National Institute of Mental Health Obstacles in the Pathways to Prepaid Mental Health Care U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION Obstacles in the Pathways to Prepaid Mental Health Care | Melvin A. Glasser, LL.D. Thomas J. Duggan, Ph.D. William S. Hoffman, Ph.D. Michigan Health and Social Security Research Institute, Inc. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute of Mental Health 5600 Fishets Lane Rockville, Maryland 20857 PUBLIC 14425 wea? PUBL This report was prepared by Michigan Health and Social Security Research Institute, Inc., under Grant 5 R12 MH20373-02 from the National Institute of Mental Health. The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of the National Institute of Men- tal Health of the U.S. Department of Health, Education, and Welfare. DHEW Publication (ADM) 76-383 Printed 1977 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 Stock No. 017-024-00597-5 FOREWORD The relevance of identifying specific obstacles to the use of mental health services is a timely topic which becomes more significant as union-negotiated mental health benefits spread. In order to investigate barriers to treatment, a Michigan community was selected as a study site on the basis of two general criteria: a large concentration of United Auto Worker (UAW) members and a variety of mental health facilities. The research was conducted primarily to determine which factors served to prevent UAW workers and their families from more effectively utilizing mental health services. It is most appropriate, therefore, that the National Institute of Mental Health publish at this time a highly relevant study on the barriers to utilization of pre- paid mental health care which can be identified and examined within a model of a service delivery system. This study represents the work, over a 2-year period, of an outstanding and highly experienced group of experts who studied and researched barriers to utilization of prepaid mental health benefits system- atically from the perspectives of potential users of service, potential referrers to service, and providers of service. As part of the study, the researchers col- lected data which will provide a basis for a practical program to counteract barriers to prepaid mental health care and thus facilitate the linking of potential users to the providers of service as a means of increasing the potential use of these services. The findings of the sample survey of UAW workers in the State of Michigan will be particularly useful inasmuch as previous studies of obstacles in the pathways to mental health care were conducted in hospital settings and con- tained no reference to outpatient treatment. It is the hope of the Institute that the material presented in this study will be of increasing interest to the mental health field as National Health Insurance comes closer to a decision in the Congress. Bertram S. Brown, M.D. Director National Institute of Mental Health iii th D 7116 A83 U634 PUBL Foreword Chapter 1 Chapter 2: Section Section Section Section Section Section Section Section Section TABLE OF CONTENTS : Introduction and Background ............ccceeeiiiiiiiiiieiniieeeeieee TRE WOTKEIS «cee e eee ee ee eeeenanaas : Who Are the WOrKers? .......ocoeeeeeiiiiiiiiieeeeeeeeeeeeeeenn Il: Awareness of Services Available ...........cccoocvvveeveeeeeennnn.. lll: Evaluation of Services Available .............cccouvvvveereeeenen.... IV: Awareness of Insurance Benefits ..........cccoovvvvevreeereen..n. V: Definitions of Need for Mental Health Treatment ......... VI: Identification of Potential Obstacles to Treatment ....... VII: Personal Problems of Workers ..........cccccoevvviiiiiiieivnnnnnnn. VIII: Experience With and Perceptions of Treatment ........... IX: The Workers Viewed as Referral Agents ...................... Chapter 3: The Referral AGents .........cccoooiiiiiiiiiiniienieeeeeeee eee Section |: Section Section Section Section Section Section Section Section : Professional and Nonprofessional Agents .................... Il: Awareness of Services Available ............cccccecvveiniiennnns lll: Evaluation of Services Available ...........ccccccccoviiiiniieennns IV: Referral Agents’ Knowledge of Workers’ Eligibility for Mental Health Benefits .........ccccccviiiiiiiiiiiiiiiiiceeceeeee, V: Definitions of Need for Treatment ............ccccceeeirennenn. VI: Identification of Potential Obstacles to Treatment ....... VII: Perceptions of Causes for Workers’ Emotional Problems ....ccooueiiiieieee eee VIII: Referral Agents’ Personal Experience With Mental Haalth TrRatMBNL .......cccconsmssiimmmsssesssssnsesesmssinmissimms IX: Referral Agents’ Experience With Referral Activities ... ChAapler 4: TRE PrOVIGBIS ..cuivcinssnissismnsssismmssmmmsmmsmssimss issn aiuiaians Section Section Section Section Section Section Section Section Section Section I: Representation of Various Fields ..........ccccooviinnnnnnn. I: Awareness of Available Services .........ccccoovvvvevveeeeeeeennn. lll: Evaluation of Available Services .........ccccccceveveeeeeeeeeeeennnns IV: Awareness of Insurance Benefits .........ccccceveeeeeeeeeeeeennnnns V: Definition of Need for Mental Health Treatment ........... VI: Identification of Potential Obstacles to Treatment ....... VII: Providers’ Perception of the Workers’ Problem Areas . VIII: Providers’ Experience in Treating Those Eligible for the UAW Mental Health Benefits .......cccevveeeeeeivnnnnnnnnn. IX: The Treatment Characteristics of the Providers’ PRACTICE: i... sonsnsssansisessssmiadiinsinns ainsi primp nmi S av LaCie X: Providers’ Experience With and Evaluation of the Prepaid Mental Health Program ...........cccccociiiiinnnns Vv TABLE OF CONTENTS Page Chapter 5: Comparison of the Workers, Referral Agents, and Providers 85 Section I: Knowledge of Available Services ...........ccccceeveeiienuennnnn. 85 Section II: Evaluation of Available Services .........ccccccovvvveiveeeecnnnn. 85 Section lll: Knowledge of the Benefits ..........cccocoiiiiiiiiiiiiicennee 86 Section IV: Definition of Need for Treatment ...........cccceeeeeieeeeeeennen.n. 87 Section V: Identification of Potential Obstacles to Treatment ....... 89 Section VI: The Identification of Workers’ Problem Areas .............. 92 Section VII: Attitudes Toward Mental Health ............c...cccoeevieeennn.. 93 Chapter 6: Summary and CONCIUSIONS ........ccccevieuieeeieieieierieereee eee 95 BIBHOGIAPINY cosivmisimmimmummsmmmsamm mss imam a Ts SATs 101 APPENAIX eevee ete ete ete ete ese e esate sees esate ese se ese se sense se stent ese nese aren eneas 105 vi CHAPTER 1: INTRODUCTION AND BACKGROUND This study grew out of a background which encompassed several years. As is now well known, the United Auto Workers successfully negotiated a health benefit in 1964 to provide pre- paid mental health services to its members and their dependents. The purpose of the benefit was to virtually eliminate financial barriers to this form of service, which is ordinarily excluded in basic health insurance coverage. By reducing such financial deterrents, it was assumed that a large working-class population could be benefited by provision of mental health services on an outpa- tient basis. As this form of benefit was quite innovative, it aroused considerable attention, and plans were laid to monitor the use of these new benefits. Such research, it was believed, would help to es- tablish guidelines and provide useful figures on the rates of utilization for such a program of ben- efits. Such data were deemed essential because neither providers of mental health services nor insurance carriers had any real large-scale experi- ence in this area. As a response to this situation, the Michigan Health and Social Security Research Institute in Detroit received a grant from the Na- tional Institute of Mental Health to study the use of this benefit and its effects and to plan for addi- tional research in areas adjudged by evidence from that study to be most promising. The funded research focused on the use of these services from the initiation of the benefit on September 1, 1966, through December 31, 1969. A basic conclusion of that research was that this program of benefits was indeed economically fea- sible. While that result may be considered noteworthy in itself because of the uncertainty surrounding the planning and initiation of these benefits, it also suggested a negative factor. Because rates of utilization of the prepaid mental health services were quite low, reaching only slightly above 1 percent by 1969, the question naturally was raised about these utilization rates in view of the much higher estimates of need for mental health care in the population, In short, a gap was reasoned to exist between need and use even when financial considerations were virtually eliminated. One could rationalize this gap by the cliche answer of a ‘“‘working-class stigma attached to mental health care.”” But the Research Institute staff believed that such a stigma was only one of many factors separating people with problems from providers of care for those problems—that is, it was one of many potential obstacles in the pathways to men- tal health care and those obstacles would require systematic study to assess their effects. Accordingly, the present study was designed, submitted, and funded by NIMH. In an oversim- plified form, it established a model of the path- ways to mental health care. The model consisted of three categories of people: workers (or people who suffer from problems), providers of service who can alleviate those problems, and people with whom the workers talk about their problems (or potential sources of referral). The model suggests a two-step process in link- ing the person who has the problem to the pro- vider of service. In order for this process to operate effectively, each category of individuals should have the same, or at least similar, understandings. For example, if potential sources of referral do not define a worker’s problem as needing profes- sional help, the process ends at that point. If the potential source of referral does not know the name or location of a provider of service, again the process breaks down. Of course, many other examples can be drawn upon to illustrate other possible breakdowns or obstacles in the process of linking the potential patient with the provider of care. The information for this research project was obtained from two sources. First, conversations with people involved in the implementation of the UAW mental health service program indicated that appropriate services and resources were not always being utilized or referred to when indi- vidual needs for service were made evident. Sec- ond, the feeling that people needing mental health treatment somehow have a stigma attached to them had to be dealt with. The idea that this feel- ing was the chief reason for not using mental health services turned out to be an oversimplica- tion of a more complex situation. Indeed, a re- view of the literature on pathways to mental health care revealed that little was really known about the obstacles to receiving such service. INTRODUCTION AND BACKGROUND Accordingly, a project was designed to attempt to identify some of the general obstacles in the pathway to mental health care. The main catego- ries were awareness of benefits and treatment resources, definitions of need for care, belief in the usefulness of such care, and understandings of the cost factors involved. As to the definition of need for treatment for nervous and mental conditions, the degree to which the definitions of need for treatment vary in the three segments is certain to form a signifi- cant obstacle to mental health service. There were valid and reliable instruments to measure this concept, such as the vignettes developed by Star! which were easily adapted to this study. The second basic concept was the availability of services. ‘‘Availability’’ means several things in addition to the number of treatment resources in a community and their visibility. What are the efforts required for a wage earner to get into treatment and what are the efforts he is willing to put forth to get into treatment? What are the de- lays encountered in getting into the treatment sys- tem and how do these affect the wage earner’s views of the efforts wage earners should be will- ing to exert? This area constitutes a potentially significant barrier to treatment in view of the “‘now’’ orientation of the blue-collar population. Another basic concept was the belief in the efficacy of treatment. Do the three involved seg- ments have harmonious or conflicting views of the efficacy of mental health care? Do wage earners prefer other channels of counseling, for example, clergymen? Do solo-practice psychiatrists want wage-earner patients and do they believe they can treat them successfully? Many sources cited working-class cultural differences and lifestyle as constituting a problem in therapy. Further, how do providers view this situation in the light of a benefit designed for short-term treatment? This is especially relevant in view of the potential user’s choice between care in solo practice, where there is a reverse deductible copayment, or in approved group facilities, which emphasize the team ap- proach to mental health service and which do not have the copayment requirement. A further concept was the anticipated cost of mental health care. The UAW benefit has a re- verse deductible for services received from a psy- chiatrist in private practice. Babysitters may be needed; driving and parking may cost money, as would public transportation. Does the potential consumer view these as a hindrance? There are also noneconomic costs involved, such as leisure time lost and the anticipation of long-term treat- ment. All of these factors may serve as obstacles to treatment, even more so if referrers and poten- tial users perceive them differently. Finally, we must refer to the basic matter of awareness of the provisions of the benefit. All segments of the sample can be measured on their knowledge of these provisions, their knowledge of the choices open to users of service, their attitude toward these provisions, and their opinions on how to extend knowledge of these provisions. For preventive use of mental health services and for early detection of problems, awareness must precede the use of services. Some practical illustrations of the preceding concepts may serve to emphasize their cogency and their varying definitions and the need for ask- ing different but related questions of each seg- ment of the sample. These illustrations were a sampling of the behind-the-scenes observations of a senior staff member of the Research Institute. First, quite obviously it would be inappropriate, without modification, to query providers of care with the vignettes of Star,2 but both potential users of service and referrers to service could profitably be interviewed by means of these items. Further, consider the case of the worker who performed his job adequately but talked to the machines, thus upsetting his fellow workers. The insurance committeeman in this case recog- nized a need for care, but the worker did not. Even for the union officer this raised a deeper question: “How do you walk up to this guy and tell him he ought to go to a psychiatrist?’’ This question, of course, is an oversimplification of the referral process, but it epitomizes an all-too- common situation, a recognition that something should be done, but not a full realization of the need for doing something and the treatability of conditions such as this. For individuals inexperienced in the mental health service system, the simple matter of where to look for services available under the benefit can become a complex problem. Comparatively few wage-earner families have regular family doc- tors. Reliance on the yellow pages of the tele- 1. Star, Shirley A., ‘The Public Ideas About Mental Iliness,”’ Paper presented at the Fifth Annual Meeting of the National As- sociation for Mental Health, Indianapolis, Nov. 4, 1955. 2. Ibid. INTRODUCTION AND BACKGROUND phone book has been cited as a frequent pathway to treatment. It has been discovered from direct contact with detectors (union insurance commit- teemen and community referral agents such as school social workers, family service workers, and others) that there is frequently a vague awareness on the part of these potential referral agents about the existence of a mental health benefit for the UAW families but considerable confusion as to how and where it can be used. For example, in a large school system where many youngsters were from UAW families, a worker was hired .specifically to provide some coordination for referral of such children. Al- though this person was engaged a few years after the benefit had been in operation, and although ostensibly he was supervised by a professional with experience relative to all referrals, and to UAW referrals in particular, after several weeks on this new job the coordinator made a call to a UAW contact to inqure what the UAW wanted to do with the referrals now that he had managed to find some! The nature and anatomy of the wage-earner family members’ belief in the efficacy of measures to improve mental health required study. Exam- ples range from a somewhat magical concept that miracles can be performed quickly to a disbelief that any efforts can bring positive results. For example, a lifetime labor leader working in a stra- tegic spot in a community welfare-planning struc- ture with specific responsibility for labor liaison, including tasks of referral to mental health re- sources, expressed a belief that most labor people had tried their best to cooperate with mental health professionals but that the mental health experts didn’t seem to ‘‘cure’’ anybody. Con- versely, representatives from mental health re- sources have consistently cited initial experiences with wage-earner families which were character- ized by expectations of immediate, quick, tangible relief such as could be expected for a broken arm or an aching tooth. Others cited the effects of lifestyle and value systems on the use of mental health resources as being related to a fundamen- talist type of religious orientation held by many wage-earner family members. Belief that behavior is directly influenced by a deity with an attendant system of rewards and punishments, often sup- ports doubts about the efficacy of mental health concepts and methods. Another aspect of the complexities of the belief in efficacy as influenced by the particular value systems of wage-earner families has been cited by clinicians at widespread locations. This phenome- non is seen in the newfound independence of the wage-earner’s wife, who, after an early marriage and period of child-rearing, realizes when she enters the employment situation that she no long- er has to put up with aspects of a marraige that prior to economic independence were seen as unchangeable. Conflicts about the efficacy of men- tal health intervention have been noted as varying from ‘‘you make my husband over and quickly’ to emotional breakdowns on the part of women because of guilt over their conflicting emotions. Belief in efficacy is seen as a factor here in either expecting too much too quickly or reluctance to make use of help when it is sought. Experienced workers in mental health settings from a wide variety of locations have consistently cited examples, from their contacts with UAW families, that the discovery that a heavy out-of- pocket expenditure was not necessary in order to seek help can result frequently in the end of citing financial hardship as a pretext for resistance. Cli- nicians indicate that this change occurs only through acquisition of knowledge that prepayment covers the service being offered. It has also been a widespread experience that many UAW poten- tial users are informed about the existence of a benefit for mental health care but are confused or puzzled by the specifics of the benefit even if they do know that it exists. The clinician who is so- phisticated about this part of the benefit can help the potential user in overcoming his remaining resistances at a more realistic level. It has also been observed that wage-earner fam- ilies are sometimes presented with an obstacle to their use of their mental health benefits by the presumption on the part of detectors and pro- viders that they do not have financial means to seek psychiatric care. Wage-earner families do tend to equate mental health services with inpatient services. In addition, a similar tendency has been observed among union-related detectors, especial- ly insurance representatives in the Blue Cross labor liaison who are occasionally involved in re- ferrals. Representatives of a carrier in one location expressed sincere doubt that children would be in need of psychiatric care. They felt any problems which might be related to school performance, for example, should be taken care of by school re- sources and should not be considered ‘‘psychia- tric.”” The assumption was that only inpatient care could be legitimately charged to psychiatric serv- ices for children. Often among such detectors there is little knowledge that there is a list of ‘‘approved’’ facil- ities for outpatient services. Even when such a list is known to exist, there has been a universal INTRODUCTION AND BACKGROUND expression among this group in the detection-re- ferral system of a need for help as to how to as- sist families to make use of such facilities. Such areas of work are seen as ‘‘touchy’ to get into. For example, an insurance chairman of a local union cited the case of an individual who worked on the line for years. The man began to avoid his fellow workers, stopped talking, and suddenly one day attacked the foreman. The insurance chair- man described graphically his awareness that the man needed help but admitted his inability to rec- ommend a treatment resource. By bringing together such data from the three sample segments, it was judged, it might be possi- ble to develop a thorough picture of the barriers to treatment in the community. To accomplish this objective it was decided to concentrate ef- forts on a community in Michigan with a large concentration of