Tuesday, December 15, 2009

After Strict Religious Upbringing, a Path Back to His Faith

JOYCE COHEN

Jeffry Trepp makes friends easily. He talks to people in the synagogue, on the subway, on the sidewalk.

In fact, that is how Mr. Trepp found his new apartment in Flatbush, Brooklyn. He encountered a woman putting trash out and stopped to help, mentioning that he was on his way to see his rabbi. She asked him to pass the word along that she had a half-furnished basement apartment for rent.

Well, he was interested. And that is where he currently lives, for $450 a month.

Mr. Trepp, 20, manages to pay his rent, but until recently he had feared he would end up on the street. He was hospitalized in September with a lung infection, lost his job and faced eviction from his previous apartment. He had no one to take him in.

Mr. Trepp was born in Little Rock, Ark. All he knows about his birth parents, he said, is that his mother was Puerto Rican and his father an Italian Jew. He was adopted as an infant by religious Jews and was converted to Judaism. The family lived first in Washington Heights and then in Far Rockaway, Queens.

Around age 13, shortly after his bar mitzvah, he began to rebel against his strict upbringing, and his parents distanced themselves. His mother “wanted me to learn Bible every single day,” he said. “I guess I wasn’t living up to her standards of Judaism.”

He admits he was difficult: hyperactive and impulsive. “I was flying off the wall,” he said. Medication did not help.

His parents sent him to a group home for religious youths, where, he said, he fell into drugs and delinquency. “I don’t feel I had an addiction,” he said. “It was a problem, not an addiction.”

His parents had Jewish authorities declare that he was no longer a Jew, he said, and he felt betrayed.

At age 16, he was sent by the group home to the campus of the Jewish Child Care Association in Westchester, a beneficiary agency of UJA-Federation of New York, one of the seven agencies supported by The New York Times Neediest Cases Fund. There he met Ed Sperling, director of one of the residential treatment centers, who took him to Jewish services on weekends and holidays, and to daily minyan, or prayer services. He received schooling, counseling and culinary training. “Jeff wanted to go on a path back to Judaism,” Mr. Sperling said.

He was welcomed at the Mount Kisco Hebrew Congregation, where Rabbi Aaron Goldscheider arranged for his reaffirmation as a Jew. “He underwent a second conversion,” Rabbi Goldscheider said. “It is an affirmation that you are embracing all the laws of Judaism.”

Later, Mr. Trepp went to live on his own, in Bushwick, Brooklyn. He worked at a variety of jobs, mostly at delicatessens, restaurants and supermarkets, and took some college courses.

But his health issues interfered. He was hospitalized in September with the lung infection and put on a respirator. When he was released, he had no job, no money and no MetroCard. He was facing eviction from his apartment and could not pay his phone or credit card bill. (He had been a little too enthusiastic about buying clothes, he said.)

He called Mr. Sperling, who arranged for him to receive $496 from the Jewish Child Care Association. “I was moved by the fact he had no family roots,” Mr. Sperling said. “We serve youth who have estranged family ties, but they have some sort of family, people they call Auntie or Uncle or Cousin. He had nobody.”

The money went toward his rent, phone bill and MetroCard, as well as a new skullcap and prayer shawl. (His were lost during the hospitalization.)

Now, living in Flatbush, Mr. Trepp works as a telephone fund-raiser for Naaleh, a Jewish educational Web site. “It is an interesting and diverse job,” he said, and the people he calls are often glad to speak with him.

He hopes to study criminal justice or forensic psychology.

And he has reconnected with his father, and talks with him on the phone.

“On a simplistic, basic level, Judaism is all I am familiar with,” Mr. Trepp said. “That’s what I grew up around. On a deeper level, I feel spiritually connected to Judaism. Some people are quick to judge. Everybody should be able to observe their religion in their own way.”

Reference: The New York Times
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Sowing Patriotism, But Reaping Nationalism? Consequences of Exposure to the American Flag

Markus Kemmelmeier
University of Nevada
David G. Winter
University of Michigan


ABSTRACT

The American flag is a frequently displayed national symbol in the United States. Given its high visibility and importance, the present research examines the consequences of exposure to the flag on Americans' sense of national attachment. We hypothesized that the flag would increase patriotism, defined as love and commitment to one's country, and nationalism, defined as a sense of superiority over others. Two experimental studies supported the idea that the American flag increased nationalism, but not necessarily patriotism. The discussion focuses on the practices surrounding the American flag and its implications for the reproduction of American national identity.

Full text, here
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Attentional processing of location and color cues during driving

RUTING XIA, MASATO FUKUSHIMA, SHUN'ICHI DOI
Intelligent Mechanical Systems Engineering, Kagawa University, Japan
TAKAHIKO KIMURA and TOSHIAKI MIURA
Department of Applied Cognitive Psychology, Osaka University Yamadaoka, Japan


ABSTRACT

Studies have shown that prior information concerning the spatial location of a subsequent target facilitates the selection of that target for further visual processing in three-dimensional (3-D) space. Using Posner's cuing paradigm, our work examined the reaction time of drivers when cue duration and peripheral environment luminance was changed, and explored the effect color and location on reaction time. Experiment 1 showed that reaction time was not affected by cue duration, and that shifts of attention operated more efficiently for cue location validity. Experiment 2 showed that there was no main effect of background luminance on reaction time. Experiment 3 showed that location produces a greater effect than color.

