purchased over the Internet was bogus (Associated Press, 2007). People who offer therapy may be well-meaning and even helpful, but they could do harm too. To be safe, it is important to shop wisely for a therapist whose training and credentials reflect expertise and inspire confidence.

How should you shop? One way is to start with people you know: your general practice physician, a school counselor, or a trusted friend or family member who might know of a good therapist. Or you can visit your college clinic or hospital or contact an Internet site of an organization such as the American Psychological Association that offers referrals to licensed mental health care providers. When you do contact someone, he or she will often be able to provide you with further advice about who would be just the right kind of therapist to consult.

Before you agree to see a therapist for treatment, you should ask questions such as those below to evaluate whether the therapist’s style or background is a good match for your problem:

• What type of therapy do you practice?
• What types of problems do you usually treat?
• For how long do you usually see people in therapy?
• Will our work involve “talking” therapy, medications, or both?
• How effective is this type of therapy for the type of problem I’m having?
• What are your fees for therapy, and will health insurance cover them?

Not only will the therapist’s answers to these questions tell you about his or her background and experience, but they will also tell you about his or her approach to treating clients. You can then make an informed decision about the type of service you need.

Although you should consider what type of therapist would best fit your needs, the therapist’s personality and approach can sometimes be as important as his or her background or training. You should seek out someone who is willing and open to answer questions, who has a clear understanding about the type of problem leading you to seek therapy, and who shows general respect and empathy for you. A therapist is someone you are entrusting with your mental health, and you should only enter into such a relationship when you and the therapist have good rapport.

Approaches to Treatment

Early mental health workers used water dowsing, or “hydrotherapy,” for psychological disorders. Here a patient at the Pennsylvania Hospital for the Insane gets a cold “douche bath” (Haskell, 1869). Such treatments were given in the forlorn hope that something might work, but often they were simply torture.

COURTESY UNIVERSITY OF MICHIGAN’S MAKING OF AMERICA/HTTP://MOA.UMDL.UMICH.EDU

Treatments can be divided broadly into two kinds: (a) psychological treatment, in which people interact with a clinician in order to use the environment to change their brain and behavior; and (b) biological treatment, in which the brain is treated directly with drugs, surgery or some other direct intervention. In some cases, both psychological and biological treatments are used. Christine’s OCD, for example, might be treated not only with the ERP but also with medication that decreases her obsessive thoughts and compulsive urges. For many years, psychological treatment was the main form of intervention for psychological disorders because few biological options were available. There have always been folk remedies that propose to have a biological basis—such as hydrotherapy (pouring cold water on those with mental disorders), trephination (drilling holes in the skull to let the evil spirits escape), and bloodletting (the removal of blood from the body)—used to try to cure psychological disorders (Note: Do not try these at home. Turns out they don’t work). As we learn more about the biology and chemistry of the brain, approaches to mental health that begin with the brain are becoming increasingly widespread. As you’ll see later in the chapter, many effective treatments combine both psychological and biological interventions.

CULTURE & COMMUNITY: Treatment of Psychological Disorders around the World

Barriers that keep people from receiving treatment for mental disorders exist all around the world. However, they are greater in some places than in others. One recent study examined what percentage of people with a mental disorder in 17 different countries around the world received treatment for their disorder in the past year (Wang et al., 2007). Several different findings are interesting to note. First, people with a severe mental disorder are much more likely to be treated. This makes sense. For instance, if your disorder is so severe that it prevents you from going to school or work you will probably seek treatment, but if it doesn’t really interfere with your daily life you may not go for help. Second, people living in high-income countries (as defined by the World Bank) are much more likely to get treatment than those in middle- or low-income countries. This makes sense too. The more resources a country has, the more able it is to make psychological treatments available to its people. Third, most people with a mental disorder do not receive any treatment. This is true even in the countries with the highest income. This means that although we have a better understanding of mental disorders than we ever had before (as described in the last chapter), and we have better treatments than ever before (as described in this chapter), we still have to do a much better job removing the barriers that prevent those with mental disorders from getting help.