UAW members, with a variety of mental health resources, and convenient enough to Detroit to facilitate management of data collection and the routine field problems as- sociated with it. Accordingly, Pontiac, Michigan, was selected as a study site meeting these criteria. The method of procedure for this study already has been partly suggested. The investigators had reasoned out a general model for linking the suf- fering person with proper professional help, but the model made provisions for obstacles in the linkages between people with problems, potential referral agents, and providers of care. The first stage was to approach members of each of these three groups and, as far as possible, enable them to define or describe obstacles as they perceived them. It was reasoned that this process would provide a basis for constructing a more complete list of obstacles, which could then be translated into an interview schedule to establish the varying perceptions of these matters. This, then, entailed a three-phase operation prior to the analysis of data and presentation of this final report. Phase | During phase I a wide variety of personnel in the study area were contacted and interviewed. These persons represented a broad spectrum of those involved in the problems under investigation in this project. On the one hand a variety of per- sons involved in the delivery of mental health services were interviewed. These consisted of some providers of care, clinic and agency admin- istrators, and even some clerical personnel in- volved with patient contact and record-keeping associated with the prepaid mental health benefit. Interviews were also conducted with those who cculd act as sources of referral, e.g., social-agen- cy personnel, union officials, court personnel, hospital-based professionals, and school and church officials. Finally, a small number of work- ers were also included in this phase of interview- ing. Because the purpose of this phase was to ob- tain voluntary and personal information about problems in the mental health delivery system rather than to collect and analyze data, these per- sons were interviewed by means of an open-end- ed interview guide consisting of a small number of rather general questions about the overall topic of mental health care. Respondents were invited to relate their own experiences and concerns with each question. These interviews were considered informal, aimed largely at tapping undirected information on the topic of obstacles to treatment. They were received enthusiastically by most respondents, who appreciated the opportunity to contribute their viewpoints to what they had been informed would be a more comprehensive and detailed study in the community. The professional staff members who conducted the interviews wrote responses as fully as possible and, in addition, the interviews were recorded on cassettes (unless the respondent objected to the recording). The staff then listened to these recordings and typed copies were made. Phase II Phase II involved a considerable amount of care and decisionmaking. The phase I interviews were repeatedly reviewed with an eye toward de- tecting any possible common themes regarding obstacles to mental health treatment under a pre- paid benefit. While the staff expected certain comments, e.g., stigma attached to mental health treatment, they were also attuned to picking up less obvious topics. The result of this series of operations was the gradual development of an interview schedule, first for the workers to be surveyed and then for the other two segments of the referral and treat- ment process. The instrument for the workers was focused on first because they would make up the largest sample in the final survey. Following the development of this instrument, the items were adapted to be appropriate for the other two groups for the final survey. Thus, as much com- parable information as possible was incorporated into the three final interview schedules. Of course, a pretest was conducted with these instru- ments, and necessary modifications were made prior to each final survey. INTRODUCTION AND BACKGROUND Phase lll Phase III consisted of the selection of samples of respondents and the actual accumulation of data according to the guidelines described above. For the workers a systematic sample was drawn of the UAW members from the three major UAW Local Unions in the Pontiac area. The sample, originally consisting of 574 members, finally yield- ed 447 respondents, giving a response rate of 77.9 percent. To obtain a sample of potential referral sources, several lists were constructed. They consisted of all physicians in the community, all social agencies, all school principals and coun- selors, all churches, all local union stewards and committeemen, and all police and court personnel whose specific duties might bring them into con- tact with mental health problems. Samples were then selected from each list to yield a total of 112 individuals, of whom 81 were interviewed, for a response rate of 72.3 percent. Because of the special nature of this referral group, key organizations were sought out, officers were apprised of the nature of the research, and their endorsements of the interviews were sought and received. Finally, all providers of mental health services in the community were listed and, except for those who were involved in the pretest, in this instance the entire list was used instead of a par- tial sample, a procedure adopted because of the relatively small size of this group and because it was the group from which the most exhaustive information was sought. Thus, the list numbered 76, of whom 72 granted interviews, for a response rate of 94.7 percent. In this case, the specific cooperation of the psychiatric section of the county medical society was sought and obtained, and that group’s endorsement was very helpful in obtaining interviews, especially within the private sector of the profession. The data from each of these three segments of the community were coded and analyzed sepa- rately. In the chapters that follow, the format consists basically of a description of the respon- ses of the members of each of the three groups. Following thereafter is a chapter containing the appropriate comparisons of the three groups and, finally, a summary of the research. CHAPTER 2: THE WORKERS Section I: Who Are the Workers? This segment of the mental health delivery sys- tem is comprised of 447 men and women who during this survey were active members of the United Automobile Workers and were employed in a major automobile plant located within the study area. Each worker is eligible for the union- negotiated mental health benefits and is, there- fore, considered to be a potential recipient of services within the mental health care delivery system examined in this project. While the individuals who comprise the sample of workers are often grouped together and re- ferred to variously as blue-collar, factory work- ers, production workers, or simply members of the working class, there is much that is glossed over by such references. There are important var- iations among these individuals which are lost when such labels are used, and this section will draw attention to these variations (see table 1). Sex The UAW is a large industrial union represent- ing workers in a relatively heavy manufacturing enterprise. It is therefore not surprising that males constitute a vast majority of the union and over 90 percent of the respondents. Race Another important social variable is the catego- ry of race. In this instance whites constituted about 85 percent of the respondents. The remain- der were nonwhite, almost all of whom were black. Age The workers in this study ranged from 19 to 65 years of age. The median age was 38. Thus about half of the workers can be considered young and about half middle-aged or older. Further, about three-quarters of these were quite equally distrib- uted among the first three age categories, that is, under age 50. It should be recalled that these were working members of the union. Retired members were not included in this study. Marital Status About 85 percent of the respondents were mar- ried. Of the remainder, slightly more than 5 per- cent were never married (in most instances, the youngest respondents). Only about 2 percent were widowed, and almost 7 percent were either sepa- rated or divorced. Family Size Numbers of family members ranged from 1 to 10, the average size being 3.8, a fact which sug- gests that an average UAW family ordinarily consists of a worker, a spouse, and two depend- ent children. About one-third of the families consisted of five or more members. Religion About 75 percent of the workers professed a Protestant religious belief, while about 18 percent were members of the Catholic faith. The remain- ing 7 percent either claimed no religious affiliation or were members of other religious groups not included among the three major religious catego- ries in the United States. These workers were equally divided in their church attendance: about 38 percent attended services at least once a month, and a similar pro- portion did not attend services at all. The remain- ing 23 percent attended services occasionally but less often than once a month. Education While on the average the workers completed a median of 11.0 years of schooling, the range in- cluded workers with a low of 2 years and a high of 16 years. Further, about 43 percent of the workers have a high school diploma and as many as 2 percent completed college. There is thus a great deal of variation in the workers’ educational backgrounds. About 7 per- cent have only a grade school education or less, about 41 percent more finished grade school but did not complete high school, and over 38 percent completed high school but did not continue. Con- THE WORKERS TABLE 1.—Characteristics of the Workers, in Percentage Sex Dwelling Unit Male 91.0 Detached Single Family House 86.4 Female 2.0 Duplex 3.8 Race Detached 3 or 4 Family Structure 0.5 White 85.1 Townhouse 2.2 Nonwhite 14.9 Apartment 0.9 Age Trailer 2.7 19-29 27.5 Other 0.2 30-39 25.1 Unknown 3.4 40-49 25.5 Years in Pontiac Area 50-65 21.9 Two or Less 1.4 Marital Status Two - Five 5.6 Married 85.5 Five - Nine 14.5 Widowed 2.0 Nine - Fifteen 8.3 Divorced 5.6 Fifteen - Twenty 10.7 Separated 1.4 Over Twenty 59.5 Never Married 5.6 Years Worked in Auto Industry Other 0.2 Three or Less 7.6 Family Size Three - Ten 38.9 Respondent Only 5.4 Ten - Twenty 215 Two 17.2 Twenty - Thirty 19.3 Three 21.5 Thirty or More 6.3 Four 23.9 Unknown 8.3 Five 16.3 Skill Level, Self-Classified Six or More 15.7 Skilled 23.7 Education Semiskilled 20.6 Grade School or less 7.2 Unskilled 53.9 Some Jr. High School 14.5 Other 0.9 Some High School 26.9 Unknown 0.9 High School Graduate 38.5 Skill Level, Classified by Job Title Some College 12.4 Skilled 20.4 Unknown 0.8 Semiskilled 66.0 Religion Unskilled 12.3 Protestant 74.9 Other 1.1 Catholic 17.7 Unknown 0.2 Other 4.0 Number of Plants None 3.2 One 54.1 Unknown 0.2 Two 24.4 Church Attendance Three 9.0 More Than Once a Week 9.0 Four or More 8.9 Once a Week 14.8 Unknown 3.6 Two to Three Times a Month 7.8 Attendance at Union Meetings Once a Month 72 All 2.2 Less Than Once a Month 22.8 Most 3.8 Not at All 38.3 About Half 1.8 Unknown 0.2 Few 33.8 Years at Present Address None 58.2 Two or Less 20.1 Unknown 0.2 Two - Five 25.5 Five - Nine 17.9 Nine - Fifteen 14.8 Fifteen - Twenty 11.4 Over Twenty 9.8 Unknown 0.5 sidering that this is a working-class group, it is Finally, over 35 percent of the workers, regard- significant to note that 12 percent of the workers less of years of formal schooling, completed some have some schooling beyond high school. phase of an apprenticeship program. WHO ARE THE WORKERS? Geographic Mobility and Stability The length of time the workers lived in the study area and the period of time they had lived at their current address were both noteworthy. A high proportion of workers (78.5 percent) had lived in the study area for at least 9 years prior to the interview, and a high proportion (53.9 percent) had lived at their current address for at least 5 years. These workers were clearly not a transient population. Further, less than 2 percent had lived in the study area for 24 months or less at the time of the interview, and over one-fourth had lived there all their lives. This relative stability is further evidenced by information on the workers’ housing. About 86 percent lived in detached single-family dwelling units, another 10 percent in trailers, duplexes, or townhouses. Only about 4 percent lived in multi- ple-family dwelling units larger than duplexes. Work History in the Automobile Industry For these workers, the median number of years employed in the auto industry was 10, and only about 8 percent had 3 years or less seniority. Further, almost 26 percent had been employed in the industry for more than 20 years. Thus, while the range of years worked included some workers with less than 1 year and some with over 40 years, the mean number of years worked in the auto industry was 13.4 at the time of the survey. Further, these workers were quite stable in place of employment in the auto industry, since about 54 percent had been employed in only one plant for their entire work history and about 80 percent were employed in no more than two plants. The sample of workers points to an expe- rienced and stable work force. Attendance at Union Meetings Although these workers were all members of the UAW, over 90 percent responded that in the past year they attended few or none of their local union meetings. This phenomenon will be ex- pounded further in a later section as it relates to the questions regarding the workers’ knowledge of their mental health benefits, since one of the prime sources of information about workers’ ben- efits is the union local. Skill Level Over half of the workers classified their own jobs as unskilled, the remaining workers being equally divided in classifying themselves skilled and semiskilled. Yet, when the workers’ actual job titles were classified according to occupational status, many of the positions which they defined as unskilled actually fell within the range of sem- iskilled jobs. This final distribution shows that about 20 percent of the workers had skilled posi- tions, just over 12 percent had unskilled positions, and about two-thirds of the workers were in the semiskilled range. Summary There were important differences among the sampled workers in education, age, skill level, family size, religion, work history, and geographic mobility. In summary, the average worker in the study is a married white male, 39 years old, with two children, and he and his family live in a one- family house. He is a semiskilled worker who has worked in the auto industry for just over 13 years, most likely in the same plant. He has com- pleted the 11th grade in school but has not com- pleted an apprenticeship program. Further, he has lived in the study area for at least 15 years and has lived at his present address for more than 5 years. Although he professes adherence to the Protestant faith, he at best attends religious serv- ices only intermittently. Although he is a member of the UAW, he does not attend his local union meetings. Many of these characteristics will be recalled in later sections as they relate to specific materials relevant to mental health services. They are pre- sented here to provide a brief overview of the union membership and the variability within it. Section II: Awareness of Services Available Two measures of the workers’ awareness of existing mental health services were obtained. The first item simply asked if the workers could name any mental health outpatient services that operate in the study area. The second asked the workers to name such services specifically. The responses to these items, as data below indicate, clearly reveal the workers’ lack of awareness of such resources. Table 2 shows the workers’ response patterns for these measures. Less than half of all workers could name even one existing mental health serv- ice. Of those who could name at least one, about half could name more than one. Thus, only about one-fourth of all workers questioned could name more than one of the existing mental health serv- ices which provide outpatient care. THE WORKERS TABLE 2.—Awareness of Available Mental Health Facilities by Age and Education, in Percentage Could Not Aware of Aware of Aware of Aware of Aware of Number of Identify Any One Two Three Four Five Total [Respondents Age 19-29 50.4 23.6 13.0 8.1 4.9 0.0 100.0 123 30-39 55.4 20.5 17.9 4.5 1.8 0.0 100.0 112 40 - 49 46.5 28.9 14.0 8.8 0.9 0.9 100.0 114 50+ 62.0 19.4 6.2 10.2 1.1 1:1 100.0 98 Average 53.3 23.3 13.0 7.8 2.2 0.4 100.0 447 Education Grade School or Less 81.3 15.6 0.0 3.1 0.0 0.0 100.0 32 Some Jr. High 55.4 215 16.9 6.2 0.0 0.0 100.0 65 Some High School 54.2 26.7 13.3 5.0 0.8 0.0 100.0 120 High School Graduate 49.4 22.7 13.4 10.5 35 0.6 100.0 172 Some College 46.3 22.2 13.0 11.1 5.6 1.9 100.0 54 Unknown (frequency) (1) (2) (1) (0) (0) (0) - 4 Average 53.3 233 13.0 7.8 2.2 0.4 100.0 447 Age as a Factor in Awareness Table 2 also contains a very interesting correla- tion between age and awareness of the various facilities. Those over age 50 were the least in- formed. Only about three in eight were able to name at least one facility. In the younger ages approximately one-half of the respondents were able to name at least one facility. And almost one-fourth of those in their forties could name at least one facility. Among those in their thirties, almost one-fourth could name more than one fa- cility. Those under 30 had the highest proportion, almost one-fourth, who could name one facility, but knowledge of more than one facility was low- er percentagewise in this age group than in any of the other age groups, except those over age 50, that is, the oldest respondents. Education as a Factor in Awareness The cross-classification of education with awareness of facilities reveals a direct correlation between education and awareness of at least one of the available services. Those with less than some high school education were poorly informed about the available mental health facilities, with only about 18 percent of this total group being able to name even one facility. Among the groups with at least some high school education, that percentage increased to approximately 50 percent or higher for each education category. Further, among high school graduates and among those with some college, the percentages able to name more than one facility are larger than those able to name only a single facility. Thus, there is, with increased education, not only a greater ability to name one facility but also an ability to name an increasing number of facilities. Awareness of Psychiatrists in Private Practice A further measure of the workers’ awareness of agencies and facilities which provide outpatient mental health treatment is the awareness workers have of the psychiatrists who have a private prac- tice. Table 3 shows the workers’ awareness of this source of mental health treatment. Clearly, the overwhelming majority was unable to name at least one such mental health practitioner. In fact, only 11.4 percent of the workers could give the name of a psychiatrist in private practice. As with awareness of facilities, most of these could name only one such practitioner. TABLE 3.—Awareness of Psychiatrists in Private Practice, in Percentage Number of Respondents: 447 Could Name One 72 Could Name Two 4.2 Don’t Know 88.6 Total 100.0 10 Section Ill: Evaluation of Services Available This section of the findings presents data on the workers’ evaluations or opinions of the mental health services available in the study area. While EVALUATION OF SERVICES these opinions in no way constitute a professional evaluation, they do provide some insight into two important dimensions in the identification of po- tential obstacles in the mental health delivery sys- tem. First. If a large proportion of the workers are dissatisfied with the adequacy of the services, they would not be likely to utilize those services on a health-maintenance basis. This does not mean that a negative perception would hinder util- ization for severe problems or for crisis situa- tions, but utilization for preventive care and health maintenance on an outpatient basis could be affected by such opinions. Table 4 shows that the workers were evenly divided in their views of the adequacy of the mental health services available. Three in ten felt the services were adequate, and the same propor- tion felt the services were inadequate. Also im- portant is the rather high proportion (4 in 10) who were unable or unwilling to offer an opinion. Thus, only about one-third of the workers ex- pressed a positive evaluation of the mental health services. Second. The high proportion of workers who were unable or unwilling to offer an opinion of the adequacy of services is an indirect measure of the low level of workers’ awareness of the availa- ble services. Age Related to Opinions A more detailed analysis of the workers’ opin- ions can also be seen in table 4. Two important response patterns are indicated. There is an in- verse relation between age and willingness or abil- ity to offer an opinion regarding the adequacy of services. A higher proportion of workers in the youngest two age groups was not able or willing to make an evaluation, while a lower proportion of workers in the older age groups responded to the question in a similar manner. From the preceding it is clear that age is an important fac- tor in the views held by workers regarding the adequacy of available mental health services. And considering only those workers who offered an opinion, younger workers more often expressed a positive evaluation of the adequacy of mental health services available, while older workers more often expressed a negative evaluation, al- though the differences in percentages are slight. The proportions expressing negative opinions in- crease with age from only 20 percent of those under 30 to about 39 percent of all those over 50. Thus, with increasing age, there was an increase in negative evaluations of the services available. Education Related to Opinions Table 4 also shows the workers’ opinion of the adequacy of available mental health services with- in categories of educational attainment. Examina- tion of this portion of the table indicates two important response patterns. First. The proportion of workers who were unable or unwilling to express an opinion increas- es from the lowest educational level to the highest except for a slight decrease in the highest educa- tional category. With increased education, the proportion of workers who were unwilling or unable to express an opinion on this topic also increases. TABLE 4.