Full Text, here
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Windows of reflection: conceptualizing dyslexia using the social model of disability

Stephen. J. Macdonald
School of Health, Natural and Social Sciences, University of Sunderland, Sunderland, UK


Abstract
The aim of this study is to develop perceptual knowledge of dyslexia from adults diagnosed with this condition. Historically, the dominant conceptual frameworks used to study dyslexia stem from psychological or educational practice. These disciplines predominantly draw on professional neuro-biological or educational knowledge that can be broadly summarized within a medical or educational model approach. Both the medical and educational models view dyslexia as resulting from a neurological and learning dysfunction. As such, only a small amount of research has attempted to locate dyslexia within a sociological context. This paper analyses the life narratives of adults diagnosed with dyslexia using the social model of disability. The author investigates the impact that disabling barriers have in education and employment for people with dyslexia. The implications of this are discussed, particularly how issues of disabling barriers and social-class structures affect the lives of people with dyslexia. The paper argues that social-class positioning and institutional discrimination (in the form of disabling barriers) shape the experiences of people living with this condition.

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Disseminating Incredible Years Series early-intervention programs: Integrating and sustaining services between school and home

Carolyn Webster-Stratton
University of Washington
Keith C. Herman
University of Missouri - Columbia

The Incredible Years (IY) Series is a well-established set of parent, teacher, and child programs for treating and preventing conduct problems and promoting social competence and emotional regulation in young children. The purpose of this article is to describe the development of this evidence-based series within the context of a prevention science framework. We first summarize the conceptual grounding of the intervention series including the risk and protective factors that are targeted by IY. We then review the extensive literature demonstrating the impact of the various programs. The bulk of this article, however, focuses on the challenge of disseminating evidence-based programs with high fidelity. To help overcome these challenges, we describe a model and a set of strategies for implementing IY in community and school settings with high fidelity, so as to help reduce the population prevalence of major childhood mental disorders.

Full Text, here
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Between Peirce (1878) and James (1898): G. Stanley Hall, the origins of pragmatism, and the history of psychology

David E. Leary
University Professor, University of Richmond, Richmond, Virginia

Abstract
This article focuses on the 20-year gap between Charles S. Peirce's classic proposal of pragmatism in 1877-1878 and William James's equally classic call for pragmatism in 1898. It fills the gap by reviewing relevant developments in the work of Peirce and James and by introducing G. Stanley Hall, for the first time, as a figure in the history of pragmatism. In treating Hall and pragmatism, the article reveals a previously unnoted relation between the early history of pragmatism and the early history of the new psychology that Hall helped to pioneer.

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Pornography and attitudes supporting violence against women: revisiting the relationship in nonexperimental studies

Gert Martin Hald, Neil M. Malamuth, Carlin Yuen
University of California, Los Angeles, California
University of Copenhagen, Copenhagen, Denmark
New York University Law School, New York City, New York



Abstract
A meta-analysis was conducted to determine whether nonexperimental studies revealed an association between men's pornography consumption and their attitudes supporting violence against women. The meta-analysis corrected problems with a previously published meta-analysis and added more recent findings. In contrast to the earlier meta-analysis, the current results showed an overall significant positive association between pornography use and attitudes supporting violence against women in nonexperimental studies. In addition, such attitudes were found to correlate significantly higher with the use of sexually violent pornography than with the use of nonviolent pornography, although the latter relationship was also found to be significant. The study resolves what appeared to be a troubling discordance in the literature on pornography and aggressive attitudes by showing that the conclusions from nonexperimental studies in the area are in fact fully consistent with those of their counterpart experimental studies. This finding has important implications for the overall literature on pornography and aggression.

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Monday, December 14, 2009

Global Warming Effects to Mental Health

Climate change has been knock down across the world. Some examples: the increasing frequency of storms, glacier melt quickly, crop failure and rising sea level. Major states of the United States, California, one of the countries that have experienced this misery, from global warming, droughts, heat waves, reduced snow in mountainous areas, etc.

Climate change not only in view of the harsh weather, the more details main effects of global warming is human health. Shift the disease today, especially in the mosquito. Malaria appear in the air because population in certain areas. For example in Africa, because the air is too cold, the mosquitoes are not move up to mountain. But if the air temperature is changed, the mosquitoes will rise higher into the mountains. For example there are several major cities in Africa, namely Nairobi and Harar which was in places up on the mountain to avoid malaria.

Expansion of other disease vectors are:
Increased vomiting due warming aqueduct are enter the result to environment insects growing better. Rising sea levels, caused by the displacement of coastal residents with health-related effect. Improvement in psychological aberration, because climate change could also cause stress to person. Stress is not all negative, and could also encourage a person to act, the possibility is good, but obviously there is the downside. There will be psychological stress on the population of refugee.
As a result of all possible emergence of new lifestyles resulting from climate change are also more real. Some people try to adjusting conditions of the hot weather, for example, more often wear thin clothes, making the house a lot of ventilation, car air-conditioned, etc.
If the global warming problem is not immediately be taken seriously, it does not close possibility of chaos. Chaos is not only environmentally but also in a human. Because everyone wants to get comfortable life. Today, the comfort it must be fought with a variety of ways. Law of the jungle can not even inevitable.

The scientists have seen major impact of climate change on public health's most vulnerable citizens of children in developing countries. There has been systematic research on health effects, because of climate change began in 2000 there were 150,000 premature deaths around the world. Now that the research was on repeat. Will grow the problem is not the 150,000, in the fact that it developed and the suspect will be many. This idea of this impact throughout the word distribution. and 88% of the impacts that are childrens of the world into three, because they are fragile, malnutrition, who had no access to health services, those who live in poor environments. So they will suffer because the health effects of climate change.

The fact is concerned with the health impact of climate change, in fact the children, especially children in Africa, India, and the poorest places in Latin America. And it is because of malaria, vomiting, malnutrition or other effects of health, climate change due to changes in agricultural productivity in areas where sea levels have risen right in the corner of malnutrition.

Climate change will increase water pollution in the open air, especially ozone, because right now it is a function of temperature and sunlight. Before civilization and agriculture all of these things happened within a period of very stable climate in the Holocene call ten thousand years from being born. Previously the ice age. Ice age climate is much more turbulent and there are strong changes; only in a few years the climate will change from one state and then back again.
But at a time when civilization mankind has existed, the climate is very stable and now they threatened to a climate in which human beings as a species never seen before.