—Evaluation of Available Mental Health Facilities by Age and Education, in Percentage Consider Services | Consider Services Number of Adequate Inadequate Don’t Know Total Respondents Age 19-29 33.3 20.3 46.4 100.0 123 30-39 31.3 27.7 43.1 100.0 112 40 - 49 31.6 35.1 33.3 100.0 114 50+ 21.5 38.8 33.7 100.0 98 Total 31.1 30.0 38.9 100.0 447 Education Grade School or Less 28.1 43.8 28.1 100.0 32 Some Jr. High 32.3 36.9 30.8 100.0 65 Some High School 36.7 29.2 34.2 100.0 120 High School Graduate 29.1 25.0 45.9 100.0 172 Some College 24.1 29.6 42.6 100.0 54 Unknown (frequency ) (2) (2) (0) - 4 Total 31.1 30.0 38.9 100.0 447 11 THE WORKERS Second. Considering those workers who offered an opinion, the proportion of positive evaluations is higher than the proportion of negative evalua- tions among those workers who attended high school and among those who graduated from high school. A reverse situation is found among those workers with a grade school education or less, those with some junior high school, and those with at least some schooling beyond high school. Thus, the least-educated and most-educated work- ers together responded negatively more often, while workers with educational achievement lev- els between the two extremes responded in an opposite or more positive manner. It is apparent, then, that educational back- ground has an important influence upon both the direction of evaluations when they are made and whether or not such opinions are expressed at all. Reasons Cited for Negative Opinions Table 5 presents the types of inadequacies specified by those who felt the available mental health services were inadequate. Nearly half of those workers who offered a negative evaluation of the adequacy of the available mental health facilities expressed a belief that the delivery of mental health care was poor. The second most frequently cited reason was a general dissatisfac- tion with the number and quality of the existing facilities. One in five of those expressing a nega- tive opinion cited this as the basis for their opin- ion. The next two reasons cited had frequencies of about one in nine and were based, on the one hand, on beliefs that the quality of treatment was poor and, on the other, on dissatisfaction with the lack of enough personnel to provide adequate mental health treatment. Also important is the almost total lack of res- ponses related to the cost of treatment. The work- ers who expressed negative views of the adequa- cy of the available sources of treatment for men- TABLE 5.—Reasons Cited for Negative Evaluations of the Available Mental Health Facilities, in Percentage Number of Respondents: 130 Inadequate Facilities 20.0 Inadequate Service Delivery 44.6 Inadequate Treatment 14.6 Inadequate Personnel 12.3 Expense of Treatment 1.6 Other 6.9 Total 100.0 12 tal or emotional problems thus based their opin- ions on perceptions of the sources of treatment themselves and not upon perceived costs or other factors such as location of facilities and associat- ed difficulties in gaining access to treatment. The number of facilities and professionals and the manner in which treatment is provided were the overwhelming concerns of those who expressed dissatisfaction. Section IV: Awareness of Insurance Benefits To measure the workers’ awareness of their eli- gibility for services, six major provisions of the workers’ mental health benefits were utilized in this study. One of these is the provision for hos- pitalization, and the remaining five deal with as- pects of outpatient care. This material examines a major potential deterrent to workers’ seeking treatment for mental or emotional problems prior to crises. Two important and interrelated consid- erations have been cited as the basis for the inau- guration of the outpatient mental health provi- sions—first, the perceived need to provide pre- ventive care toward the goal of health maintenance and, second, the removal of the cost barrier from a form of treatment which many may consider nonessential. In order for these considerations to reach fruition, those who are eligible must at least be aware of their eligibility for the outpatient services. Without such an awareness, the per- ceived cost of treatment could easily continue to deter many potential users of outpatient mental health care from that service. Before discussing workers’ awareness of each of the six provisions, a note of caution must be raised. The measurement of knowledge of this sort raises some problems. Union members ques- tioned about their awareness of their eligibility for insurance provisions are likely to make assump- tions regarding the purpose of the questions, es- pecially if their health coverage is known to be quite comprehensive. If they perceive this section of the interview as a test of their knowledge, they may assume they are supposed to have and to know about the benefit in question and that the benefit in question is part of their health cover- age. Accordingly, the rates of the workers’ aware- ness of their benefit provisions presented in this section are assumed to be overestimates of the true picture. This assumption is supported by the fact that about 10 percent of the workers subse- quently stated that they had first heard of the mental health provisions during the interview. AWARENESS OF BENEFITS Hospitalization for Mental or Emotional Problems The first provision covers the cost of hospitali- zation for the workers and their eligible depend- ents. This item was included to provide a com- parison between the workers’ awareness of their eligibility for inpatient care and for outpatient care. As can be seen in table 6 nearly 6 in 10 at least thought they were eligible for this provision, and over one-third were sure they were eligible. While fewer than one in seven thought or were sure they were not eligible, over one-fourth of the workers questioned did not have enough informa- tion even to offer an opinion about their eligibili- ty. This low level of awareness is significant in view of the fact that workers ordinarily are aware of the fact that hospitalization is a form of cover- age for which they have quite a comprehensive benefit. It may also be noted that the workers under age 30 had the lowest proportion of respon- ses indicating they were sure of their eligibility (26.8 percent). In contrast, over 40 percent of those aged 30 to 49 were sure they had this cover- age. TABLE 6.—Workers’ Awareness of Hospitalization Provision, by Age and Education, in Percentage Sure They Think They Think They Sure They Don’t Number of Are Are Are Not Are Not Know Total Respondents Age 19-29 26.8 309 13.0 33 26.0 100.0 123 30-39 40.2 21.4 134 1.8 23.2 100.0 112 40 - 49 41.2 15.8 105 3.5 28.9 100.0 114 50+ 31.6 245 16.3 3.1 245 100.0 98 Total 34.9 23.3 13.2 29 25.7 100.0 447 Education Grade School or Less 34.4 25.0 15.6 3.1 21.9 100.0 32 Some Jr. High 33.8 23.1 10.8 4.6 27.7 100.0 65 Some High School 43.3 125 10.8 0.8 32.5 100.0 120 High School Graduate 29.1 29.7 14.0 35 23.8 100.0 172 Some College 370 27.8 16.7 3.7 14.8 100.0 54 Unknown (Frequency) (1) (0) (1) (0) (2) 4 Total 34.9 233 13.2 29 25.7 100.0 447 Psychological Testing Prescribed by a Physician The first of the outpatient provisions to be examined is the provision which covers the cost of psychological testing when prescribed by a physician. In general, the workers were unsure about their eligibility for psychological testing. While those workers who were sure that they were covered outnumbered by a margin of three to one those workers who were sure they were not covered, only 16 percent were sure. Over 40 percent of the workers responded that they didn’t know whether they were covered, and only 21 percent thought they might be covered for this benefit. An analysis of the workers within age categories showed little difference in these re- sponse patterns and the same may be said with regard to educational background. The most common response was simply not knowing wheth- er or not they had this benefit. (See table 7.) 13 Treatment by a Private Psychiatrist About one-fifth of all workers were sure of their eligibility for this provision in their mental health insurance benefit; yet about one-third of the workers didn’t know if they were covered, and 14.5 percent were sure that they were not eli- gible for this provision. Almost one-third of those workers aged 30 to 39 and only 12.2 percent of those workers over 50 responded that they were sure they had this benefit. Among those workers with less than a junior high school education, only 12.5 percent were sure of their eligibility. Work- ers who completed high school but did not contin- ue with their education had a higher proportion of being sure that they were eligible, and those workers who at least had some college had the highest proportion of being sure that they were covered (22.7 percent and 27.8 percent, respec- tively) (See table 8). THE WORKERS TABLE 7.—Workers' Awareness of Psychological Testing Provision, by Age and Education, in Percentage Sure They Think They Think They Sure They Don’t Number of Are Are Are Not Are Not Know Total Respondents Age 19-29 15.4 21.1 16.3 5.7 41.5 100.0 123 30-39 19.6 21.4 13.4 5.4 40,2 100.0 112 40 - 49 16.7 21.9 18.4 3.5 39.5 100.0 114 50+ 15.3 20.4 12.2 6.1 46.0 100.0 98 Total 16.8 21.3 15.2 51 41.6 100.0 447 Education Grade School or Less 219 15.6 9.4 6.3 47.0 100.0 32 Some Jr. High 16.9 16.9 10.8 10.8 44.6 100.0 65 Some High School 14.2 20.8 15.8 25 46.6 100.0 120 High School Graduate 15.7 25.0 18.0 4.7 36.6 100.0 172 Some College 241 20.4 14.8 5.6 35.2 100.0 54 Unknown (Frequency) (0) (0) (0) (0) (4) —- 4 Total 16.8 23 15.2 5.1 41.6 100.0 447 TABLE 8.—Workers' Awareness of Provision for Treatment by a Psychiatrist in Private Practice by Age and Education, in Percentage Sure They Think They Think They Sure They Don’t Number of Are Are Are Not Are Not Know Total Respondents Age 19-29 17.9 13.0 195 17.9 31.7 100.0 123 30-39 31.3 134 13.4 16.2 26.8 100.0 112 40 - 49 20.2 123 14.9 11.4 41.2 100.0 114 50+ 12.2 19.4 235 13.3 31.6 100.0 98 Total 20.6 14.3 17.7 14.5 329 100.0 447 Education Grade School or Less 125 94 125 219 43.7 100.0 32 Some Jr. High 18.5 16.9 13.8 15.4 35.3 100.0 65 Some High School 18.3 15.0 16.7 125 375 100.0 120 High School Graduate 22.7 12.8 20.9 14.5 29.1 100.0 172 Some College 27.8 18.5 14.8 13.0 25.9 100.0 54 Unknown (Frequency) (0) (0) (2) (1) (1) - 4 Total 20.6 14.3 17.7 14.5 329 100.0 447 Treatment at a Mental Health Clinic or Center Overall, only 19 percent of the workers were sure that they were eligible for this provision and an additional 21 percent were not sure whether they were covered. Workers’ age was related to being sure of their eligibility in that the middle categories (30 to 49) had the highest proportions giving this response. Again, education was also related to awareness. Among those workers with the highest level of education, 28 percent were sure they were eligible. This figure was almost 10 percent higher than the closest rate for any other 14 education category. Further, although the differ- ences were slight, the higher the education the more likely workers were to respond that they were sure they were covered for the treatment of mental or emotional problems at a mental health clinic or center (see table 9). Treatment of Workers’ Dependents The last two items were asked with regard to the workers’ own eligibility for treatment. These same questions were rephrased to assess the workers’ knowledge of the same benefits for de- pendent family members, but these questions AWARENESS OF BENEFITS TABLE 9.—Workers' Awareness of Provision for Treatment at a Mental Health Clinic or Center, by Age and Education, in Percentage Sure They Think They Think They Sure They Don’t Number of Are Are Are Not Are Not Know Total Respondents Age 19-29 13.8 24.4 13.0 33 45.5 100.0 123 30-39 22.3 25.0 8.9 4.5 39.3 100.0 112 40 - 49 23.7 12.5 14.9 2.6 41.3 100.0 114 50+ 14.3 15.3 22.5 71 40.8 100.0 98 Total 18.6 20.8 14.5 43 41.8 100.0 447 Education Grade School or Less 125 15.6 28.1 6.3 375 100.0 32 Some Jr. High School 16.9 15.4 18.5 4.6 44.6 100.0 65 Some High School 115 25.0 10.0 5.0 425 100.0 120 High School Graduate 18.0 209 145 4.1 42.5 100.0 172 Some College 27.8 222 13.0 1.9 35.2 100.0 54 Unknown (Frequency) (1) (0) (0) (0) (3) — 4 Total 18.6 20.8 14.5 4.3 41.8 100.0 447 were asked only of those respondents who either knew or thought they were eligible for the serv- ice. Only the better informed respondents were queried with regard to treatment for their de- pendents. What is significant here is that workers’ aware- ness of their dependents’ eligibility for the bene- fits was even lower (see tables 10 and 11). Thirty percent of the well-informed workers responded that they did not know or were not sure or thought their dependents were not eligible for treatment by a psychiatrist. Also, 17 percent re- sponded similarly with regard to treatment of dependents at a mental health clinic. These fig- ures, then, indicate an even lower level of aware- ness with regard to the eligibility of the workers’ families. In addition to the items measuring the workers’ awareness of the six mental health provisions previously discussed, several items were present- ed during the interview which were designed to obtain information about various related aware- ness dimensions. Included among these items were questions about how the workers first heard of the mental health provisions, how the workers viewed being eligible for the benefits, whether they perceived any drawbacks to the coverage, and how much they felt their fellow workers knew about the benefits. There are two important findings in the work- ers’ responses to the question of how they first learned about the mental health benefits (see table 15 TABLE 10.—Workers’ Awareness of Dependent’s Eligibility for Treatment by a Psychiatrist in Private Practice, in Percentage Number of Respondents: 195 Sure They Are 29.7 Think They Are 241 Think They Are Not 0.7 Sure They Are Not 72 Don’t Know 29.2 Total 100.0 TABLE 11.—Workers’ Awareness of Dependents’ Eligibility for Treatment at a Mental Health Clinic or Center, in Percentage Number of Respondents: 216 Sure They Are 29.2 Think They Are 38.0 Think They Are Not 8.3 Sure They Are Not 5.1 Don’t Know 19.4 Total 100.0 12). Over one-third of the workers said they never heard of the benefits or said they first heard of the benefits during the interview itself. These res- ponses indicate that even the low levels of aware- ness reported earlier are an overestimate. A wide range of information sources were mentioned by those who had knowledge of the benefits. This THE WORKERS TABLE 12.—Sources from Which the Workers First Heard of the Mental Health Benefits, in Percentage TABLE 14.—Workers' Perceptions of Their Fellow Workers’ Awareness of the Mental Health Benefits, in Percentage Number of Respondents: 447 Never Heard 25.5 From Interviewer 8.1 UAW 15.2 Family Friends 129 Mass Media 3.1 Employee 2.0 Psychiatrists 1.3 Insurance Carrier 3.8 Other 7.1 Don’t Know 21.0 Total 100.0 indicates the lack of an effective program for dis- seminating information about the benefits. While it is true that about 15 percent said they learned about the benefits from some type of UAW source, almost 13 percent cited family and friends as their source of awareness, and mass media, their employer, psychiatrists and the insurance carriers were together cited by about 10 percent. It should be recalled that only a small proportion regularly attended their local union meetings, which may account for the low proportion citing the union as their source of awareness. However, the responses of the workers to this item clearly identify a major obstacle to treatment. That is, an effective information dissemination program to inform workers about their eligibility for mental health benefits does not exist. Table 13 also reflects the workers’ low level of awareness, since about 68 percent lacked enough information to offer an opinion about the adequa- cy of the benefits. Additionally, the workers themselves supported the reported low-awareness levels, as about 88 percent said that their fellow workers knew ‘‘very little’” about the benefits, and only about 1 percent said that their fellow workers knew ‘‘a great deal’ (see table 14). TABLE 13.—Workers’ Opinions of the Adequacy of the Benefits, in Percentage Number of Respondents: 447 Great Deal 1.4 Some 8.7 Very Little 87.7 Don’t Know 2:2 Total 100.0 With regard to the workers’ opinions about being eligible for the mental health benefits, about 60 percent of the workers placed a positive value on being eligible, over one-third were neutral on the matter, and only about 2 percent thought such coverage was not needed. Further, the reasons offered for the positive opinions centered on fi- nancial considerations and the perceived general need for access to mental health care. These res- ponses (see table 15) indicate that the workers were concerned about being able to have access to mental health care without being financially strained if such care is needed. In a related issue the workers were asked if they were aware of any source from which they could obtain information about their mental health benefits. Table 16, which presents the identified sources, indicates a strong tendency for the work- ers to seek such information from some union TABLE 15.—Reasons Cited for the Workers’ Positive Opinions About Being Eligible for the Mental Health Benefits, in Percentage Number of Respondents: 397 Remove Financial Burden of Treatment 55.4 Need for Mental Health Treatment 32.0 Good Service Received Under Benefits 6.1 Others 6.5 Total 100.0 TABLE 16.—Sources to Which Workers Would Turn for Information About Mental Health Benefits, in Percentage Number of Respondents: 447 Benefits Adequate 19.7 Don’t Cover Enough of the Cost 4.9 Not Enough Services Provided 25 People Not Well Informed About Benefits 3.6 Other 2.0 Don’t Know, or No Response 67.3 Total 100.0 Number of Respondents: 447 Union 44.7 Family Physician 7.2 Company 3.8 Insurance Carrier 28.0 Other 145 Don’t Know 1.8 Total 100.0 16 DEFINITIONS OF NEED source. Further, the workers’ health insurance fining need for treatment and responses identify- carrier was also seen as an appropriate source of ing who could best help is important to an under- information. These two sources were cited by standing of how workers perceive the roles of about 73 percent of the workers. Thus, while the = mental health professionals. workers were less than fully knowledgeable about the benefits themselves, a vast majority of the Situation 1: workers were aware of sources which could pro- “A working man watches television from the vide them with information about their eligibility time he gets home from work until he goes to for those benefits. bed and refuses to talk to his family. Do you think he needs mental health treatment?’ i _ This situation was viewed by nearly two-thirds Section V: Definitions of Need for of all workers as requiring mental health treat- Mental Health Treatment ment. Table 17, which shows this finding, further reveals that there was virtually no variation in this In an effort to formulate a definition of prob- response pattern between age categories. With lems actually requiring mental health treatment, regard to educational backgrounds, it is clear that eight items were included in the interview. Each at each level of education a vast majority of described a situation, and the worker was asked, workers viewed this situation as requiring mental first, if the situation required attention and, then, health treatment and, again, there is little varia- who could best provide assistance in alleviating tion between educational groupings. The introduc- the problem situation described. Each of these tion of these two variables clearly indicates that eight situations are discussed. It should be noted the definition of need is consistent among the that the item asking who could best help was pre- ~~ workers regardless of age or education. sented to each worker regardless of how he de- fined the situation. This approach provides the Who Could Best Help? analysis with some depth and allows for a check Psychiatrists were the most frequently cited of the specific meaning of the definition the work- source of treatment to remedy the problem pre- ers gave to each situation. For example, if a sented in situation 1. As can be seen in table 18, worker responded that a situation required mental nearly one-third of all the workers cited a psy- health treatment and that family members could chiatrist in this manner. The workers themselves, best help alleviate the problem, it would be clear or members of their families, were the second that the worker was using a rather broad defini- most frequently identified source of treatment, as tion of mental health treatment. The information about one in five cited this source. Two other provided from jointly viewing the responses de- sources were rather frequently identified as best TABLE 17.—Definitions of Situation 1 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 64.2 30.9 4.9 100 123 30-39 65.2 32.2 2.6 100 112 40 - 49 66.7 31.6 1.7 100 114 50+ 67.3 28.6 39 100 98 Education Grade School or Less 68.8 28.1 3: 100 32 Junior High School 69.2 26.1 4.7 100 65 Some High School 62.5 325 5.0 100 120 High School Graduate 65.1 32.6 23 100 172 Some College 70.4 27.8 1.8 100 54 Education Unknown (Frequency) (2) (2) (0) — 4 All Workers 65.8 30.8 34 100 447 17 THE WORKERS TABLE 18.