But the other, apart from a volcanic explosion that emits large amounts of carbon dioxide, this is a human caused by the accumulation of carbon dioxide gas from fossil that is very high. That matter human right can doubt the amount of carbon dioxide in the atmosphere and compare that with how much fossil fuel that be fueled by human, and it is clear that carbon dioxide levels rise due to human activities. Not because of the volcano or something else like that.

But the effect would be similar to what humans see in the past. The earth will heat up in a similar way and the result will be similar. There used to be a climatic conditions 55 million years ago that the maximum condition called Paleocene-Eocene thermal and so is not clear what happened, but there was some release of carbon dioxide into the atmosphere from the earth quickly, in approximately the instant of ten thousand year, they do not know exactly how much how long in need. But the amount of carbon in the release may be compared with the amount of coal that people have or the amount of methane hydrate. And then the earth heats up and then it took 150,000 years for the climate to recover from it which is the same length that the need for Earth to recover from global warming, too.

Carbon dioxide during the release in the air, it will only accumulate in the atmosphere and ocean system needs a very long time to recover. Earth has a mechanism to stabilize the climate, is like a miracle to imagine, but it looks correct. But these mechanisms to stabilize the climate working very slowly because of ice melting drastically in the summer.

The destruction of the Wilkins ice shelf in the Antarctic in 2008 in which the pieces of ice for 406 square miles of crumbling into the sea. Attract attention and global forces of climate change beyond the level of scenarios. The worst case made by the Intergovernmental Panel United Nations on climate change.

Definition: sea ice plays an important role in climate because the sun reflecting back to sky and when sea ice melts, the sun was shining in the Arctic during the year, for 24 hours a day in summer. So there are lots of sunlight, then it began to absorb sunlight. And it can add to the Arctic climate with a very strong and it indirectly affects the methane gas. And also a layer of ice on the Green Land and the circulation of the North Atlantic and many other things in high places.

Are levels of carbon dioxide in the air right now and anything previously before people realize that there is global warming is in progress. These levels in 1750, no one can measure the levels at the time, but humans have a wave of air trapped in ancient ice cores. So humans can measure and know that at that time before human activities, levels of carbon dioxide is about 280 parts per million. One million molecules of air, 280 of them is carbon dioxide. Which is currently up to 380 or 385.

Before the period of hot climate in the last ice age, levels of CO2 in the air is around 200. So the change from 200 to 280 was enough to change Earth's climate from the ice world in which time there were two miles above the human head. Being interglacial world.

Ice core data that tells us of the value in the year 1750 or the current ice age 800,000 years back and this time CO2 levels much higher than had ever occurred during a period of 800,000 years.

In the history of the earth, mankind has experienced global warming before it. Recovered from humans and humans into the period of glacier ice and humans become hot again.
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Sunday, December 13, 2009

Tiger Woods, Sex and Schizophrenia

Dr. Mark Goulston

According to the Wall St. Journal, it appears that Tiger Woods has put his golf career on hold to focus on his family.

This entire Tiger Woods/sex scandal issue reminded me of something I hadn't thought about in more than 35 years.

In 1973 I was clerking as a medical student at the Topeka State Hospital. One of the psychiatrists there told me that he felt it was a pity to have to seclude any of the schizophrenics who were having sex with other patients.

When I asked him why he said, "Nearly all day long these very troubled people are completely out of touch with the world and with their fellow human beings. When they are engaged in sex with another person, it is one of the only times they are in touch with their human side. And just when they are getting in touch with being human, we go and lock them up in seclusion."

'm not saying Tiger is schizophrenic, however the analogy for him and other incredibly successful, goal minded to a fault, ambitious people is this. When they are in pursuit of their goals and when Tiger has the "eye of a tiger" as he attacks a golf course, they are different than other mere mortals who are all too human when they play golf and see their games fall apart under pressure.

That difference causes them to be out of touch with their humanness. They are more like a machine, a "robogolfer" if you will. And when the pendulum of their minds and being swings too far to that end, it may be that when it comes back it needs to engage in something that is much more human.

Now you may say, why not express that humanness with a gorgeous wife such as Elin? Perhaps one of the reasons for that is that the intensity, adrenaline rush seeking part of Tiger's personality doesn't leave him whether he is on the golfer side of his pendulum or the sexual excitement seeking side.

Just as you can take someone out of the country, but you can't take the country out of that someone; perhaps you can take someone out of their adrenaline addiction, but you can't take the adrenaline addiction out of that someone.

Perhaps the new focus of Tiger's adrenaline addiction will be to repair his marriage, his public reputation (especially in someone so private) and his character flaws. That would be a comeback worthy of a true champion.

Reference: Psychologytoday.com
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Saturday, December 12, 2009

Taking a “Hands On” Approach to Diversity in Higher Education: A Critical-Dialogic Model for Effective Intergroup Interaction

Nicholas Sorensen
University of Michigan

Biren (Ratnesh) A. Nagda
University of Washington

Patricia Gurin and Kelly E. Maxwell
University of Michigan


ABSTRACT

This article reviews divergent empirical evidence on interracial contact. While research on diversity in higher education provides ample evidence for the educational benefits of engaging with diversity in informal interactions or courses, experimental and naturalistic studies in social psychology on interracial interactions reveal a complicated picture, showing what appear to be both positive and negative effects. Rather than addressing the question of whether or not to promote interracial interactions on campus, we present a critical-dialogic model of intergroup dialogue that centers on communication processes as an avenue toward intergroup relationships, understanding, and collaboration. Prior research and preliminary results from a nine-university research collaboration provide strong empirical support for the proposed model. We conclude with program and policy considerations for higher education institutions interested in promoting meaningful intergroup interaction.