—Situation 1—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health Clinic 122 41.6 6 4.3 3 131 29.3 Counselor or Social Worker 27 9.2 i 79 0 38 8.5 Nonpsychiatric Medical Practitioners 43 14.9 7 5.0 0 50 11.2 Self, Family, or Relatives 35 12.0 51 36.8 4 90 20.1 Clergy 8 2.7 4 29 0 12 2.7 No Need for Treatment 2 0.6 1 7.9 2 15 34 Other or No Response 15 5.0 32 23.0 2 49 11.0 Don’t Know a1 14.0 17 12.2 4 62 13.8 Total 293 100.0 139 100.0 15 447 100.0 able to help—nonpsychiatric medical practitioners and social workers. Combined, these were identi- fied by 20 percent of the workers as the best sources of help. From the sources identified as best being able to help, it is clear that a bimodal response pattern is indicated. The workers were concentrated in relying on themselves, their families, and friends on the one hand and on mental health profession- als on the other hand. It is also important to note that workers perceive nonpsychiatric medical practitioners as sources of mental health treat- ment. Consideration must be given separately to the sources workers cited as being best able to help when the situation was defined as requiring or not requiring treatment. Among those who defined situation 1 as requiring mental health treatment, the dominant source of help cited was the psy- chiatrist or mental health clinics (41.6 percent). Further, this group was not inclined to view the involved person himself, his family, or relatives as being the best source of help. On the other hand, the involved person, his family, or relatives were seen as being best able to help by 36.8 per- cent of those who defined this situation as not requiring mental health treatment, and only 4.3 percent of this group viewed psychiatrists or men- tal health clinics as the best source of help. Thus, as might be expected, if situation 1 is viewed as requiring treatment, mental health professionals are seen as the best source of help. But, if treat- ment is defined as not being required, the person involved in the problem, or his family and rela- tives, are seen as appropriate sources of help. Situation 2: ““A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment?”’ 18 Table 19 presents the response pattern for this situation. Analysis of the responses indicates that nearly two-thirds of all workers defined this situa- tion as requiring mental health treatment. Exami- nation of the responses to this item within age categories shows that, among the workers who are under 20, only 85.5 percent defined this situa- tion as requiring treatment, while 68.3 percent of the workers over 50 responded in a similar man- ner. Thus, even though a definite majority in all age levels agreed that mental health treatment was indicated, there was a difference between the youngest and oldest workers. The oldest workers were more likely than the youngest workers to define this situation as requiring treatment. In regard to education, there is also some varia- tion in response to this item. The largest differ- ences are at the extremes, 75 percent of those with no more than a grade school education say- ing this situation requires help, and only 50 per- cent of those with some education beyond high school indicating a need for help. Who Could Best Help? Table *C shows the sources most frequently cit- ed by the workers as best being able to provide assistance in resolving situation 2. Psychiatrists or a mental health clinic again constituted the most frequently identified sources by an overwhelming margin, as 38.3 percent of all workers offered these responses and no other source was identi- fied by as many as 10 percent of the respondents. However, when the responses of workers who defined this situation as requiring or not requiring mental health treatment are viewed separately, a different response pattern is evident. While over 50 percent of the workers who viewed the situa- tion as requiring treatment cited psychiatrists or a mental health clinic as the best source of help, DEFINITIONS OF NEED TABLE 19.—Definitions of Situation 2 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 58.5 34.2 7.3 100 123 30-39 65.2 295 53 100 112 40 - 49 63.1 28.0 8.9 100 114 50+ 68.3 28.6 3.1 100 98 Education Grade School or Less 75.1 18.9 6.0 100 32 Junior High School 63.1 323 4.6 100 65 Some High School 68.4 258 5.8 100 120 High School Graduate 62.8 29.1 8.1 100 172 Some College 50.0 46.3 3.7 100 54 Education Unknown (Frequency) (2) (2) (0) = 4 All Workers 63.6 30.2 6.2 100 447 TABLE 20.—Situation 2—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health Clinic 156 54.9 1 8.2 5 172 38.5 Nonpsychiatric Medical Practitioners 37 13.0 5 3.7 2 44 9.8 Counselor or Social Worker 8 28 2 1.5 0 10 2.2 Union 4 14 1 0.7 0 5 1: Company or Management 20 7.0 17 12.6 1 38 8.5 Self, Family, or Friends 1 39 15 11.1 3 29 6.5 No Need for Treatment 1 0.4 19 14.1 0 20 45 Don’t Know or No Response 47 16.6 65 48.1 17 129 28.9 Total 284 100.0 135 100.0 28 447 100.0 less than 10 percent of those who defined the situ- ation as not requiring treatment responded in a similar manner. In fact, among this latter group two other sources were cited with about equal frequency. About 11 percent of these thought that the involved man himself or his family and rela- tives could provide the best help, while about 12 percent felt that the company or its representa- tives could offer practical solutions to the prob- lem. It is very interesting to note that a higher proportion, about 14 percent, reiterated their defi- nition of the situation by stating that no need for help was indicated in the situation. The workers were divided about two to one in viewing this situation as requiring mental health treatment. Further, when the situation was viewed as requiring treatment, mental health pro- fessionals were overwhelmingly seen as the best source of help. Yet, when the situation was not viewed as requiring treatment there was a lack of agreement as to who could provide help. Situation 3: “A husband and wife are having marital prob- lems and seldom see each other because they both work and they work on different shifts. Do you think they need mental health treat- ment?”’ This situation was defined by 80.9 percent of the workers as not requiring mental health treat- ment. It is interesting to note in table 21 that al- though in every age level an overwhelming major- ity defined the situation as not requiring treatment there is a direct relationship between age and the proportion who defined the situation as requiring treatment. There is an increase in the proportion 19 THE WORKERS TABLE 21.—Definitions of Situation 3 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 9.8 88.7 1.5 100 123 30-39 125 83.9 3.6 100 112 40 - 49 20.1 76.3 3.6 100 114 50+ 23.5 735 3.0 100 98 Education Grade School or Less 18.7 81.3 0.0 100 32 Junior High School 18.5 80.1 1.4 100 65 Some High School 18.3 79.2 2.5 100 120 High School Graduate 15.2 79.6 5.2 100 172 Some College 11a 88.9 0.0 100 54 Education Unknown (Frequency) (0) (4) (0) - 4 All Workers 16.2 80.9 29 100 447 of ‘‘yes’ responses with each increase in age. And the proportion of ‘‘yes’’ responses is over twice as high among the oldest as among the youngest. This difference exhibits its sharpest in- crease in a comparison of workers under and over 40. Examination of responses of workers within education categories indicates agreement with the overall response pattern regardless of education. In the lower four categories the proportions of workers who defined situation 3 as requiring or not requiring treatment nearly duplicate the pro- portions for all workers. The only category which differs from the overall response pattern is the most-educated group. However, that group differs only in that nearly 90 percent define the situation as not requiring treatment, compared with about 80 percent who so responded overall and in every other educational level. Who Can Best Help? The sources most frequently cited as being best able to help resolve situation 3 are presented in table 22. Of interest is the fact that, although 80 percent of all workers defined this situation as not requiring treatment, over 30 percent of the work- ers responded that a counselor or social worker could best provide treatment. It appears here that the workers distinguish between mental health treatment, which they tend to confine to the realm of psychiatric personnel, and help with personal problems, which they identified as being in the province of nonpsychiatric mental health person- nel. Additionally important is the fact that over 20 TABLE 22.—Situation 3—Who Could Best Help by Definition of Need for Treatment Treatment ! Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Counselor or Social Worker 29 40.3 111 30.6 8 143 32.0 Psychiatrist or Mental Health Clinic 9 125 4 11 0 13 2.9 Nonpsychiatric Medical Practitioners 7 9.7 3 0.7 0 10 2.2 Self or Family 7 9.7 91 25.1 1 29 22.2 Clergy 7 9.7 12 3.3 2 21 4.7 Management 1 14 13 3.6 0 14 3.1 Union 0 0.0 2 0.6 0 2 0.5 No Need for Treatment 0 0.0 9 25 0 9 2.0 Don’t Know or No Response 12 16.7 118 325 6 136 30.4 Total 72 100.0 363 100.0 12 447 100.0 20 DEFINITIONS OF NEED percent responded that either self-help or assist- ance from family members was the best source of help for the problem presented in this situation. When the responses of those who did not view this situation as requiring treatment are examined further, it is clear that not only was it the opinion of the workers that this situation does not require mental health treatment, but that the problem pre- sented can be best worked out within the family or with the aid of nonpsychiatric counseling. Situation 4: “A 12-year-old boy lies, steals, and skips school. Do you think he needs mental health treatment?’’ The workers’ responses to this situation can be seen in table 23. Overall, 58.2 percent of the sam- ple defined this situation as requiring treatment. Moreover, the least-educated group is divided evenly between those who defined this situation as requiring or not requiring treatment. Addition- ally, there is a direct relationship between age and defining situation 4 as requiring treatment. Slightly over half of the youngest category defined this situation as requiring treatment. The proportion increases at each age level, nearly two-thirds of the workers over 50 responding that situation 4 requires mental health treatment. Thus, the younger and least-educated workers were the least likely to view situation 4 as requiring treat- ment. Who Could Best Help? In response to the question of who could best help resolve the problem posed in situation 4, ta- ble 24 shows that family members were cited by TABLE 23.—Definitions of Situation 4 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 52.1 43.9 4.0 100 123 30-39 58.0 35.7 6.3 100 112 40-49 60.5 36.0 3.5 100 114 50+ 63.3 33.6 31 100 98 Education Grade School or Less 50.0 50.0 0.0 100 32 Junior High School 63.0 33.9 3.1 100 65 Some High School 60.8 36.7 2.5 100 120 High School Graduate 56.4 38.9 4.7 100 172 Some College 57.4 33.3 9.3 100 54 Education Unknown (Frequency) (2) (1) (1) it 4 All Workers 58.2 37.6 4.2 100 447 TABLE 24.—Situation 4—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health Clinic 82 31.6 3 1.8 1 86 19.2 Nonpsychiatric Medical Practitioners 25 9.6 2 1.2 1 28 6.3 Family or Relatives 86 33.1 134 79.3 10 230 515 School or Counselor 43 16.5 12 79 4 59 13.2 Clergy 7 2.7 1 0.5 0 8 1.8 Don’t Know 4 15 0 0.0 0 4 0.8 Other or No Response 13 5.0 17 10.1 2 32 7.2 Total 260 100.0 169 100.0 18 447 100.0 21 THE WORKERS over half of the workers questioned. Twenty per- cent felt that psychiatrists were the best source of help, while about 13 percent thought that counsel- ors or social workers could best help resolve the problem. This response pattern is consistent with the responses given within education and age cat- egories. Important differences are seen in the response rates these three sources of help received among only those workers who defined this situation as requiring mental health treatment. Among those who did view the situation as requiring treatment there were about equal proportions, around 30 percent, who viewed the family or relatives as the best sources of help, on the one hand, and those who similarly viewed psychiatrists or a mental health clinic on the other. Further, about half again as many (16 percent) viewed school counsel- ors as the best source of help. Among only those workers who defined this situation as requiring mental health treatment, one-third viewed the boy’s family or relatives as being best able to help. It must be concluded that this group used a rather broad definition of mental health treatment. Among those who described the situation as not requiring treatment, almost 80 percent cited the family as the best source for help, and an addi- tional 7 percent said that school personnel or counselors could help. There was no concentra- tion in any of the remaining sources. Situation 5: “A person always refuses to ride in elevators. Do you think this person needs mental health treatment?’’ Over 70 percent of all workers studied defined this situation as not requiring mental health treat- ment. As table 25 shows, there is little variation between age levels, the proportions of ‘‘yes’’ and “no’’ responses within each age level being simi- lar to the response proportions for the total sam- ple. However, examination of educational levels shows an important variation in responses among those workers who had continued their education beyond high school. One-third of this group de- fined the situation as requiring treatment. Thus, while the vast majority of workers defined this situation as not requiring treatment, a solid minor- ity of the workers within the highest education category differed. Who Could Best Help? Reiterating the view expressed in their defini- tion of situation 5 (see table 26), only slightly more than 30 percent of the total sample respond- ed that recourse to a professional resource could best help resolve the problem posed in the situa- tion, and almost 20 percent said there was no need for seeking help. Further, among the small proportion who de- fined this situation as requiring mental health treatment, 64 percent viewed a psychiatrist or TABLE 25.—Definitions of Situation 5 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 22.8 74.0 3.2 100 123 30-39 23.2 74.1 2.7 100 112 40 - 49 23.7 68.4 7.9 100 114 50+ 19.4 74.5 6.1 100 98 Education Grade School or Less 25.0 68.8 6.2 100 32 Junior High School 23.1 70.8 6.1 100 65 Some High School 20.8 73.3 5.9 100 120 High School Graduate 19.7 75.6 4.7 100 172 Some College 333 64.9 1.8 100 54 Education Unknown (Frequency) (0) (4) (0) —- 4 All Workers 22.4 72.3 4.9 100 447 22 DEFINITIONS OF NEED TABLE 26.—Situation 5—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health 64 64.0 35 10.8 2 101 22.6 Nonpsychiatric Medical Practitioners 14 14.0 25 7.6 1 40 8.9 Self, Family, or Friends 5 5.0 63 19.4 2 70 15.7 No Need for Treatment 0 0.0 80 24.6 0 80 17.9 Don’t Know 7 7.0 63 19.4 9 79 17.7 Other or No Response 10 10.0 59 18.2 8 77 17.2 Total 100 100.0 325 100.0 22 447 100.0 mental health clinic as the best source of help. This compares with only about 10 percent among the vast majority who viewed treatment as not required. The workers in the latter group reiterat- ed their definition of the situation as not requiring mental health treatment, as about one-fourth stat- ed that there was no need for help and about one- fifth cited the involved man himself or his family and friends as being best able to help. Situation 6: “A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treat- ment?”’ With slight variation within age and education categories, the workers overwhelmingly viewed this situation as not requiring mental health treat- ment. Table 27 shows that nearly 80 percent so defined this situation. While this proportion was not below about 73 percent in any age category, it should be noted that almost one-fourth of those 40 to 49 did define this situation as requiring treat- ment. This proportion was considerably higher than for any other age group and was almost twice as high as the similar response for the 30-39 group. In regard to education, it is significant to note that the least-educated and the best-educated groups had the highest proportions responding that this situation did not require treatment. In both these groups the proportion actually ap- proached 90 percent. Further, the highest educa- tion group had the lowest proportion responding that treatment was needed, while all other groups had quite similar proportions with this response. TABLE 27.—Definitions of Situation 6 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 18.7 78.0 33 100 123 30-39 125 83.1 4.4 100 112 40 - 49 23.7 72.8 35 100 114 50+ 14.3 81.7 4.0 100 98 Education Grade School or Less 18.7 81.3 0.0 100 32 Junior High School 16.9 78.5 4.6 100 65 Some High School 175 79.2 33 100 120 High School Graduate 18.3 755 6.2 100 172 Some College 13.0 87.0 0.0 100 54 Education Unknown (Frequency) (1) 3) (0) —- 4 All Workers 17.4 78.7 3.9 100 447 23 THE WORKERS Who Could Best Help? It is clear that the workers viewed this situation as being a matter for the family to work out. Ta-- ble 28 shows that over 60 percent of the total sample cited either the individuals themselves or the family as the best source of help. No other source was cited by more than 6 percent of the workers. Even among those who defined this situation as requiring treatment, there was about equal divi- sion between those who viewed the family as the best source of help and those who similarly viewed psychiatric treatment. Of additional im- portance is the fact that nearly 58 percent of the total sample jointly defined this situation as not requiring treatment and also cited the family group as the best source of help. On the other hand, only about 5 percent of the total sample jointly defined this situation as requiring treatment and also viewed psychiatrists or a mental health clinic as the best source of help. Situation 7: “A man cannot seem to hold a job very long because he drinks so much. Do you think this person needs mental health treatment?’ The problem presented in situation 7 is clearly one which the workers viewed as requiring mental health treatment. Table 29 shows that over 80 percent of the total sample defined the situation as requiring treatment. All age categories were quite uniform in giving this response. With regard TABLE 28.—Situation 6—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health Clinic 24 30.8 3 0.9 0 27 6.0 Self or Family 26 33.3 258 73.1 9 293 65.6 Counselor 8 10.3 12 34 1 21 4.7 Nonpsychiatric Medical Practitioners 7 9.0 6 1.7 1 14 3.1 Clergy 2 25 6 1.7 0 8 1.8 Don’t Know 4 5.1 10 2.8 0 14 3.1 Other or No Response 7 9.0 58 16.4 5 70 15.7 Total 78 100.0 353 100.0 16 447 100.0 TABLE 29.—Definitions of Situation 7 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 82.1 16.2 1.7 100 123 30-39 81.2 15.2 3.6 100 112 40-49 84.1 11.5 4.4 100 114 50+ 85.7 10.2 4.1 100 98 Education Grade School or Less 81.3 18.7 0.0 100 32 Junior High School 89.2 7.2 3.6 100 65 Some High School 86.7 75 5.8 100 120 High School Graduate 80.2 15.7 4.1 100 172 Some College 77.8 222 0.0 100 54 Education Unknown (Frequency) (3) (1) (0) — 4 All Workers 83.0 134 3.6 100 447 24 DEFINITIONS OF NEED to education, all groups had high proportions de- fining this situation as requiring treatment, but the proportion was lowest (75 percent) in the least- educated group, highest in the next group (almost 90 percent), and then decreased with each further educational level. Who Could Best Help? Table 30 presents the most frequently cited best sources of help for situation 7. Alcoholics Anony- mous or similar programs were cited by over 50 percent of the total sample. Psychiatrists were cited by 17 percent and almost 12 percent cited other medical practitioners. There is little difference in the sources cited as being best able to help between those who defined situation 7 as requiring treatment or not requiring treatment. In each case over half cited Alcoholics Anonymous or similar programs as the best source of help, and about an equal proportion viewed nonpsychiatric medical practitioners in a similar manner. The only difference found be- tween the two groups is the proportion citing psy- chiatrists or a mental health clinic as the best source of help. Nearly 20 percent of those who viewed treatment as being required cited this source of help as compared to only about 3 per- cent of those who expressed the contrary view. Thus, even though this situation was defined by an overwhelmingly majority of the total sample as requiring mental health treatment, only about 17 percent of all the workers so defined the situation and also cited psychiatric practitioners as the best source of help. This figure may be compared to about 45 percent who similarly defined situation 7 and viewed lay alcoholism programs as the best source of help. TABLE 30.—Situation 7—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Social Agency, i.e., A.A. 203 54.6 36 60.0 10 249 55.7 Psychiatrist or Mental Health Clinic 74 199 2 33 0 76 172.0 Nonpsychiatric Medical Practitioners 46 124 6 10.0 0 52 11.6 Self or Family 19 5.1 5 8.4 1 25 5.6 Clergy 7 18 0 0.0 0 7 1.6 Don’t Know 8 2.2 2 33 2 12 2.7 Other or No Response 15 4.0 9 15.0 2 26 5.8 Total 372 100.0 60 100.0 15 447 100.0 Situation 8: Who Can Best Help? “A young man is always getting into fights and often gets into trouble on the job. Do you think this person needs mental health treatment?”’ As can be seen in table 31, over 70 percent of the total sample defined this situation as requiring mental health treatment. The vast majority within every age and education category responded in the same way, but the proportion was considera- bly lower for those 40 to 49. There are, however, considerable differences between workers with different educational backgrounds. Among those workers with a grade school education or less, 65.6 percent defined the problem as requiring treatment. This result compares with 85.2 percent of those workers who had some education beyond high school. 