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Thursday, December 10, 2009

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Conceptualizing Mental Health Care Utilization Using the Health Belief Model

Erin J. Henshaw and Carol R. Freedman-Doan
Department of Psychology, Eastern Michigan University
Address correspondence to Erin J. Henshaw, Denison University, Department of Psychology, 100 South Loop, Granville, OH 43023. E-mail: henshawe@denison.edu.

ABSTRACT

This article uses the Health Belief Model (HBM; Health Education Monographs, 1974, 2:409) as a framework for explaining what factors might encourage or inhibit an individual from utilizing mental health services. The HBM is a socio-cognitive approach that proposes that people are likely to engage in a given health-related behavior when they believe the problem could have serious consequences for daily living activities, when they believe the intervention will be effective, and when they perceive few barriers to taking action. When applied to mental health utilization, this model provides a structure for developing and evaluating programs designed to increase mental health awareness and appropriate utilization.

Article Text

The process of change in psychotherapy, regardless of the clinician's orientation, length of treatment, or outcome measure, begins with this: The client must attend a first session. However, several national surveys in the past decade converge on a rate of approximately one-third of individuals diagnosed with a mental disorder receiving any professional treatment (Alegría, Bijl, Lin, Walters, & Kessler, 2000; Andrews, Issakidis, & Carter, 2001; Wang et al., 2005). A review of the literature surrounding mental health utilization reveals evidence that a complex array of psychological, social, and demographic factors influence a distressed individual's arrival to a mental health clinic. Thus, developing effective strategies for decreasing barriers to care is a critical task for clinicians and administrators. The

aim of this article was to review current research focused on appropriate utilization of mental health services and to use the Health Belief Model (HBM; Becker, 1974) as a parsimonious model for conceptualizing the current knowledge base, as well as predicting and suggesting future research and implementation strategies in the field.

First, it is important to address whether increasing mental health service use is an appropriate public health goal. A World Health Organization (WHO) survey comparing individuals with severe, moderate, or mild disorder symptoms indicated that approximately half of those surveyed went untreated in the past year (WHO World Mental Health Survey Consortium, 2004), with even less treatment among those with more severe symptoms. Many costs are associated with untreated mental disorders, including overuse of primary care services for a variety of reasons (Katon, 2003; White et al., 2008), lost productivity for businesses and lost wages for employees (Adler et al., 2006), as well as the negative impact of mental disorders on medical disorders, such as diabetes and hypertension (Katon & Ciechanowski, 2002). These com

bined expenses have been calculated to rival some of the most common and costly physical disorders, such as heart disease, hypertension, and diabetes (Druss, Rosenheck, & Sledge, 2000; Katon et al., 2008).

The consequences of providing additional services to address unmet need may vary by the cost-effectiveness of treatment, availability of providers, and the interaction of mental health symptoms with other illnesses. Medical cost offset and cost-effectiveness research address these questions (for further review, see Blount et al., 2007; Hunsley, 2003). Medical cost offset refers to the estimation of cost savings produced by reduced use of services for primary care as a result of providing psychological services. Reduced medical expenses could occur for several reasons: increased adherence to lifestyle recommendation changes such as diet, exercise, smoking, or taking medications; improved psychological and physical health; and reduction in unnecessary medical visits which serve a secondary purpose (e.g

., making appointments to fill social needs; Hunsley, 2003). In comparison with the indirect costs to society, the individual, and the health care system, costs for providing mental health treatment are quite low (Blount et al., 2007).

However, debate continues regarding how to facilitate mental health care utilization. Identification of mental health need through primary care screening for depression is one research area that highlights the complexity of this issue. Palmer and Coyne (2003) point out several important issues in developing a strategy for addressing this goal: First, several studies suggest that identification of depression in primary care is not enough, as outcomes for depression are similar in primary care patients who have detected depression and those who have not (e.g., Coyne, Klinkman, Gallo, & Schwenk, 1997; Williams et al., 1999). This is supported by research indicating a large gap between the number of individuals who are identified through screening and referred to care, and those who actually receive care (Flynn, O'Mahen, Massey, & Marcus, 2006). Second, it is critical to evaluate attempts to increase utilization, rather than to assume they will be successful, cost-effective, and targeting the appropriate individuals. Therefore, a theoretical framework that addresses both psychological and practical factors associated with treatment utilization will be a beneficial addition to this literature.

Little systematic research has been conducted on the specific topic of psychological factors related to seeking mental health services. However, extensive work has been conducted within two broad, related areas of research: help-seeking behavior and health psychology. Many models have been proposed to explain help-seeking and health-protecting behaviors, none of which has been accepted as wholly superior to the rest. The HBM (Becker, 1974; Janz & Becker, 1984; Rosenstock, 1966) is one of several commonly used social-cognitive theories of health behavior. This model will be reviewed, followed by a brief discussion of several other models. A discussion of the strengths of the HBM and its applicability to mental health treatment utilization research will follow.

Health Belief Model

The HBM (Rosenstock, 1966, 1974), based in a socio-cognitive perspective, was originally developed in the 1950s by social psychologists to explain the failure of some individuals to use preventative health behaviors for early detection of diseases, patient response to symptoms, and medical compliance (Janz & Becker, 1984 ; Kirscht, 1972; Rosenstock, 1974). The theory hypothesizes that people are likely to engage in a given health-related behavior to the extent that they (a) perceive that they could contract the illness or be susceptible to the problem (perceived susceptibility); (b) believe that the problem has serious consequences or will interfere with their daily functioning (perceived severity); (c) believe that the intervention or preventative action will be effective in reducing symptoms (perceived benefits); and (d) perceive few barriers to taking action (perceived barriers). All four variables are thought to be influenced by demographic variables such as race, age, and socioeconomic status. A fifth original factor, cues to action, is frequently neglected in studies of the HBM, but nevertheless provides an important social factor related to mental health care utilization. Cues to action are incidents serving as a reminder of the severity or threat of an illness. These may include personal experiences of symptoms, such as noticing the changing shape of a mole that triggers an individual to consider his or her risk of skin cancer, or external cues, such as a conversation initiated by a physician about smoking cessation. In addition, Rosenstock, Strecher, and Becker (1988) added components of social cognitive theory (Ba ndura, 1977a, 1977b) to the HBM. They proposed that one's expectation about the ability to influence outcomes (self-efficacy) is an important component in understanding health behavior outcomes. Thus, believing one is capable of quitting smoking (efficacy expectation) is as crucial in determining whether the person will actually quit as knowing the individual's perceived susceptibility, severity, benefits, and barriers.

Other health care utilization theories

Other models for health care utilization have been proposed and used as a guide for research. In general, these theories pull from a number of learning theories (e.g., Bandura, 1977a, 1977b; Lewin, 1936; Watson, 1925). Two such models, the Theory of Planned Behavior (TPB; Ajzen, 1991) and the Self-Regulation Model (SRM; Leventhal, Nerenz, & Steele, 1984), share many commonalities with the HBM. Ajzen's TPB proposes that intentions to engage in a behavior predict an individual's likelihood of actually engaging in the given behavior. Ajzen hypothesizes that intentions are influenced by attitudes toward the usefulness of engaging in a behavior, perceived expectations of important others such as family or friends, and perceived ability to engage in the behavior if desired (Ajzen, 1991). This theory has been applied to a variety of health behaviors and has receiv

ed support for its utility in predicting health behaviors (Ajzen, 1991; Armitage & Conner, 2001; Godin & Kok, 1996). However, its relevance in predicting mental health care utilization has received relatively little attention (for two exceptions, see Angermeyer, Matschinger, & Riedel-Heller, 1999; Skogstad, Deane, & Spicer, 2006). Similarly, the SRM (Leventhal et al., 1984) focuses on an individual's personal representation of his or her illness as a predictor of mental health treatment use. The SRM proposes that individuals' representation of their illness is comprised of how the individual labels the symptoms he or she is experiencing, the perceived consequences and causes of the symptoms for the individual, the expected time in which the individual would expect to be relieved of symptoms, and the perceived control or cure of the illness (Lau & Hartman, 1983).

The HBM, TPB, and SRM are well-estab

lished socio-cognitive models with similar strengths and weaknesses. The models assume a rational decision-making process in determining behavior, which has been criticized for not addressing the emotional components of some health behaviors, such as using condoms or seeking psychotherapy (Sheeran & Abraham, 1994). There is substantial overlap in the constructs of these three models. For example, an individual's perception of the normative beliefs of others can be seen more generally as a benefit of treatment (e.g., if I seek treatment my friends will support my decision) or as a barrier (e.g., my family will think I am crazy if they know I am seeking professional help). The SRM lacks a full description of the benefit and barrier aspects of decision making identified in the HBM. However, the illness perceptions about timeline, identity, and consequences do provide a more complete conceptualization of aspects of perceived severity, and in this way the SRM can inform the HBM with these factors.

Andersen's Sociobehavioral Model (Andersen, 1995) and Pescosolido's Network Episode Model (Pescosolido, 1992; Pescosolido, Brooks Gardner, & Lubell, 1998) emphasize the role of the health care and social network system in influencing patterns of health care use, while Cramer's (1999) Help Seeking Model highlights the role of self-concealment and social support in decisions to seek counseling. In particular, the Network Episode Model hypothesizes that clear, independent choice is only one of seve

ral ways that clients enter treatment, along with coercion and passive, indirect pathways to care. According to Cramer's model, individuals who habitually conceal personally distressing information tend to have lower social support, higher personal distress, and more negative attitudes toward seeking psychological help. Thus, according to this model, self-concealment creates high distress, which pushes an individual toward seeking treatment, but also creates negative attitudes toward treatment, pushing an individual away from treatment. The HBM includes system-level benefits and barriers to utilization, but these three models more fully emphasize the social-emotional context of decision making.

Critiques and limitations of the HBM

The HBM has received some criticism regarding its utility for predicting health behaviors. Ogden (2003), in a review of articles from 1997 to 2001 using social cognition models, questions whether the theory is disconfirmable. She found that two-thirds of the studies reviewed found one or more variables within the model to b

e insignificant, and explained variance accounted for by the model ranged from 1% to 65% when predicting actual behavior. Yet, Ogden writes, rather than rejecting the model, the majority of authors offer alternative explanations for their weak findings and claim that the theory is supported. While authors' conclusions about their findings may be overstated in many cases, some explanations of insignificant findings are valid limitations of the model. For example, some (e.g., Castle, Skinner, & Hampson, 1999) point out that construct operationalization could be improved for the particular health behavior being studied. However, insignificant results should not be explained away without considering alternative models as well. Certainly, the HBM has received strong support in predicting some health behaviors (Aiken, West, Woodward, & Reno, 1994; Gillibrand & Stevenson, 2006), but questions remain as to its ability to predict all preventative health situations. The usefulnes

s of the HBM in predicting mental health utilization has not adequately been tested to our knowledge.

The HBM may be limited further by its ability to predict more long-term health-related behaviors. For example, from an early review of preventive health behavior models including the HBM by Kirscht (1983), we can anticipate that the factors associated with initiating treatment, as discussed here, may differ from the factors that predict mental health treatment adherence and engagement. Thus, these outcomes—attending one therapy appointment versus completing a full course of psychotherapy treatment—should be clearly distinguished from each other.