25 The most frequently cited sources viewed by the workers as being best able to help resolve the problem presented in situation 8 are presented in table 32. Over 40 percent viewed psychiatrists as the best source of help, and the next most fre- quently cited source, management personnel, was so viewed by only about 11 percent of the total sample. Workers who viewed this situation as requiring treatment differed sharply from those who did not so define it. The former group cited mental health practitioners as the most likely source for help in 56 percent of the responses. The latter group, those who did not identify this situation as requir- ing treatment, referred to self, family, and friends much more frequently as the most likely source THE WORKERS TABLE 31.—Definitions of Situation 8 by Age and Education, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Total Respondents Age 19-29 72.3 228 49 100 123 30-39 78.5 16.1 5.4 100 112 40 - 49 64.9 28.9 6.2 100 114 50+ 73.5 19.4 71 100 98 Education Grade School or Less 65.6 31.3 3.1 100 32 Junior High School 70.8 24.6 4.6 100 65 Some High School 66.6 24.2 9.2 100 120 High School Graduate 73.3 20.3 6.4 100 172 Some College 85.2 14.8 0.0 100 54 Education Unknown (Frequency) (4) (0) (0) — 4 All Workers 72.2 21.9 5.9 100 447 TABLE 32.—Situation 8—Who Could Best Help by Definition of Need for Treatment Treatment Treatment Don’t Know or Required Not Required No Response Total N % N % N N % Source of Best Help Psychiatrist or Mental Health Clinic 182 56.2 2 20 2 186 41.7 Foreman or Management 26 8.0 20 204 4 50 12.2 Nonpsychiatric Medical Practitioners 34 10.5 5 5.1 0 39 8.7 Self, Family, or Friends 18 5.6 26 26.5 4 48 10.7 Counselor 21 6.5 5 5.1 0 26 5.8 Clergy 4 1.2 5 5.1 0 9 2.0 Don’t Know 23 74 6 6.1 9 38 85 Other or No Response 16 4.9 29 29.7 6 51 11.4 Total 324 100.0 98 100.0 25 447 100.0 of help. Clearly, here, definition of need dictates the source of help. Overview Several points are worthy of some summary statement. It should be pointed out that the workers are somewhat discerning and selective in what they perceived to be problems requiring attention, as demonstrated by the variation in respondents defining situations as serious enough to require attention or treatment. These responses range from 83 percent who recognized the drinking problem as requiring treatment to only 16 percent who stated that the problem of the two-shift fami- ly who seldom saw each other needed help. Thus, these workers as a group did not simply respond 26 in a stereotyped fashion to the various situations presented to them. The situations perceived as most serious, however, dealt with rather concrete and obvious behavioral patterns. These response patterns usually were not relat- ed to either age or education, though there were a few exceptions. Even then the exceptions were frequently rather slight and/or concentrated in only one or two age or educational levels. Further, regardless of the proportion actually defining the situation as serious enough to require treatment, there was a consistent difference in who was perceived to be most likely to help alle- viate this situation. That is, those who defined the situation as serious tended to cite mental health professionals as the best source of help, but those not defining the situation as serious tended to cite DEFINITIONS OF NEED self, family, and friends as the best source of help. This result clearly suggests a significant po- tential obstacle—namely, defining situations as requiring help. If they are not so defined, mental health resources are not called to mind as being helpful. The Workers’ Perception of the Appropriateness of Professional Treatment The above discussion relates to specific prob- lem situations that were presented to each worker as hypothetical cases not involving the workers personally. An equally essential dimension com- prises the responses of the workers to a question that involved them personally. The workers were, therefore, asked what they would do if they had personal problems which caused them to be very unhappy for a long time and the situation did not appear to be getting better. The responses to this item can be seen in table 33 which reveals a de- finite tendency among the workers to avoid pro- fessional mental health care. Almost 27 percent of the workers said they would either do nothing, ignore the problems, or cope with the problems themselves. While about 14 percent said they would seek help from a mental health profession- al, and about 20 percent said they would go to their family physician or a social worker, over 7 percent said they would seek help from their fam- ily or friends, and about 9 percent said they would talk over their problems with a member of the clergy. It is clear from these responses that mental health professionals are not viewed by the workers as the first line of assistance for their own personal problems. In contrast to this tend- ency, over half of the workers viewed educating people about the need for mental health care as the best way to encourage people with problems TABLE 33.—What Workers Would do if They Had Personal Emotional Problems, in Percentage Number of Respondents: 447 Handle Problems Themselves 19.2 Do Nothing or Ignore Problems 7.6 Seek Help From Family or Friends 7.4 Seek Help From a Mental Health Professional 139 Seek Help From Family Physician 15.7 Seek Help From a Social Worker 4.0 Seek Help From Clergy 8.7 Seek Help, Source Unspecified $1.7 Don’t Know, or No Response 11.8 Total 100.0 to seek professional mental health care at an early stage of problem development. While many of the workers did not view seek- ing professional treatment as an early alternative if they themselves had problems, they did, on the other hand, express the view that people in gener- al would be encouraged to seek professional help sooner if they knew more about mental health care. This point is again supported in the responses the workers gave to three related questions. The first of these is shown in table 34 which presents the workers responses to the questions of why people finally decide to seek help. Over one- fourth stated that they felt it requires a crisis of some sort or the individual ‘‘gets into trouble’ before professional help is sought. And about 4 percent said that professional help is sought when it is the only alternative left. Other responses in- cluded self-realization of problems, being de- pressed, family problems, and an inability to get along with others. The responses to the other two questions are presented in tables 35 and 36 which TABLE 34.—Reasons People Finally Decide to Seek Help, in Percentage Number of Respondents: 447 Self-realization 21.5 Feeling Upset With Self, Depression 14.5 Can’t Get Along With Others 25 Family Problems 18.3 Only Alternative Left 3.6 They Reach a Crisis, or Get Into Trouble 25.5 Don’t Know, or No Response 7.8 Other 6.3 Total 100.0 TABLE 35.—Do People Wait Until a Crisis Occurs Before Seeking Help, in Percentage Number of Respondents: 447 Yes 94.7 No 3.1 Don’t Know 2.2 Total 100.0 TABLE 36.—Should People Wait Until a Crisis Occurs Before Seeking Help, in Percentage Number of Respondents: 447 Yes 5.6 No 93.1 Don’t Know 1.3 Total 100.0 THE WORKERS reveal that over 90 percent of the workers felt that, while people do wait for a crisis to occur before seeking help, it was better if they sought help prior to such a crisis. In summary, the workers viewed professional mental health treatment as a source of remedy for personal problems only after other alternatives are tried. While they expressed the view that people wait until problems lead to a crisis before seeking professional help, they saw educating the community about mental health care as the best way of encouraging people to seek professional care earlier, before a crisis occurs. It is also clear that the workers distinguish between themselves and others in terms of what should be done when one is confronted with difficult personal problems. On the one hand they do not view professional treatment as an early alternative for themselves, while on the other they expressed the view that such care should be an early alternative for oth- ers. The prospect that the institution of the men- tal health benefits would lead to health-care maintenance appears not to have reached fruition when viewed from the workers’ responses to these last series of questions. On the basis of the responses of workers, professional mental health care appears not to be a remedy that workers would likely turn to before exhausting other alter- natives. However, when asked what would en- courage people with emotional problems to seek help sooner, over half of the workers replied that people need to be educated about the need for mental health care. Section VI: Identification of Potential Obstacles to Treatment This section is a report of the workers’ percep- tions of the degree to which potential obstacles might keep people from seeking mental health treatment. Fifteen items were presented, and the workers were asked to decide how much each potential obstacle might prevent people from going for help for their mental or emotional prob- lems. The response choices included: Very much, Somewhat, Very little, Not at all, and Don’t know. The selection of the items included as po- tential obstacles was made after preliminary inter- views and subsequent pretesting with a sample of members of the three main groups from which the final samples were drawn. The items then repre- sent the types of obstacles identified during the preliminary stages of this project. Further, the items cover a broad range of potential barriers to treatment, including such varied categories as 28 cost, knowledge, and concern for social reactions to individuals receiving mental health treatment. The workers’ responses to each of the 15 items are shown in table 37. The items measuring the deterrent value of social stigma were viewed by the workers as being serious obstacles to treat- ment. About 60 percent of the workers responded “Very much’ to the question whether or not each of the stigma items would keep people from treat- ment. The items which are considered indicators of stigma include embarrassment, fear that others will learn about it, and being afraid people would think one is crazy. Further, at least 80 percent of the workers viewed each of the indicators of stig- ma as being at least somewhat of a deterrent to treatment. About two-thirds of the workers responded that either not knowing they need help or not knowing they are covered by insurance would keep people from treatment. Nearly half of the workers viewed the fear of talking to a psychiatrist as “very much” of a deterrent, and a similar number felt that the attitude that people should be able to handle their own problems would keep people from treatment. The workers strongly expressed the view that males feel that asking for help is a sign of weakness and they feared that receiving treatment would affect their jobs. Not knowing that services are available was also considered a strong deterring factor. Only three remaining items were viewed as not being potential obstacles to treatment. It is impor- tant to note, however, that each of these items deals with practical problems that might be en- countered if treatment is sought. The workers expressed the view that neither the lack of trans- portation, nor the cost of a babysitter, nor a con- flict between an appointment for treatment and a favorite TV program would likely deter someone from getting treatment. The workers strongly expressed the view that the potential for stigmatization involved when receiving treatment would act as a strong personal inhibitor to seeking treatment. The effect that being in treatment might have on a person’s em- ployment and the feeling among males that asking for help is a sign of personal weakness were also viewed as strong potential obstacles, as were the lack-of-knowledge items. Further, the workers viewed the fear of talking to a psychiatrist, the feeling that talking doesn’t do any good, and the positive value placed upon a person’s being able to handle his own problems as definite factors that have the potential to keep people from seek- ing treatment. They suggest that the major sources of obstacles do not relate to cost or in- IDENTIFICATION OF OBSTACLES TABLE 37.—Identification of Potential Obstacles to Treatment, in Percentage Don’t Know or Number of Very Much Somewhat Very Little Not At All No Response Respondents No transportation 11.6 16.3 43.0 28.9 0.2 447 Would miss favorite T.V. program 7.2 11.2 30.6 50.3 0.7 447 Afraid people would think he is crazy 60.6 228 8.7 7.4 0.4 447 Cost of a babysitter 5.6 21.7 45.4 26.6 0.6 447 The feeling they can handle their own problems 49.0 304 13.0 6.3 1.3 447 Afraid to talk to a psychiatrist 485 298 11.2 9.6 09 447 Not knowing they need help 62.4 226 8.7 4.7 1.5 447 Embarrassment 56.6 a3 9.2 2.2 0.6 447 Not knowing services are available 34.4 29.8 20.1 15.4 04 447 Not knowing they are covered by insurance 67.1 19.7 8.3 4.0 0.9 447 Worrying about what might happen 43.2 33.8 15.7 6.7 0.6 447 The feeling that asking for help is a sign of weakness for males 40.9 30.6 17.4 10.1 0.9 447 The fear that others will learn about it 58.8 27.1 8.7 4.7 0.6 447 The feeling that just talking will do no good 30.0 40.9 20.6 7.4 1:1 447 The fear it will affect his job 34.4 29.8 20.1 15.4 0.4 447 convenience factors, but do relate to various as- pects of stigma and to preconceptions of what mental health treatment would involve. In a related matter, the workers were asked to conceive of the difficulties they would expect to encounter if they decided to seek professional mental health treatment. As can be seen in table 38, over 56 percent of the workers said they would not expect to encounter any difficulties, and about one-fourth viewed the cost of treatment as a problem. Thus, the above discussion of the strength of specific potential barriers appears to relate to the factors the workers would consider in deciding to seek or not to seek professional treatment. But if they did decide to enter treat- ment, their main concerns would be based on financial matters. Further, even these financial concerns were not viewed as prohibitive, since over 94 percent of the workers said that if they decided they needed professional treatment they would indeed be able to attend treatment sessions scheduled on a weekly basis (see table 39). TABLE 38.—Perceived Difficulties in Going to a Psychiatrist or Mental Health Clinic Once a Week, in Percentage Number of Respondents: 447 No Difficulty 56.2 Transportation 2.2 Cost 26.4 Too Busy 8.5 Not Knowing Service Available 25 Don’t Know, or Other 4.2 Total 100.0 TABLE 39.—Would Workers be Able to Go to a Psychiatrist or Mental Health Clinic Once a Week if They Desired, in Percentage Number of Respondents: 447 Yes 94.6 No 4.0 Don’t Know 1.4 Total 100.0 29 THE WORKERS Section VII: Personal Problems of Workers In this section we examine the personal prob- lem areas the workers reported as having caused them difficulty in the 5-year period prior to the interviewing. Table 40 contains the distributions for the first four problem areas mentioned by each worker. It is clear that the workers reported that they had experienced difficulty in a number of different areas. Among the frequently cited first problems, concerns about health, income, work, and family are clearly dominant. However, the workers’ second and subsequent responses indicate problems centering around being dissatis- fied with themselves, in addition to repeats of the most frequent first responses. It is important to note that over 90 percent of the workers did iden- tify at least one problem which caused them per- sonal concern, and about three-fourths of the workers identified at least two such problems. While the proportions identifying more problems decreased, over 40 percent of the workers identi- fied four personal problems which in the past had caused them some difficulty. TABLE 40.—The Workers’ Personal Problem Areas in Previous Five Year Period, in Percentage First Problem Second Problem Third Problem Fourth Problem Area Mentioned Area Mentioned Area Mentioned Area Mentioned Health 29.3 3.1 4.3 2.0 Work 14.5 11.9 4.7 3.6 Income 15.9 15.4 7.4 3.6 Parents 29 3.1 2.7 0.7 Children 6.0 78 6.3 3.4 Marriage 4.7 5.1 3.1 2.2 Alcohol 29 2.7 0.9 1.1 Drugs 0.2 0.7 0.4 0.2 Loneliness 1.3 25 25 1.3 Sex 0.9 25 4.3 1.8 Getting Along With Others 0.7 2.5 22 3.1 Dissatisfied With Self 4.7 8.9 10.3 9.8 Suffering a Loss 3.4 3.8 4.3 3.4 Problems With Leisure Time 3.1 3.6 5.8 5.1 No Problems Reported 9.7 26.4 40.8 58.7 Total 100.0 100.0 100.0 100.0 Number of Respondents: 447 447 447 447 Section VIII: Experience With and Perceptions of Treatment Three items were used to separate the workers into three groups: (A) those who had themselves been in treatment or knew about the treatment experiences of members of their families; (B) those who had not had such experiences but could identify past problems where treatment could have helped; and (C) those who did not have such experiences and did not feel that they or members of their families could in the past have been helped by treatment. The proportions of the total sample in each of the groups are: group A, 36.7 percent; group B, 14.8 percent; group C, 48.5 percent. 30 Each of the three groups was then asked ques- tions relevant to their experiences with and per- ceptions of mental health treatment. These items were included because personal experience with mental health treatment must be considered an important source of information within the focus of this research. Group A A surprisingly large number of respondents were included in this group. The workers themselves were the recipients of the treatment in 48.2 per- cent of the reported experiences, and in 25.6 per- cent of the experiences the recipients of the treat- ment were the workers’ children. Spouses, sib- lings, and parents were each named by less than 10 percent of the workers who reported treatment PERCEPTIONS OF TREATMENT experiences. Thus, about three-fourths of the reported treatment experiences involved either the worker himself or his children (see table 41). The types of problems which necessitated the reported treatments are shown in table 42. Marital problems and problems with children were the most frequently cited specific areas. However, about 21 percent of the workers who reported treatment experiences cited the general category of mental problems as the basis for the treatment. About 6 percent reported problems involving drugs or alcohol, and the remainder were spread out without any appreciable concentration in any specific category. Table 43 presents the sources of treatment for these reported experiences. The workers reported using a wide range of treatment sources. While about one-third cited a psychiatrist or a mental health clinic as the treatment source, nearly one- TABLE 41.—Workers Who Reported Treatment Experiences, Recipients of Care, in Percentage Number of Respondents: 164 Worker 48.2 Children 25.6 Spouse 79 Siblings 7.3 Parents 4.9 Other Relatives 0.6 Unspecified 65.5 Total 100.0 TABLE 42.—Workers Who Reported Treatment Experiences, Type of Problem, in Percentage Number of Respondents: 164 Marital 39.0 Children 15.2 Mental Problems 20.7 Drugs or Alcohol 6.1 Getting Along With Others 4.3 Health 24 Other 2.5 Unspecified 9.38 Total 100.0 fourth cited members of the clergy. Nonpsychia- tric medical personnel were cited by 17 percent, and counselors or social workers were both cited as treatment sources by another 17 percent. Thus, two-thirds of group A reported that treatment was sought with either mental health care profession- als themselves or with traditional gatekeepers in the referral process to professional mental health care, but a substantial number of persons re- ceived their ‘‘treatment’’ outside of these custom- ary sources. The factors that promote seeking treatment are complex and may involve a series of situations involving crises or suggestions by friends, rela- tives, or professionals. The workers overwhelm- ingly cited either themselves or their families and friends as providing the final impetus to receiving treatment. Table 44 presents the responses to the question of how these individuals got to treat- ment. Twenty-five percent responded that family or friends prompted the seeking of treatment, while self-realization and self-referrals were men- tioned by 31.1 percent. These few sources ac- counted for the final motivation to seek treatment in over half of the cases. The category of self-re- alization may require some definition. It is best exemplified by qualitative statements such as ‘I finally decided I needed help,’ or ‘““My problems grew so troublesome that I knew I had no other choice.” This type of response clearly suggests a last-resort type of action. The workers reported a high rate of satisfaction with their treatment experiences. Table 45 shows TABLE 44.—Workers Who Reported Treatment Experiences, Source of Motivation to Treatment, in Percentage TABLE 43.—Workers Who Reported Treatment Experiences, Source of Help, in Percentage Number of Respondents: 164 Family or Friends 25.0 Referred by Family Doctor 9.8 Referred by Social Worker 9.8 Referred by Clergy 24 Referred by Other Health Professionals 79 Self-realization and Self-referral 31.1 Other or Reason Unspecified 14.0 Total 100.0 Number of Respondents: 164 Psychiatric or Mental Health Clinic 32.9 Clergy 23.9 Nonpsychiatric Medical Practitioners 171 Counselors, Social Workers 17.1 Others 9.0 Total 100.0 TABLE 45.