Strengths of the HBM

Researchers have not explicitly investigated mental health utilization patterns using the HBM framework; however, much of the

existing literature can be conceptualized as dimensions of severity, benefits, and barriers, indicating that the model may be a useful framework for guiding research in this area. For example, cultural researchers often examine barriers to treatment and perceived severity of symptoms and benefits of treatment in various ethnic populations (e.g., Constantine, Myers, Kindaichi, & Moore, 2004; Zhang, Snowden, & Sue, 1998). In general, the focus of these studies has been to examine cultural differences in beliefs about symptom causes (Chadda, Agarwal, Singh, & Raheja, 2001), changing perceptions of mental health stigma among various ethnic groups (Schnittker, Freese, & Powell, 2000), and cultural mistrust or perceived cultural insensitivity of mental health providers as a barrier to effective treatment (Poston, Craine, & Atkinson, 1991). These studies lay the groundwork for using the HBM as a framework for understanding mental health care utilization for all populations.

Parsimonious and Clear

The model's use of benefits and barriers opposing each other provides a dynamic representation of the decision-making process. In this "common sense" presentation, the impact of each positive aspect is considered in the context of the

negative aspects. The model in this way provides a parsimonious explanation of a variety of constructs within one clear framework.

Useful and Applicable

One strength of focusing on attitudes and perceptions related to treatment seeking is the clinical utility of such models. By identifying attitudes that may inhibit appropriate help seeking, psychologists can then use research findings to develop interventions for addressing maladaptive attitudes or inaccurate beliefs about mental health and its treatment. Therefore, socio-cognitive theory provides a useful focus for research that ultimately may result in programmatic changes to benefit clients. Once developed, perception-change interventions can be evaluated through changes in observed treatment utilization.

Within the HBM framework, three general approaches can be used to increase appropriate utilization: increasing perceptions of individual susceptibility to illness and severity of symptoms, decreasing the psychological or physical barriers to treatment, or increasing the perceived benefits of treatment. The following discussion will highlight how each perception can be increased or decreased, and the implic

ations for such intensification of the perceptions. Examples of intervention strategies that can serve as individual or system-level "cues to action" will be reviewed within each domain of the model. In addition, where appropriate, the discussions will highlight how sociodemographic factors such as age, sex, and ethnicity impact the perceived threat from the disorder and the expectations for the benefits of therapy. The model we discuss assumes that the individual seeking therapy is autonomous in this decision making. That is, it is not directly applicable to those who are required to seek therapy by the judicial system, a spouse, or their place of employment, nor does it address children's mental health care utilization. We will address some of these issues briefly later in our discussion.

Figure 1 is a visual representation of the model we propose for conceptualizing mental health care utilization using the HBM as a framework. The studies reviewed in each section below were designed primarily without use of the HBM framework. However, the model is a useful heuristic tool to organize and draw in research from a variety of disciplines—marketing, public health, psychology, medicine, etc.


Sociodemographic variables in the HBM

Several demographic variables consistently predict utilization of mental health services. Despite similar levels of distress, some groups are less likely to seek professional treatment than others, creating a gap between need and actual use of outpatient mental health services. Groups identified as consistently underutilizing services include men, adults aged 65 and older, and ethnic minority groups in the United States (Wang et al., 2005). Within the HBM framework, these demographic variables are hypothesized to influence clients' perceptions of severity, benefits, and barriers to seeking professional mental health services. Studies exploring the relationship between demographic variables and HBM constructs will be highlighted throughout this article.

Systems approaches to addressing perceived susceptibility and severity

According to the HBM, individuals vary in how vulnerable they believe they are to contracting a disorder (susceptibility). Once diagnosed with the disorder, this dimension of the HBM has been reformulated to include acceptance of the diagnosis (Becker & Maiman, 1980). In addition, increasing an individual's perception of the severity of his or her symptoms increases the likelihood that he or she will seek treatment. In relation to mental health, perceived susceptibility goes hand in hand with perceived severity (i.e., Do I have the disorder and how bad is it?), and so they will be discussed together. In health-related decisions, the majority of consumers are dependent upon the expertise and referral of the medical professional, usually the trusted general practitioner (Lipscomb, Root, & Shelley, 2004; Thompson, Hunt, & Issakidis, 2004). Unlike decisions about the need for a new vehicle or a firmer mattress, determining whether or not feelings of sadness should be interpreted as normal emotional fluctuation or as indicators of depression is a decision often left to an expert in the area of mental health or a primary care physician. This places a great responsibility on practitioners, psychiatrists, psychologists, and other mental health service providers when discussing the severity of a client's symptoms and options for treatment.

Ethical Considerations in Increasing Perceived Severity and Symptom Awareness

The American Psychological Association (APA) provides ethical guidelines for clinicians about how to inform the public appropriately about mental health services. According to the 2002 Ethics Code (American Psychological Association, 2002), psychologists are prohibited from soliciting testimonials from current therapy clients for the purpose of advertising, as individuals in such circumstances may be influenced by the therapist–client relationship they experience. Additionally, psychologists are prohibited from soliciting business from those who are not seeking care, whether a current or potential client. This may include a psychologist suggesting treatment services to a person who has just experienced a car accident or handing out business cards to individuals at a funeral home. However, disaster or community outreach services are not prohibited, as these are services to the community. Psychologists are prohibited from making false statements knowingly about their training, credentials, services, and fees, and are also prohibited from making knowingly deceptive or exaggerated statements about the success or scientific evidence for their services. In this way, limits are placed on the influence of practitioners on those in vulnerable situations.

Identification of Symptoms

What, then, does an ethical symptom awareness intervention look like? It would involve clearly differentiating between clinical and nonclinical levels of distress, with an indication of what types of intervention strategies may be most effective for each. For example, in cases of mild symptomatology, individuals may be encouraged to use a stepped care approach beginning with bibliotherapy, psychoeducation, and increases in social support. Also important is the provision of accurate, research-based information regarding symptoms of psychological disorders and treatment options. This may call for challenging our assumptions that psychotherapy is helpful for all psychological distress. Recent studies of grief counseling and postdisaster crisis counseling, for example, suggest there may be an iatrogenic effect of therapy for some individuals (Bonanno & Lilienfeld, 2008). On the other hand, some research indicates that individuals with subclinical levels of distress who receive treatment early may avoid developing more severe pathology (e.g., prodromal psychosis; Killackey & Yung, 2007). In programming for all components of health beliefs, not just severity, the credibility of psychotherapy is dependent upon ethical, appropriate public health statements and service marketing.

Many examples of mental health education campaigns have been discussed in the literature, often focusing simultaneously on increasing awareness of mental illness, destigmatizing individuals with mental illness, and increasing awareness of mental health resources. The Defeat Depression Campaign of the UK was designed with these goals in mind, and results of nationally representative polls before, during, and after the campaign indicated positive changes in public attitude toward depression and recognition of personal experiences of symptoms (Paykel, Tylee, & Wright, 1997). Similarly, more recent national campaigns in Australia have provided some evidence that education increases public accuracy in identifying mental illness (Jorm & Kelly, 2007). National screening day initiatives for depression, substance abuse, and other psychological disorders also aim to increase awareness of illness severity for individuals who may not recognize symptoms as signs of illness warranting treatment.

Approximately 71% (Lipscomb et al., 2004; Thompson et al., 2004) of individuals report looking to their primary care physician for mental health information, treatment, and referrals. However, many physicians lack the appropriate knowledge to identify mental health problems (Hodges, Inch, & Silver, 2001). After examining five decades (1950–2000) of articles evaluating the adequacy of physician training in detecting, diagnosing, and treating mental health, Hodges et al. (2001) offer several suggestions for improving primary care physicians' training to effectively identify patients with mental health issues. Beyond learning the diagnostic criteria for the major disorders and providing appropriate medications when needed, however, physicians also need to be aware that they can act as a "cue to action" in the patient seeking psychotherapy. Such cues would alert the patient that his or her symptoms of distress or depression had reached severe levels and that the trusted family physician believes additional treatment is needed.

Influence of Demographic Variables on Perceived Severity

An individual's personal label of the symptoms and illness are thought to contribute to perceived severity. In a study of four large-scale surveys of psychiatric help seeking, Kessler, Brown, and Broman (1981) found that women more often labeled feelings of distress as emotional problems than men did, a factor thought to help explain the consistent finding that men seek mental health services less often than women even when experiencing similar emotional problems. Similarly, Nykvist, Kjellberg, and Bildt (2002) found that among men and women reporting neck and stomach pains, women were more likely to attribute pains to psychological distress, while men were more likely to indicate no significant cause and little concern regarding the somatic symptoms.

Relatively little research has been conducted regarding how individuals of diverse backgrounds perceive the severity of their mental illness symptoms. However, some evidence suggests that individuals of different ethnic backgrounds appraise the severity of their illness symptoms differently, such that individuals from minority cultures are more influenced by their own culture's norms about mental illness symptoms than White Americans (Dinges & Cherry, 1995; Okazaki & Kallivayalil, 2002). Cues to action from providers may be more effective if they are framed in a way that is congruent with individuals' attributions about symptoms. In other cases, education about symptoms, provided in a culturally sensitive manner, may be necessary. This is an area where additional research is needed to determine practice.

Older adults are more likely to seek treatment when they perceive a strong need for treatment (Coulton & Frost, 1982). However, some aspects of aging may influence whether or not older adults perceive ambiguous symptoms as psychological in nature or due to physical ailments. For example, among older adults, particularly those experiencing chronic pain or illness, somatic symptoms of mental illness may be interpreted as symptoms of physical illness or part of a natural aging process, rather than as symptoms of depression or anxiety (Smallbrugge, Pot, Jongenelis, Beekman, & Eefsting, 2005). In this way, some depression symptoms may be overlooked by older individuals and the physicians who see them (Gatz & Smyer, 1992).

Systems approaches to addressing perceived benefits

Even if clients do view their symptoms as warranting attention, they are unlikely to seek treatment if they do not believe they will benefit from professional services. Thus, increasing perceived benefits of treatment is a second approach to increasing appropriate utilization.

Public Perceptions of Psychotherapy

In response to changing health care markets, the 1996 APA Council of Representatives called for the creation of a public education campaign to inform consumers about psychological care, research, services, and the value of psychological interventions (Farberman, 1997). Results of preprogram focus group assessments indicated that participants were frustrated with changes in health care service delivery in the United States and many participants did not know whether their health insurance policy included mental health benefits. Participants indicated that they did not know when it was appropriate to seek professional help, and often cited lack of confidence in mental health outcomes, lack of coverage, and shame associated with help seeking as main reasons for not seeking treatment. Participants reported that the best way to educate the public about the value of psychological services was to show life stories of how they helped real people with real-life issues. Informed by the focus groups and telephone interviews, APA launched a pilot campaign in two states using television, radio, and print advertisements depicting individuals who have benefited from psychotherapy, as well as an 800 telephone number, a consumer brochure, and a consumer information website. During the first six months of the campaign, over 4,000 callers contacted the campaign service bureau for a referral to the state psychological association to request campaign literature, with over 3,000 people visiting the Internet site weekly (Farberman, 1997). In sum, addressing perceived benefits of treatment means answering the question, "What good would it do?" When individuals are made aware of how treatment could improve their daily functioning, they may be more motivated to overcome the perceived barriers to treatment. Especially for individuals who have not previously sought mental health treatment, describing realistic expectations for treatment may be an essential first step in orienting individuals to make informed treatment decisions.