—Workers Who Reported Treatment Experiences, Satisfaction, in Percentage Number of Respondents: 164 Treatment Definitely Helped 62.2 Treatment Helped Somewhat 6.1 Treatment Did Not Help 29.3 Don’t Know 24 Total 100.0 THE WORKERS that 62.2 percent felt that the treatment experi- ence helped resolve the problem, and 68.3 percent felt that treatment was at least somewhat helpful. Group B Those workers who did not report treatment experiences, but who did admit or recognize prob- lems which could have benefited from treatment, constituted about one-seventh of the respondents. In about one-fifth of these cases, the involved in- dividual either chose to ignore the problem or said that at the time he wouldn’t admit that he needed help. Nearly 5 percent said that at the time they didn’t realize that they needed help. These re- sponses, then, constitute about one-fourth of group B. In addition, 15.2 percent of the group thought that they could handle the problems by them- selves, and about 9 percent said that at the time they felt that treatment wouldn’t do any good. Thus, in nearly half of the cases, the involved individuals either thought that they could handle their problems themselves or chose to ignore or not admit the need or efficacy of treatment (see table 46). It is also worthy of note that over 10 percent of group B stated that they simply were not aware of available services. Over 40 percent of the workers in group B said that they themselves were the ones who had the problems for which treatment could have been helpful (see table 47). Other immediate family members, children, or the workers’ spouses were cited by about one-fifth of the workers in group B. These figures do not differ drastically from those reported by members of group A, the group actually treated. Over 40 percent of group B cited marital and family problems as the personal difficulties they were considering during this series of questions (see table 48). Further, about 6 percent specified problems they had had with their children, and almost 9 percent specified alcohol-related prob- lems. In response to the question of who could have provided treatment, only about 9 percent said that psychiatrists or a mental health clinic would have been the best source of treatment (see table 49). Counselors or social-work agencies were men- tioned by about 20 percent, and about 12 percent of the workers felt that members of the clergy could have assisted in resolving their problems. A wide range of treatment sources was seen as being appropriate to the problems workers and their families had had previous to the interview session and for which treatment had not been sought. What is most striking about these respon- ses in contrast to group A is the small proportion 32 TABLE 46.—Reasons Why Workers Who Recognized Problems Did Not Seek Help, in Percentage Number of Respondents: 66 Ignored or Wouldnt Admit Problem 16.7 Didn’t Know They Needed Help 4.6 Thought They Could Handle Their Own Problems 15.2 Felt Treatment Wouldn't Help 9.1 Not Aware of Available Services 10.6 Embarrassed 6.1 Other or No Response 34.6 Don’t Know 3.1 Total 100.0 TABLE 47.—Identification of Person with Problems for Which No Help Was Sought, in Percentage Number of Respondents: 66 Workers 43.9 Spouse 7.6 Children 10.6 Siblings 6.1 Parents 7.6 Other Relatives 6.1 Unspecified 18.1 Total 100.0 TABLE 48.—Type of Problem for Which Help was not Sought, in Percentage Number of Respondents: 66 Marital Problems 424 Children 6.1 Alcohol 9.1 Mental Problems 13.6 Grief 4.5 Sex 1.5 Income 15 Don’t Know 4.5 Other or No Response 16.8 Total 100.0 TABLE 49.—Who Could Have Provided Help, in Percentage Number of Respondents: 66 Psychiatrist or Mental Health Clinic 9.1 Clergy 121 Counselors or Social Workers 19.7 No One 10.6 Family Relatives, Friends 9.1 Nonpsychiatric Medical Practitioners 4.6 Worker 1.5 Don’t Know 13.6 Others or No Response 19.7 Total 100.0 WORKERS AS REFERRAL AGENTS citing mental health professionals and the large proportion, about 25 percent, who stated that they did not know who could have helped. Group C Group C consists of workers who neither had experiences with treatment themselves, nor were aware of other members of their family being in treatment, nor were able to conceive of problems that they or their families had in the past where treatment could have been helpful. Nearly half of the total sample (48.6 percent) were in this group. These workers were asked whether they always considered themselves capable of handling their own problems or if they could conceive of situa- tions in which they would seek mental health treatment. It is important to note that about one- third of group C felt that they could always han- dle their own problems and that they could not conceive of situations in which they would seek mental health treatment. There were 69 workers who responded in this manner, and it is significant that this group constitutes over 15 percent of the total sample. Section IX: The Workers Viewed as Referral Agents Even though the workers in this study and their eligible dependents were viewed as the potential recipients of mental health care due to their eligi- bility for prepaid mental health insurance, these same workers may often be in a position to assist their friends, co-workers, and relatives by offering advice as to the best way to deal with personal emotional problems. The workers are, therefore, a potentially excellent source of referrals to pro- fessional mental health care. This section explores the attitudes of the workers toward acting in the referral role. Workers’ Experience as Referral Agents: About 18 percent of the workers in the sample said that others often asked their advice about personal problems, nearly one-third said that oth- ers sometimes asked their advice, almost 20 per- cent said that they were seldom asked for advice, and just under one-third said that they had never been asked for advice. Therefore, about two- thirds had at least some opportunity to act as re- ferral agents. In over half of the cases, co-workers were the ones asking the workers’ advice about personal emotional problems, while friends and family 33 members were less frequently reported as in need of advice. When asked for advice about personal mental and emotional problems, the workers over- whelmingly either just listened to the individual presenting the problems or offered personal ad- vice themselves. In fact, less than 14 percent said that they referred the individual seeking advice to either a mental health care professional or one of the traditional gatekeepers to the mental health care delivery system. It is clear that, while potentially the workers are excellent sources of referral to professional mental health care as others seek out their advice for help with personal emotional problems, they do not, when in the role of potential referral agents, often undertake referral activities. Nearly 60 percent of the workers said they had in the past known individuals who, they thought, needed professional help for an emotional problem but that they did not suggest that that individual seek treatment. The reasons the workers offered for not sug- gesting that these individuals seek help are also important. The workers most frequently said that the problems expressed by those troubled indivi- duals were none of their business or that referring those individuals to treatment would have hurt their personal relationship with that person. About 20 percent said that the individual asking for help wouldn’t have listened anyway or else that it wouldn’t have helped to suggest that he seek treatment. The workers were also asked if they had ever engaged in specific referral activities. About one- fourth said that they had at some time in the past suggested that an individual seek treatment from a psychiatrist. Reflecting an earlier finding that the majority of the workers did not know the name of a specific psychiatrist, the majority of those who did suggest that an individual seek help from a psychiatrist did not give that person the name of a specific psychiatrist nor were they able to give the person a telephone number. However, over 40 percent of those who suggested an individual seek help from a psychiatrist were aware that the per- son seeking help was able to get to a psychiatrist, and over 58 percent of those said that the person seeking help went to the psychiatrist on their rec- ommendation. Unlike the high number of workers who had at one time or another suggested a person seek help from a psychiatrist, only about 10 percent sug- gested that an individual seek help from a mental health clinic and less than half of those were able to offer the name of a specific clinic. In about half of these instances, the workers were aware that THE WORKERS the individual seeking help actually received treat- ment at a mental health clinic. Over half were able to say that the individual who sought help at a mental health clinic went to the clinic on their recommendation. The workers were also asked if they had sug- gested that individuals seek help from any other source and about one-fourth of all the workers responded that they had. These additional sources of help to which the workers had referred others include the clergy, the family physician, and so- cial-work agencies. Over one-third of the workers who had suggested that others seek nonprofes- sional sources of mental health treatment said that the clergy was the source of treatment sug- gested. The family physician and a social-work agency were each suggested by about one-fifth of these workers. Attitudes Toward Engaging in Referral Activities The workers expressed attitudes toward their referral activities that are somewhat contrary to the experiences reported among those workers who actually had engaged in referrals. Over 85 percent of all the workers said that they, in the future, would be willing to advise their friends, relatives, or fellow workers to seek professional help for an emotional problem. This finding is contrary to the reported referral activities of the workers, as over 80 percent who had engaged in such referral activities stated that they referred to other than professional sources. Over half of all the workers said that they did not feel that their relationship with another person would be hurt if they recognized that the other person had a men- tal health problem and suggested that he/she seek treatment. This expression of attitude is contrary to the finding reported earlier. Among those work- ers who recognized that an individual needed mental health treatment but did not suggest that person seek professional treatment, the most fre- quently cited reasons for not suggesting treatment as an alternative indicated that the workers per- ceived such activity as potentially harmful to their relationship with the troubled individual. The 34 workers were asked to whom they would report that a co-worker was acting strangely on the job. Nearly 75 percent of the workers said that they would report it to their foreman and nearly 10 percent said that they would not report it at all. While this situation is specifically related to the job, and there are undoubtedly other considera- tions operating in addition to a desire to get help for that individual, the fact that few of the work- ers suggested the individual exhibiting ‘‘strange’’ behavior seek professional treatment supports the contradictory findings reported in this section. Workers’ Perceptions of Their Union Representative, Their Foreman, and Their Company Nurse or Doctor: Workers do not view their shop committeeman or steward as being a source of help for their per- sonal emotional problems. They view these indivi- duals as either unqualified to help or not wanting to help and think that personal problems not relat- ed to work are not within the shop committee- man’s realm of responsibility. The shop foreman was viewed in a similar light, although over one- fourth of the workers said that they would discuss personal problems with their foreman. Among those who said that they would not discuss their personal problems with their foreman, almost half said that personal problems not related to work were not within the realm of the foreman’s exper- tise. While these findings are not very surprising, they do indicate that two potentially active refer- ral sources are not seen as viable alternatives for individuals when they have problems. What is surprising is the perception that work- ers have of their company nurse or doctor. About two-thirds said that they would not discuss a per- sonal problem with their company nurse or doc- tor, and about one-third of these offered the rea- son that they viewed the company nurse or doctor as either unqualified or not wanting to help. Addi- tionally, over one-fourth of the workers viewed the company nurse or doctor as being manage- ment personnel to whom such problems are not to be taken. CHAPTER 3: THE REFERRAL AGENTS Section |: Professional and Nonprofessional Agents Since the purpose of this project was the identi- fication of barriers to treatment, it was reasoned that the referral group should not be limited to only those individuals who engage in referral ac- tivities as part of their professional duties. Others could play an important role by nature of their association with those potentially in need of help, or by the nature of the community positions they hold, or because of a combination of these two factors. Accordingly, the referral group included two categories, professionals and nonprofession- als. The professional referral category included physicians, school counselors and principals, so- cial case workers and administrators of social agencies, and nurses employed in public health activities. The nonprofessional category included elected union officials (stewards and committee- men), members of the clergy, and court or police representatives. This last group is comprised of judges, probation officers, police officers, court social workers, and investigation officers of the Friend of the Court office. The selection of those included in both catego- ries was made through a process of selecting ei- ther individuals, or agencies, or positions within agencies. Table 50 shows the response rates for the various types of positions selected. It should be noted that over half of the medical practition- ers refused to grant an interview. These refusals are important not only because they occurred in spite of advance letters from the county medical society urging their cooperation, but also for the reasons some of these individuals offered as the basis for their refusals. When asked to cooperate, a noticeable number of those medical profession- als who refused cited their belief that their prac- tice was not related to the field of mental health. When a request was made for an appointment with a physician specializing in plastic surgery, he replied that he could not see the relationship of this specialty to treatment for mental or emotional problems. Therefore, although external to the findings of the survey itself, one potential barrier to treatment is already implied in the reasons cit- TABLE 50.—Referral Agents Total Selected Refusals Interviewed M.D. 25 15 10 D.O. 7 3 4 Social Agency Personnel 5 0 5 Court/Police 13 0 13 Union 25 5 20 Clergy 20 8 12 School Personnel 17 0 17 Totals 112 31 81 Percentage 100 27.7 72.3 35 ed, among some of the medical professionals se- lected, for the refusal to cooperate. Considering the other categories, only the cler- gy and union officials did not fully cooperate. One in five union officials and just under half of the clergy contacted refused to grant an interview. The union officials who refused did not offer rea- sons. However, it may be surmised that they felt the interview constituted a quiz of their knowl- edge of the workers’ benefits, which they may have viewed as a threat to their union positions. The clergy who were counted as refusals were in the main associated with ‘‘store-front’’ churches and were never actually contacted even though more than eight attempts were made. The final referral group consists of a total of 81 respondents, 36 professionals and 45 nonprofes- sionals. The overall response rate of 72 percent is adequate although it is the lowest for all three segments of the total survey. Section Il: Awareness of Services Available The referral agents’ awareness of the mental health facilities that function within the area can be seen in table 51, which reveals that all but two of the professional agents were able to name at least one of the outpatient mental health services. Further, professionals appeared to have an exten- THE REFERRAL AGENTS TABLE 51.—Awareness of Available Mental Health Facilities Aware of: None One Two Three Four or More Total Professional Medical 1 1 5 0 7 14 Nonmedical 1 0 2 7 12 22 Subtotal 2 1 7 7 19 36 Nonprofessional Court/Police 1 0 3 1 8 13 Union 10 4 2 3 1 20 Clergy 5 2 1 1 3 12 Subtotal 16 6 5 12 45 Total 18 7 13 12 31 81 sive level of awareness, as the majority of this group were able to name four or more of the available services. The nonprofessional group was found to be less knowledgeable, as almost 40 per- cent were unable to name at least one service. However, this low measure of awareness derives almost totally from the responses of the clergy and union officials. Only one of the court and po- lice personnel was unable to name one facility, but nearly half of the clergy or union officials could not name at least one. Considering only those who could name at least one service, examination of the number of services named indicates that court and police personnel have more extensive knowledge than either clergy or union officials. Eight of the 12 court and police personnel were able to name four or more services, while only three of seven clergy and only one out of ten union officials were able to name a similar num- ber. The most frequently cited services were the Pontiac General Hospital’s Community Mental Health Clinic (48 percent) and both Pontiac State Hospital’s Community Psychiatry Division (33 percent) and their Pre- and After-Care Units (27 percent). Awareness of Psychiatrists in Private Practice An additional measure of awareness of existing mental health services is the familiarity potential referral agents have of the psychiatrists who have a private practice in the study area. As can be seen in table 52, five of every six professionals could name at least one such mental health practi- tioner, while only about half of the nonprofes- sionals could do so. This finding is not surprising. However, it further supports the fact that some potential sources of referral in the community who could assist troubled workers to find help were less than fully knowledgeable of the sources available to provide such help. TABLE 52.—Awareness of Psychiatrists in Private Practice Don’t Know Aware of: One Two Three or More of Any Total Professional Medical 1 9 3 1 14 Nonmedical 9 1 22 Subtotal 8 18 6 36 Nonprofessional Court/ Police 3 5 1 4 13 Union 6 2 0 12 20 Clergy 3 1 0 8 12 Subtotal 12 8 1 24 45 Total 20 26 5 30 81 36 EVALUATION OF SERVICES Section Ill: Evaluation of Services Available Examination of table 53 indicates that about 40 percent of those within the professional referral category were satisfied with the available serv- ices. This pattern is, however, due largely to the responses of the medical professionals. Eight of the 14 medical referral agents were satisfied with the available services, while only six of the 22 nonmedical professionals expressed a similar view. Only about one-third of the nonprofessional referral group expressed satisfaction with the adequacy of available services. The medical pro- fessionals were found to view the existing mental health services as adequate, while the nonmedical professionals and nonprofessional referral agents generally expressed a negative view. A separate item probed for specific types of perceived inadequacies. Table 54 shows that, of the professionals who were dissatisfied, 12 out of 19 felt the system of service delivery was inade- quate. Among the dissatisfied nonprofessionals, poor quality of treatment was mentioned most frequently, followed closely by a belief that the number of facilities available was less than ade- quate for the community needs. Again considering only those referral agents who viewed the available services as inadequate, it should be noted that, while nonprofessionals most often cited poor treatment as the reason for their dissatisfaction, none of the professionals held a similar view. In other words, those who were more likely to be in frequent contact with the mental health services did not view the quality of treatment to be poor, but those who were less likely to have frequent contacts with the existing services held the view that those services offered poor treatment. TABLE 53.—Evaluation of the Available Mental Health Facilities Consider Services Consider Services Adequate Inadequate Don’t Know Total Professional Medical 8 4 2 14 Nonmedical 6 15 1 22 Subtotal 14 19 8 36 Nonprofessional Court/Police 6 7 0 13 Union 4 13 3 20 Clergy 4 5 3 12 Subtotal 14 25 6 45 Total 28 44 9 81 TABLE 54.—Reasons Cited for Negative Evaluations of the Available Mental Health Facilities Inadequate Number Poor Service Poor Treatment Inadequate Don’t of Facilities Delivery Provided Personnel Know Total Professional Medical 0 4 0 0 0 4 Nonmedical 5 8 0 0 2 15 Subtotal B 12 0 0 2 19 Nonprofessional Court/Police 2 1 3 0 1 7 Union 4 2 4 2 1 13 Clergy 1 0 2 2 0 5 Subtotal 7 3 9 4 2 25 Total 12 15 9 4 4 44 THE REFERRAL AGENTS Section IV: Referral Agents’ Knowledge of Workers’ Eligibility for Mental Health Benefits In order to fulfill the potential role of referral agent, individuals in such positions should be ful- ly aware of the workers’ eligibility for prepaid mental health care. If those to whom workers are likely to turn in times of personal emotional stress are not aware that the workers are eligible for prepaid professional mental health treatment, then the perceived costs of such treatment and other related factors could act as strong deterrents to the referral process. While it is understood that referral agents’ awareness of the workers’ bene- fits doesn’t necessarily indicate that they would refer workers or members of their families who had personal problems to professional mental health care, the lack of referral agents’ awareness of the workers’ eligibility for prepaid treatment would constitute a potential obstacle in the refer- ral process. All of the benefit provisions that were present- ed to the workers were also presented to the re- ferral agents. A discussion of the referral agents’ awareness of each of the benefit provisions will be made separately. However, while neither group was found to be fully aware of the benefits overall, the professional group was much more knowledgeable than were the nonprofessional re- ferral agents. Hospitalization for Mental or Emotional Problems The responses of the referral agents to the question of whether or not workers were eligible for hospitalization for mental or emotional prob- lems can be seen in table 55. While over half of the referral agents at least thought that the work- ers were eligible, there are important differences between the professional and nonprofessional re- ferral agents’ awareness of this benefit. The pro- fessional referral agents were quite aware of the workers’ eligibility. Sixteen out of the 36 profes- sionals were sure that the workers were covered; an additional 10 weren’t sure but at least thought that the workers were eligible. None of the pro- fessional referral agents responded that they were sure that the workers were not eligible. The non- professional group displayed a different response pattern. While it is true that about the same pro- portion of nonprofessionals were sure, or at least thought that the workers were eligible for this benefit, about one in four of the nonprofessionals was unable to even offer an opinion regarding the workers’ eligibility, and four of the nonprofes- sionals were sure that the workers were not eligi- ble. Eight of the 12 clergymen were unable to offer an opinion, and three thought or were sure that the workers were not eligible. Fourteen of the 20 union officials were sure that the workers were eligible. However, four of the 20 thought or were sure that the workers were not eligible for this provision. This result indicates that, while the majority of the union officials were aware of this benefit, one in five was unaware that the workers were eligible for hospitalization for mental or emotional problems. Psychological Testing Prescribed by a Physician The referral agents’ awareness of this provision can be seen in table 56, which reveals that an ina- bility to offer an opinion was the most frequent response offered by the referral agents. Overall, TABLE 55.—Referral Agents’ Awareness of the Workers’ Eligibility for Hospitalization Don’t Think Don’t Know Think They Are They Are Sure They or Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional Medical 6 4 2 0 2 14 Nonmedical 10 6 4 0 2 22 Subtotal 16 10 0 4 36 Nonprofessional Court/Police 4 4 0 1 4 13 Union 14 2 2 2 0 20 Clergy 1 0 2 1 8 12 Subtotal 19 6 4 4 12 45 Total 35 16 10 4 16 81 5 KNOWLEDGE OF ELIGIBILITY TABLE 56.—Referral Agents’ Awareness of the Workers’ Eligibility for Psychological Testing Think They Are Don’t Know Sure They or Don’t Think They Are Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional Medical 3 4 1 0 6 14 Nonmedical 5 9 2 0 6 22 Subtotal 8 13 0 12 36 Nonprofessional Court/Police 3 4 0 1 5 13 Union 5 5 3 2 5 20 Clergy 2 2 0 0 8 12 Subtotal 10 1 3 3 18 45 Total 18 24 6 3 30 81 about one in four of the referral agents was sure that the workers were eligible for this benefit, and one in nine was sure or thought the workers were not eligible. Among the professional referral agents, one-third were unable to offer an opinion, while less than one-fourth were sure that the workers were eligible. None of the professional referral agents was sure that the workers were not covered. Half of the union officials were either unable to offer an opinion or at least thought that the workers were not eligible for this provision. Further, while 21 of the 45 nonprofessionals at least thought that the workers were eligible, 18 others lacked enough information even to offer an opinion. Treatment by a Psychiatrist in Private Practice Overall, the referral agents were about evenly split between those who were sure that the work- ers were eligible for this benefit and those who lacked enough information even to offer an opin- ion. Yet again, the professional agents were seen as being more knowledgeable than the nonprofes- sional referral agents. While one-third of the pro- fessionals were sure that the workers were cov- ered, only 13 of the 45 nonprofessionals so re- sponded. In addition, five of the nonprofessionals were sure that the workers were not covered. None of the professional group responded in this manner. In fact, of the five referral agents who responded that the workers were not eligible, three were elected union officials. It is also impor- tant to note that only 9 of the 20 union officials at least thought that the workers were eligible for this benefit provision, and 6 of the 20 were unable even to offer an opinion. Among the clergy, a similar pattern is seen. Seven of the 12 clergymen were unable to offer an opinion, and only 2 of the 12 were sure that the workers were eligible. These response patterns can be seen in table 57. TABLE 57.—Referral Agents’ Awareness of the Workers’ Eligibility for Treatment by a Psychiatrist in Private Practice Don’t Think Don’t Know Think They Are They Are Sure They or Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional Medical 5 4 1 0 4 14 Nonmedical 7 5 7 0 3 22 Subtotal 12 9 0 7 36 Nonprofessional Court/Police 4 2 0 1 6 13 Union 7 2 2 3 6 20 Clergy 2 1 1 1 7 12 Subtotal 13 5 3 5 19 45 Total 25 14 1 5 26 81 B® THE REFERRAL AGENTS Treatment at a Mental Health Clinic or Center Along with the provision establishing the eligi-- bility of workers and their dependents for treat- ment by a psychiatrist in private practice, the provision establishing such treatment at a mental health clinic or center is one of the more innova- tive aspects of the mental health care program for which the workers are eligible. This provision re- lates to health care maintenance, one of the major stated goals of the establishment of the mental health benefits. The referral agents overall were generally unaware of this provision (see table 58). While it is true that 23 of the 81 referral agents were sure that the workers were eligible for the provision, union officials comprised 10 of those 23, and among the remaining referral-agent cate- gories the proportions who were sure that the workers were eligible were very low. For exam- ple, only one of the medical professionals and five of the nonmedical professionals were sure of the workers’ eligibility. In every category except the union officials, at least as many were unable to offer an opinion as were sure that the workers were eligible. Among the medical professionals, the ratio of those unable to offer an opinion to those who were sure the workers were eligible was seven to one. Among the nonmedical profes- sionals the proportions were equal. Thus, the pro- fessional referral agents had a ratio of two to one. Even though 10 of the 20 union officials were sure that the workers were eligible, 4 of this group did not think that they were covered, and another 4 lacked enough information to offer an opinion. Even among the group that had the highest level of positive awareness there was lack of agreement indicated in their response pattern. As was the case with the other benefit provisions, the referral agents were found to be less than fully knowl- edgeable regarding the workers’ eligibility for treatment at a mental health clinic or center. Dependents Treated by a Psychiatrist in Private Practice The referral agents’ awareness of this provision can be seen in table 59. Only those referral agents who at least thought that the workers themselves were eligible for treatment by a psychiatrist in private practice were questioned regarding the workers’ dependents’ eligibility for such treat- TABLE 58.—Referral Agents’ Awareness of the Workers’ Eligibility for Treatment at a Mental Health Clinic or Center Don’t Think Don’t Know Think They Are They Are Sure They or Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional Medical 1 5 1 0 7 14 Nonmedical 5 6 1 5 22 Subtotal 6 10 7 1 12 36 Nonprofessional Court/Police 4 3 0 1 5 12 Union 10 2 4 0 4 20 Clergy 3 3 0 0 6 12 Subtotal 17 8 4 1 15 45 Total 23 18 1 2 27 81 TABLE 59.—Referral Agents’ Awareness of the Workers” Dependents’ Eligibility for Treatment by a Psychiatrist in Private Practice Don’t Think Don’t Know Think They Are They Are Sure They or Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional 16 0 1 4 30 Nonprofessional 7 1 0 0 1 9 Total 23 10 0 1 5 39 KNOWLEDGE OF ELIGIBILITY ment. One would expect that this group would express a high degree of positive awareness. While it is true that 23 of the 39 referral agents responding were sure that the dependents were eligible for this provision, 1 of the professionals was sure that the dependents were not eligible, and 5 of all of those questioned were unable to offer an opinion. Dependents Treated at a Mental Health Clinic or Center The criterion for presenting this item was the same as for the preceding provision. Only those referral agents who at least thought that the work- ers themselves were eligible for treatment at a mental health clinic or center were asked about the workers’ dependents’ eligibility for such treat- ment. Here, again, it is surprising that 6 of the 32 professionals responding were unable to offer an opinion and, additionally, one of this group was sure that the workers’ dependents were not eligi- ble (see table 60). Nearly one in four of those re- ferral agents responding was either unable to offer an opinion about the dependents’ eligibility or at least thought that the workers’ dependents were not eligible for this provision. Summary The referral agents’ responses to questions measuring their awareness of the workers’ mental health benefits indicate that, while there are dif- ferences between the professional and nonprofes- sional levels of awareness, neither group was found to be fully aware of the specific provisions. About one-third of the referral agents were unable even to offer an opinion concerning the workers’ eligibility for psychological testing, for treatment by a psychiatrist in private practice, or for treat- ment at a mental health clinic or center. Other evidence reveals that a number of the referral agents either thought or were sure that the work- ers were not eligible for these provisions. One of the potential barriers to treatment can be seen in the fact that a number of the individuals who at least potentially could function in the referral role were not fully aware of the workers’ eligibility and their dependents’ eligibility for prepaid pro- fessional mental health treatment. The referral agents were presented with several additional items relevant to their awareness of the specific benefit provisions. Although seven out of every eight referral agents expressed a positive opinion about the workers being eligible for the benefits (see table 61) and most could identify sources from whom they could learn more about the specific benefit provisions (table 62), about one-fourth said they had in fact never heard about the benefits prior to the interview sessions (10 professionals and eight nonprofessionals; see ta- ble 63). Hence, even the less than extensive awareness levels reported are considered an over- estimate of how much the referral agents actually knew about the benefits prior to the interview. TABLE 60.—Referral Agents’ Awareness of the Workers” Dependents’ Eligibility for Treatment at a Mental Health Clinic or Center Don’t Think Don’t Know Think They Are They Are Sure They or Sure They Are But Not Sure But Not Sure Are Not No Response Total Professional 13 12 0 1 6 32 Nonprofessional 5 1 1 0 1 8 Total 18 13 1 1 7 40 TABLE 61.—Referral Agents’ Opinions About Prepaid Mental Health Benefits Positive Neutral Negative No Response Total Professional 31 2 2 1 36 Nonprofessional 40 1 1 3 45 Total 71 3 3 4 81 THE REFERRAL AGENTS TABLE 62.—Referral Agents’ Awareness of Sources to Obtain Information About UAW Mental Health Benefits Psychiatrist Social UAW Mental Health Insurance Work Auto Don't No Source Clinic Carrier Agency Company Know Response Total Professional 5 2 23 2 0 3 1 36 Nonprofessional 13 6 18 2 1 4 1 45 Total 18 8 a1 4 1 7 2 81 TABLE 63.—Sources From Which the Referral Agents First Heard of Benefits Psychiatrist Family Other Never UAW or A Mental Auto Insurance or or Don't No Heard Source Health Clinic Coverage Coverage Friend Know Response Total Professional 10 3 2 1 3 2 6 9 36 Nonprofessional 8 18 2 1 3 7 6 45 Total 18 21 2 5 13 15 81 The referral agents were also asked to estimate how familiar workers were with their mental health benefits. As can be seen in table 64, the perceptions of the referral agents are quite similar to those expressed by the workers who, as report- ed earlier, estimated their co-workers’ awareness. About three of every four referral agents said that they felt the workers knew ‘‘very little’’ about the benefits, and none of the referral agents said that the workers knew ‘‘a great deal.” The referral agents’ suggestions for better in- forming the workers about their benefits are pre- sented in table 65. It is interesting that almost one-fifth said they felt an advertising program uti- lizing mass-media channels would be an effective means of disseminating such information to the TABLE 64.—Referral Agents’ Perception of the Workers’ Awareness of Mental Health Benefits Great Deal Some Very Little Don’t Know Total Professional 0 10 23 3 36 Nonprofessional 0 8 35 1 44 Total 18 58 4 80 TABLE 65.— What Could Be Done to Better Inform UAW Members About Their Mental Health Benefits? Establish a Separate Union Office for Better Send Informing Nothing, Don’t Utilize Union Union Advertise Literature Members People Know/ Mass Information Education in Union to Union About Aren't No Media Program Classes Papers Members Benefits Interested Response Total Professional 7 5 5 1 8 4 2 4 36 Nonprofessional 10 3 8 6 13 1 1 3 45 Total 17 13 21 5 3 81 42 DEFINITIONS OF NEED workers, while a similar proportion thought the most effective means would be a direct mailing of relevant literature to the workers. Other sugges- tions included placing advertisements in the union newspapers and holding educational classes at the union locals. Further, while the response frequen- cy may be small, three of this referral segment said it wouldn’t make any difference what might be done because the workers weren’t interested. Section V: Definitions of Need for Treatment The referral groups were presented with the same problem situations as were presented to the workers. As was the case in the workers’ inter- views, after the situation was defined as requiring or not requiring treatment, the referral agents were asked to suggest who might best provide help for the indicated problem. The response pat- terns for each of the eight situations are presented in the following discussion. Situation 1 “A working man watches television from time he gets home from work until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment?’ Overall, more than two-thirds of the referral agents defined this situation as requiring treat- ment. Yet, a comparison of the professional refer- ral agents with the nonprofessional group indi- cates that the professionals were more likely to define this situation as requiring treatment. Twenty-eight of the 36 professionals defined situa- tion 1 as requiring treatment, while 25 of the 45 nonprofessionals responded similarly. These find- ings can be seen in table 66, which also presents the definitions for each of the five subgroups of referral agents. The referral group was then asked who could best provide help in this situation. Four sources of help were mentioned frequently. These were a psychiatrist or mental health clinic, the involved individual himself, his family or his friends, and a counselor or social worker. Table 67 presents these findings and further reveals that among the medical professionals there was an even split between those who saw a psychiatrist or mental health clinic as the best source of help and those who saw nonpsychiatric medical practitioners as best being able to provide the treatment. Only one of the other referral agents cited a nonpsychiatric medical practitioner as the best source of help. Over one-third of the medical professionals cited persons in positions similar to their own as being best able to help resolve the problem presented in situation 1. Situation 2 ‘“A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment?”’ Table 68 presents the referral agents’ definitions of this situation. Overall, slightly more than half defined this situation as requiring treatment. However, there are differences in the definitions offered by the professional and nonprofessional referral agents. While about 56 percent of the professionals defined this situation as requiring treatment, less than half of the nonprofessionals responded similarly. Seven of the 10 clergymen who responded to this item defined this situation as not requiring treatment. There was about an even split in the definitions offered by union offi- cials and court and police personnel. TABLE 66.—Referral Agents’ Definitions of Situation 1 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 1 3 0 0 14 Nonmedical 17 5 0 0 22 Subtotal 28 8 0 0 36 Nonprofessional Court/Police 8 4 1 0 13 Union 10 7 2 1 20 Clergy 7 3 0 2 12 Subtotal 25 14 3 5 45 Total 53 22 3 3 81 THE REFERRAL AGENTS TABLE 67.—Situation 1—Who Could Best Help? Non- Don't Self/ psychiatric Counselor/ Know/ No Need Family/ Medical Social No for Help Friends Clergy Psychiatrist Practitioner Worker Employer Other Response Total Professional Medical 0 3 0 5 B 1 0 0 0 14 Nonmedical 1 4 2 6 1 4 1 1 2 22 Subtotal 1 7 2 1 6 5 1 2 36 Nonprofessional Court/Police 0 4 1 3 0 4 0 0 1 13 Union 2 5 1 4 0 5 0 2 1 20 Clergy 0 3 2 4 0 0 0 2 1 12 Subtotal 2 12 4 11 0 9 0 4 3 45 Total 3 19 6 22 6 14 1 B 5 81 TABLE 68.—Referral Agents’ Definitions of Situation 2 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 8 4 2 0 14 Nonmedical 12 9 0 1 22 Subtotal 20 13 2 1 36 Nonprofessional Court/Police 7 6 0 0 13 Union 10 9 0 1 20 Clergy 3 7 0 2 12 Subtotal 20 22 0 3 45 Total 40 35 2 4 81 Table 69 presents the best sources of help for this situation. The dominant source of help men- tioned, overall and within both the nonprofession- al and professional categorics, was the psychia- trist or mental health clinic. Overall and within both the two categories of referral agents, about one- fourth either were unable to offer an opinion or responded that they didn’t know what source could best help alleviate the problem. Situation 3 ‘“A husband and wife are having marital prob- lems and seldom see each other because they both work and they work on different shifts. Do you think they need mental health treat- ment?”’ This situation was defined by the professional referral agents as requiring mental health treat- ment and by the nonprofessional referral agents as not requiring treatment. These findings can be seen in table 70, which also shows that over three 44 times as many professionals defined this situation as requiring treatment as compared to those pro- fessionals who defined this situation as not requir- ing treatment. Twice as many nonprofessionals defined this situation as not requiring treatment as nonprofessionals who defined it as requiring treat- ment. These reported differences are also seen in a comparison of the two groups’ definitions of the best source of help to alleviate the problems pre- sented in situation 3. Table 71 shows that the pro- fessionals overwhelmingly viewed counselors and social workers as the best source of help, while the nonprofessionals viewed both the involved couple and their family or counselors and social workers, equally, as the best source of help. The two referral groups not only disagreed in their definitions of the couple’s need for mental health treatment in this situation but also disagreed as to who could provide the best help. The profession- als felt that the couple required mental health treatment and that the treatment should be ob- DEFINITIONS OF NEED TABLE 69.—Situation 2—Who Could Best Help? Non- Don't psychiatric Know No Need Self/ Medical or No for Help Friends Psychiatrist Practitioner Counselor Employer Other Response Total Professional Medical 1 1 8 1 0 1 0 2 14 Nonmedical 1 2 5 0 2 3 2 7 22 Subtotal 2 3 13 1 2 4 2 9 36 Nonprofessional Court/Police 1 1 7 1 0 1 1 1 13 Union 1 3 7 1 0 0 2 6 20 Clergy 2 1 1 0 1 1 1 5 12 Subtotal 4 5 15 2 1 2 4 12 45 Total 6 8 28 3 3 6 6 21 81 TABLE 70.—Referral Agents’ Definitions of Situation 3 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 11 2 0 1 14 Nonmedical 15 6 0 1 22 Subtotal 26 8 0 36 Nonprofessional Court/Police 4 7 1 1 13 Union 7 13 0 0 20 Clergy 3 8 0 1 13 Subtotal 14 28 1 2 45 Total 40 36 1 4 81 TABLE 71.—Situation 3—Who Could Best Help? Non- The Couple psychiatric Counselor/ No Need Themselves Medical Social No for Help or Family Clergy Psychiatrist Practitioner Worker Other Response Total Professional Medical 0 2 0 1 3 8 0 0 14 Nonmedical 0 4 0 0 0 17 0 22 Subtotal 0 6 0 1 3 25 1 0 36 Nonprofessional Court/Police 0 4 1 0 0 8 0 0 13 Union 1 11 0 0 0 7 0 1 20 Clergy 0 2 3 1 0 5 0 1 12 Subtotal 1 17 4 1 0 20 0 2 45 Total 1 23 4 3 3 45 1 2 81 45 THE REFERRAL AGENTS tained from counselors or social workers. The nonprofessional group tended to define this situa- tion as not requiring treatment, and viewed the best source of help as coming from the involved individuals themselves and their family or from outside counseling. Situation 4 “A 12-year-old boy lies, steals, and skips school. Do you think he needs mental health treatment?’ There were important differences between the professional and nonprofessional referral agents in both their definitions of the need for treatment and their recommendations as to the best source of help. There was nearly unanimous agreement among the professional referral agents that situa- tion 4 required treatment. Among the nonprofes- sional agents of referral, just over half defined situation 4 as requiring treatment. Six of the 10 clergymen who responded to this question defined the situation as not requiring mental health treat- ment. These findings can be seen in table 72. The professional and nonprofessional referral agents also differed in their view of who could best provide help for the problems involved in situation 4. Among the professional referral agents, the medical practitioners generally re- sponded that a psychiatrist or mental health clinic was the best source of help. The nonmedical pro- fessional referral agents viewed the school or counselors and social workers as being the best source of help. The nonprofessional referral agents tended to see the family as the source of best help. Eleven of the 20 union officials and 5 of the 11 clergymen who responded cited the family as being the best source of help (see table 73). Seventeen of the 22 nonmedical referral agents cited the school or counselors and social workers as the best source of help for the problems pre- TABLE 72.