Public Preference for Providers of Care

Many different types of professionals serve as mental health service providers, and individuals' beliefs about the relative benefit of seeking help from various lay and professional sources likely impact decisions to seek help. Roles have shifted in treatment over time, with the introduction of managed care and the increased role of the PsyD, master's-level psychologist or counselor, and MSW as treatment providers. Counseling has been considered a primary role of clergy for many decades; however, specificity of counseling training has changed over time, with some clergy receiving specific training as counselors within seminary education. Primary care physicians have been relied upon for treatment through pharmacotherapy with the development of improved medications for depression, anxiety, and attention deficit hyperactivity disorder, among others. While few primary care physicians conduct traditional therapy sessions, many individuals report that they first share mental health concerns with their primary care physician, making this profession an important potential gateway for psychotherapy (Mickus, Colenda, & Hogan, 2000).

Level of distress may also influence where individuals seek help: Consumer Reports' popular survey of over 4,000 participants found that individuals tend to see a primary care physician for less severe emotional distress and seek a mental health professional for more severe distress (Consumer Reports, 1995), while Jorm, Griffiths, and Christensen (2004) found that individuals with depressive symptoms were most likely to use self-help strategies in mild to moderate levels of severity and to seek professional help at high levels of severity.

Some support has been found for the importance of a match between individuals' perceptions of the cause of symptoms and the type of treatment they seek. In a German national survey, perceptions of the cause of depression and schizophrenia significantly predicted preferences for professional or lay help. Those who endorsed a biological cause of illness reported they would be more likely to advise an ailing friend to seek help from a psychiatrist, family physician, or psychotherapist, and less likely to advise seeking help from a confidant. Perceptions of social-psychological causes of illness, such as family conflict, isolation, or alcohol abuse, were related to advising a confidant, self-help group, or psychotherapist rather than a psychiatrist or physician (Angermeyer et al., 1999).

Demographic Variables and Perceived Benefits

Perceptions of mental health treatment as beneficial are likely shaped by cultural influences as well as an individual's personal experience. In a subset of randomly selected individuals from a nationally representative survey, Schnittker et al. (2000) compared Black and White respondents' beliefs about the etiology of mental illnesses and their attitudes toward using professional mental health services. Black respondents were more likely than White respondents to endorse views of mental illness as God's will or due to bad character, and less likely to attribute mental illness to genetic variation or poor family upbringing. These beliefs predicted less positive views of mental health services, and the authors found that more than 40% of the racial difference in attitudes toward treatment was attributable to differences in beliefs about the cause of mental illness.

Older adults' reluctance to seek psychological services has been connected with more negative attitudes toward psychological services (Speer, Williams, West, & Dupree, 1991). Attitudes toward psychotherapy appear to improve by aging cohort, however. Currin, Hayslip, Schneider, and Kooken (1998) assessed dimensions of mental health attitudes among two different cohorts of older adults and found that younger cohorts of older adults hold more positive attitudes toward mental health services. Thus, attitudes among older adults may be less attributable to age than to changing cultural acceptance of mental illness over time. Older adults who have engaged in professional psychological treatment tend to see mental health treatment as more beneficial than their counterparts who have never sought treatment (Speer et al., 1991).

Across diverse religious orientations, beliefs in a spiritual cause of mental illness have been associated with preference for treatment from a religious leader rather than a mental health professional (Chadda et al., 2001; Cinnirella & Loewenthal, 1999). For individuals who interpret psychological distress symptoms as spiritually based, a religious leader may be viewed as a more beneficial provider than a traditional mental health professional. Some clients prefer to see clergy for mental health concerns. Some psychologists have formed relationships between religious organizations and mental health providers to foster collaboration and access to many care options for community members (McMinn, Chaddock, & Edwards, 1998). Benes, Walsh, McMinn, Dominguez, and Aikins (2000) describe a model of clergy–psychology collaboration. Using Catholic Social Services as a medium through which collaboration took place, psychologists, priests, religious school teachers, and parishioners collaborated through a continuum of care beginning with prevention (public speaking about mental health topics, parent training workshops) through intervention (1-800 access numbers, support groups, and counseling services). The authors note that bidirectional referrals—not simply clergy referring to clinicians—and a sharing of techniques and expertise are keys to the success of such programs. Providing care to individuals through the source that they consider most credible or accessible is an innovative strategy for increasing perceived treatment benefits and decreasing barriers

Marketing Psychological Services

While the idea of marketing psychological services may seem unappealing to some psychologists, marketing strategies designed to encourage appropriate utilization may serve as both a strategy for the field of psychology as well as an outreach service to improve public health. In order to benefit from psychotherapy, individuals must view it as a legitimate way to address their problems. Strategies may include marketing psychological services at a national level, such as the APA's 1996 public education campaign (Farberman, 1997); at a group level, such as a community mental health system providing rationale for increased funding; or at an individual level, such as an independent private practitioner seeking to increase referrals. Two theories, social marketing theory and problem-solution marketing, are useful models for developing effective mental health campaigns.

Social Marketing Theory

Rochlen and Hoyer (2005) identify social marketing theory as a framework for identifying strategies specifically aimed at changing social behaviors. Three principles define social marketing: negative demand, sensitive issues, and invisible preliminary benefits (Andreason, 2004). Negative demand describes the challenge of selling a product (psychotherapy, in this case) that the individual does not want to buy. In the case of individuals who see therapy as unhelpful or a frightening experience, addressing negative demand would include considering the viewpoint of a reluctant audience and perhaps utilizing the Stages of Change model (Prochaska & DiClemente, 1984), in which the goal of the marketing campaign would be to move an individual from the precontemplation stage to the contemplation stage of change. Social marketing theory also takes into account the degree of sensitivity in the task being encouraged; that is, seeking psychotherapy requires a greater amount of mental energy and vulnerability than less sensitive purchases, such as a new motorcycle. The principle of invisible preliminary benefit reminds those marketing psychological services that the benefits of choosing to seek psychological help are often not seen immediately, as they are when receiving a pain medication. Therefore, marketing strategies for mental health must make consumers aware of psychotherapy's benefits and the long-term prospect of improving quality of life.

Reference: wiley.com

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