—Referral Agents’ Definitions of Situation 4 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 13 0 0 1 14 Nonmedical 20 1 0 1 22 Subtotal 33 1 0 2 36 Nonprofessional Court/Police 7 5 1 0 13 Union 12 7 0 1 20 Clergy 4 6 0 2 12 Subtotal 23 18 1 3 45 Total 56 19 1 5 81 TABLE 73.—Situation 4—Who Could Best Help? Non- psychiatric Counselor/ No Need Medical Social No for Help Family Clergy Psychiatrist Practitioner School Worker Other Response Total Professional Medical 0 2 0 9 2 1 10 0 0 14 Nonmedical 0 2 0 3 0 6 1 0 0 22 Subtotal 0 4 0 12 2 7 11 0 0 36 Nonprofessional Court/Police 2 2 0 5 0 1 2 1 0 13 Union 0 11 1 2 0 0 5 1 0 20 Clergy 0 5 4 2 0 0 0 0 1 12 Subtotal 2 18 5 9 0 1 7 2 1 45 Total 2 22 5 21 2 8 18 2 1 81 46 DEFINITIONS OF NEED sented in situation 4. They viewed the problems involved in situation 4 as being treated best by individuals who occupy positions similar to their own or the same as their own. A similar situation is seen in the fact that two of the medical practi- tioners and four of the clergymen viewed the problem presented in situation 4 as being treated best by someone in their own respective posi- tions. The potential importance of this set of find- ings lies in the fact that some potential referral agents view the problem presented in this situa- tion as not only being within their realm of com- petency but being dealt with best by persons in their own or similar positions. This group could hardly be expected to make a referral to a mental health care professional in a situation such as this. Situation 5 “A person always refuses to ride in elevators. Do you think this person needs mental health treatment?’’ Overall the referral agents defined this situation as not requiring mental health treatment, by a margin of three to one. Only 10 of the profession- al and 9 of the nonprofessional referral agents defined this situation as requiring mental health treatment. There was little difference between two professional referral groups. However, among the nonprofessionals, the court, police personnel, and the clergymen were nearly unanimous in their agreement that this situation would not require mental health treatment. These findings can be seen in table 74. The referral agents’ responses to the question of who might best provide help to such a person as situation 5 describes fell within three main cat- egories. Two of the response categories reiterated the referral agents’ earlier definition of this situa- tion, as about one-fourth responded that there was no requirement for help indicated, and one- fifth responded that, if help was indicated, the involved individual himself or his friends would be the best source of help. One-third responded that they either didn’t know or didn’t have enough information to offer a response. Over half of the referral agents either reiterated their defini- tion of this situation as not requiring treatment or responded that they didn’t know or did not have enough information to make a judgment. Howev- er, among the remaining 28 referral agents, 17 responded that psychiatrists or a mental health clinic would be the best source of help for the situation. There are other findings in table 75. Eight of the 22 nonmedical professional referral agents viewed psychiatrists or a mental health clinic as the best source of help. Union officials were the only other referral category where more than two agents expressed this opinion, and among this group only 4 out of 20 saw the psychiatrist or mental health clinic as the best source of help. Situation 6 “A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treat- ment?’ The referral agents overall defined this situation as not requiring treatment by about a three-to-one margin. However, as can be seen in table 76, there was a difference between the professional and nonprofessional referral agents in their views. While the two groups seem to be in agreement that this situation does not require treatment, the nonprofessional referral agents so defined the sit- uation by a five-to-one margin while the profes- TABLE 74.—Referral Agents’ Definitions of Situation 5 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 3 10 1 0 14 Nonmedical 7 14 0 1 22 Subtotal 10 24 1 1 36 Nonprofessional Court/Police 2 1 0 0 13 Union 6 14 0 0 20 Clergy 1 10 0 1 12 Subtotal 9 35 0 1 45 Total 19 59 1 2 81 47 THE REFERRAL AGENTS TABLE 75.—Situation 5—Who Could Best Help? No One Non- or Self psychiatric No Need or Medical Don't No for Help Friends Psychiatrist Practitioner Counselor Others Know Response Total Professional Medical 4 0 2 1 2 0 1 6 14 Nonmedical 0 8 8 2 2 1 4 22 Subtotal 4 3 10 3 2 10 36 Nonprofessional Court/Police 6 1 2 0 0 1 2 1 13 Union 7 2 4 1 0 2 2 2 20 Clergy 1 2 1 0 0 1 1 6 12 Subtotal 14 5 7 1 0 4 5 9 45 Total 18 8 17 4 2 5 8 19 81 TABLE 76.—Referral Agents’ Definitions of Situation 6 Treatment Required Treatment Not Required No Response Total Professional Medical 5 8 1 14 Nonmedical 6 13 3 22 Subtotal 1 21 4 36 Nonprofessional Court/Police 2 n 0 13 Union 3 16 1 20 Clergy 2 9 1 12 Subtotal 7 36 2 45 Total 18 57 6 81 sional groups defined situation 6 by only a two-to- one margin as not requiring treatment. Within each of the two professional groups, there was direct agreement with the overall professional group pattern of the two-to-one margin. Within the three categories that make up the nonprofes- sional group, there was also direct agreement with the overall pattern for the three groups viewed as a whole. Each of these three groups defined the situation by a five-to-one margin as not requiring treatment. Over half of all the referral agents responded that the best source of help could be found within the family itself (see table 77). While the family was seen as the dominant source of help cited by both the professionals and nonprofessionals, three-fifths of the nonprofessionals offered this response, as compared with less than half of the professionals. Three of the 14 medical profession- als cited persons in positions similar to their own as being the best source of help. Among union 48 officials there was a high concentration of agree- ment that the family was the best source of help. Situation 7 “A man cannot seem to hold a job very long because he drinks so much. Do you think this person needs mental health treatment?’ The responses to this item can be seen in table 78, which reveals that overall, about 80 percent of the referral agents defined this situation as requir- ing mental health treatment. While 34 of the 36 professionals so defined this situation, there was less agreement among the nonprofessional group. Nine of the 42 who responded said they viewed the situation as not requiring mental health treat- ment. While a majority in every category viewed mental health treatment as appropriate for the problem presented in this situation, 3 of the 13 court and police personnel, 3 of the 19 union offi- cials, and 3 of the 7 clergymen who responded expressed disagreement. DEFINITIONS OF NEED TABLE 77.—Situation 6—Who Could Best Help? Non- psychiatric Counselor No Need Psychia- Medical or Social Don’t No for Help Family Friends Clergy trist Practitioner Worker Other Know Response Total Professional Medical 1 6 0 0 0 3 3 1 0 0 14 Nonmedical 0 9 3 1 2 0 3 1 0 3 22 Subtotal 1 15 3 1 2 3 6 2 0 3 36 Nonprofessional Court/Police 1 7 0 0 1 1 2 0 1 0 13 Union 0 15 0 0 2 0 1 0 0 2 20 Clergy 0 5 1 0 1 0 1 2 0 2 12 Subtotal 1 27 1 0 4 1 4 2 1 4 45 Total 2 42 4 1 6 4 10 4 1 7 81 TABLE 78.—Referral Agents’ Definitions of Situation 7 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 13 1 0 0 14 Nonmedical 21 1 0 0 22 Subtotal 34 2 0 0 36 Nonprofessional Court/Police 10 3 0 0 13 Union 15 3 1 1 20 Clergy 7 3 0 2 12 Subtotal 32 9 1 3 45 Total 66 1 1 3 81 Alcoholics Anonymous and similar alcoholism prevention and treatment programs were viewed by the overwhelming majority of the referral agents as constituting the best source of help for the problem presented in this situation (see table 79). About two-thirds of the referral agents who responded to this item cited such sources as being best able to help. Psychiatrists and mental health clinics were also viewed as a source of best help. Eight of the professionals and seven of the non- professionals cited these sources. Situation 8 ‘“A young man is always getting into fights and often gets into trouble on the job. Do you think this person needs mental health treatment?” There are some striking differences between the responses offered by the professionals and the nonprofessionals to this question (see table 80). All but one of the professional referral agents responding defined this situation as requiring men- 49 tal health treatment. Yet, about one-third of the nonprofessional group defined this situation as not requiring treatment. Among court and police per- sonnel, 5 out of the 12 defined the situation as not requiring treatment, and 4 of the 10 clergy re- sponded in a similar manner. Yet, 17 out of the 20 union officials agreed with the professional refer- ral agents in viewing the situation as requiring mental health treatment. It might be expected that, for situations similar to the problem in ques- tion, court and police personnel and clergymen would be less likely than the professionals and union officials to refer an individual to mental health treatment. The situation presented is quite similar to the problems that frequently come to the attention of police and court personnel. About half of the referral agents cited a psy- chiatrist or mental health clinic as the best source of help in situation 8. Counselors and social work- ers were also cited by a substantial number. Among court and police personnel there was a THE REFERRAL AGENTS TABLE 79.—Situation 7—Who Could Best Help? Non- psychiatric A.A. and No Need Psychia- Medical Similar Don't No for Help Clergy Family trist Practitioner Programs Union Others Know Response Total Professional Medical 0 0 0 4 1 9 0 0 0 0 14 Nonmedical 0 0 0 4 0 16 0 2 0 0 22 Subtotal 0 0 0 8 1 25 0 2 0 0 36 Nonprofessional Court/Police 1 0 2 4 1 3 0 3 0 1 13 Union 0 0 0 1 0 16 0 2 1 0 20 Clergy 0 1 0 2 0 6 1 1 0 1 12 Subtotal 1 1 2 7 1 25 1 4 1 2 45 Total 1 1 2 15 2 50 1 6 1 2 81 TABLE 80.—Referral Agents’ Definitions of Situation 8 Treatment Required Treatment Not Required Don’t Know No Response Total Professional Medical 14 0 0 0 14 Nonmedical 20 1 0 1 22 Subtotal 34 1 0 1 36 Nonprofessional Court/Police 7 5 1 0 13 Union 17 1 1 1 20 Clergy 6 4 0 2 12 Subtotal 30 10 2 3 45 Total 64 11 2 4 81 wide range of sources of help cited. These includ- Summary ed the courts, the involved man’s employer, his family and friends, and sources of psychiatric care. The phenomenon of a referral agent viewing his own position as being the source of best help in alleviating the problem is seen again in table 81. In every category at least one of the referral agents cited his or her own position as being the best source of help. While the numbers are small, they not only indicate a difference in view from the overall response pattern but also reveal that in all but one category the selection of their own position was not shared by any other category of referral agents. While two of the medical professionals cited medical professionals as being the best source of help, no other referral agent responded in this manner. The same is true for the one court work- er and the one union official who cited their posi- tions as being the best source of help. 50 The professional and nonprofessional referral agents were frequently found to disagree about both the need for mental health treatment in the problem situations presented and the sources the two groups viewed as being best able to help. Although the response frequencies were small, there was a tendency among some referral agents to view positions similar to their own as being best able to provide assistance for the problems presented. The response variations indicate that the likelihood of a troubled individual being re- ferred to treatment is related to the type of refer- ral agent with whom he comes in contact, and to the views of the particular individual occupying that potential referral role. The findings of this section indicate a lack of an organized and coordinated system of referral to treatment. IDENTIFICATION OF OBSTACLES TABLE 81.—Situation 8—Who Could Best Help? Non- psychiatric No Need Family/ Medical for Help Friends Clergy Psychia- trist Counselor/ Practitioner Social Worker Courts Union Employee Other Know Response Total Don't No Professional Medical 0 0 0 10 2 1 0 0 1 0 0 0 14 Nonmedical 0 1 2 8 0 7 0 0 1 2 1 0 22 Subtotal 0 1 2 18 2 8 0 2 2 0 36 Nonprofessional Court/Police 1 1 0 4 0 2 1 0 2 0 1 1 13 Union 0 0 0 12 0 2 0 1 0 4 0 1 20 Clergy 0 1 2 6 0 1 0 0 0 0 0 2 12 Subtotal 1 2 2 22 0 5 3 1 2 4 1 4 45 Total 1 3 4 40 2 13 1 1 4 6 2 4 81 Section VI: Identification of Potential Obstacles to Treatment The same potential obstacles to treatment that were presented to the workers were also present- ed to the referral agents. As was the case with the workers, the referral agents were asked to evalu- ate the degree to which each of the factors would inhibit people from getting treatment. Table 82 reveals these evaluations and shows that the stigma items were viewed as being the strongest inhibitors to treatment. These include being afraid to be thought crazy, embarrassment, and the fear that others would learn about it. The knowledge factors—not knowing they need help, not knowing services are available, and not know- ing they are covered by mental health benefits— were also considered strong deterrents to treat- ment, as were fear of talking to a psychiatrist and the belief that males asking for help show a sign of weakness. A high proportion of the referral group felt that worrying about what might hap- pen, the fear it would affect one’s job, and the feeling that a person should handle his own prob- lems were all factors that would keep workers from seeking treatment. Section VII: Perceptions of Causes for Workers’ Emotional Problems The referral agents were asked to identify what problem areas they felt were the basis for the emotional problems of the workers. Table 83, 51 which presents the first-cited and second-cited problem areas separately, reveals that problems related to the workers’ employment situation were the most frequently cited first area, but that alco- hol, marriage, and income were also frequently cited. Yet, among the second-mentioned areas, problems related to work were infrequently cited, while martial problems, alcohol problems, and income remained dominant. Drug-related prob- lems emerged among the second-cited problems. In a related question, the referral agents were asked what characteristics of factory work, if any, they felt were responsible for or contributed to the emotional problems of workers. As can be seen in table 84, almost half of the referral agents thought that boredom, lack of variety, and job monotony involved in working in an auto plant were at least partially responsible for the emotion- al problems. Another 22, or just over one-fourth of the referral agents, thought that the social or physical working conditions involved in the auto industry could either precipitate or aggravate emotional problems, and a smaller number felt that the lack of workers’ identification with either the job or the product of their labor precipitated emotional problems or aggravated existing emo- tional problems. The referral agents were then asked for their opinions about why people finally become in- volved in treatment and what could be done to encourage people with emotional problems to seek help sooner. With only minor variations between the professionals and the nonprofession- als, the referral agents mentioned a variety of reasons (see table 85). These included the occur- rence of a crisis, self-realization, depression, and THE REFERRAL AGENTS TABLE 82.—Referral Agents Identification of Potential Obstacles to Treatment Don’t Know Very Much | Somewhat | Very Little | Not At All | or No Response Total No transportation Professional 6 11 13 6 0 36 Nonprofessicnal 4 8 22 1 0 45 Total 10 19 35 17 0 81 Would miss favorite Professional 1 12 15 8 0 36 TV program Nonprofessional 5 10 16 14 0 45 Total 6 22 31 22 0 81 Afraid people will think Professional 32 4 0 0 0 36 he is crazy Nonprofessional 33 6 2 3 a 45 Total 65 10 2 3 1 81 Cost of a babysitter Professional 2 22 10 2 0 36 Nonprofessional 2 14 18 1 0 45 Total 4 36 28 13 0 81 The feeling they can Professional 28 7 0 0 1 36 handle their own Nonprofessional 30 10 3 2 0 45 problems Total 58 17 3 2 1 81 Afraid to talk to a Professional 24 1 1 0 0 36 psychiatrist Nonprofessional 23 16 2 3 1 45 Total 47 27 3 3 1 81 Not knowing they Professional 28 6 2 0 0 36 need help Nonprofessional 29 12 2 1 1 45 Total 57 18 4 1 1 81 Embarrassment Professional 28 6 2 0 0 36 Nonprofessional 28 14 1 2 0 45 Total 56 20 3 2 0 81 Not knowing services Professional 5 0 0 36 are available Nonprofessional 6 2 1 45 Total 37 40 11 2 1 81 Not knowing they are Professional 23 13 0 0 0 36 covered by insurance Nonprofessional 30 12 3 0 0 45 Total 53 25 3 0 0 81 Worrying about what Professional 24 1 0 1 0 36 might happen Nonpfofessional 24 1 2 0 45 Total 48 29 1 3 0 81 The feeling that asking for Professional 25 10 1 0 0 36 help is a sign of weakness Nonprofessional 21 16 8 0 0 45 for males Total 46 26 9 0 0 81 The fear that others Professional 26 9 0 1 0 36 will learn about it Nonprofessional 28 14 1 2 0 45 Total 54 23 1 3 0 81 The feeling that just Professional 13 21 2 0 0 36 talking will do no Nonprofessional 13 19 13 0 0 45 good Total 26 40 15 0 0 81 52 PERCEPTIONS OF CAUSES TABLE 82.—(Cont'd.) Referral Agents’ Identification of Potential Obstacles to Treatment Don’t Know The fear it will affect Professional 15 20 1 0 0 36 his job Nonprofessional 20 16 3 6 0 45 Total 35 36 4 6 0 _81 TABLE 83.—Referral Agents’ Perception of Causes for Workers” Emotional Problems Dissatisfaction Getting Along Health Work Alcohol Income Drugs Marriage With Self With Others Other Total First Problem Area Mentioned Professional 0 6 7 4 0 9 5 4 1 36 Nonprofessional 5 13 9 6 1 5 3 1 2 45 Total 5 19 16 10 1 14 8 5 8 81 Second Problem Area Mentioned Professional 0 1 5 4 5 9 4 4 4 36 Nonprofessional 2 4 5 6 8 2 3 6 45 Total 2 5 14 9 1 17 6 2 10 81 TABLE 84.—Characteristics of Factory Work Viewed as Being Responsible or Aggravating the Emotional Problems of Workers Lack of Lack of Physical Variety, or Identification or Social Monotony, With Job or Working of Work Product Conditions Other Don’t Know Total Professional 17 4 9 4 2 36 Nonprofessional 21 2 13 6 3 45 Total 38 6 22 10 5 81 TABLE 85.—What Finally Motivates People to Seek Help? Crisis— Cause Referred Referred They Get Self- Problems Only by by Other/ Into Realization With Alternative Relatives Pro- No Trouble of Problems Depression Family Left & Friends fessionals Response Total Professional 8 9 5 6 1 6 0 1 36 Nonprofessional 13 7 5 7 4 6 2 1 45 Total 21 16 10 13 5 12 2 2 81 53 Very Much | Somewhat | Very Little | Not At All | or No Response Total THE REFERRAL AGENTS the development of a strain in family relation- tudes toward receiving treatment were all fre- ships. The final motivation is viewed as possibly quently cited as ways of removing barriers to deriving from several sources. The referral treatment. The referral agents reported what has agents’ suggestions for encouraging people with been generally known in this area: people usually problems to seek help sooner were generally relat- wait for problems to become somewhat severe or ed to the sources they viewed as providing the to cause them problems with others before finally final motivation to seek treatment (see table 86). seeking help, and the main ways of altering this Such suggestions as promoting a general knowl- phenomenon derive from changing community edge of mental health, promoting an awareness of attitudes toward mental health and mental health the benefits available, and changing peoples’ atti- treatment. TABLE 86.—What Would Encourage People with Mental or Emotional Problems to Seek Help Sooner? Change Promote Better Promote General Attitude by Promote Understanding of Knowledge of Reducing Knowledge Mental Health Don’t Know/ Mental Health Stigma of Benefits Treatment Other No Response Total Professional 16 8 5 2 4 1 36 Nonprofessional 16 7 8 5 6 3 45 Total 32 15 13 7 10 4 81 Section VIII: Referral Agents’ Personal treatment alleviated the problem in question. Ta- Experience with Mental Health ble 87 shows which family member received help. Treatment Among the professional referral agents, 6 of the 14 medical professionals reported such experi- ences. Three of these six involved the referral Forty-two percent of all referral agents reported agent himself. Among the nonmedical profession- having either been in treatment themselves or als, 12 of the 22 reported treatment experiences, having had first-hand knowledge from members of and 5 of these 12 involved the referral agent him- their own families. Thirty-three out of 34 referral self. Among the nonprofessional referral agents, 4 agents who reported such experiences answered of the 13 court and police personnel reported additional questions about the nature of the prob- treatment experiences, and 3 of the 4 experiences lem: the family member involved, the source of involved the referral agent. Six of the 20 union help, and their evaluation of whether or not the officials reported treatment experiences, and 2 of TABLE 87.—Referral Agents Who Reported Problems: Which Family Member Other Family No Response Spouse Children Self or Relatives Total Professional Medical 8 0 2 3 1 14 Nonmedical 10 1 4 5 2 22 Subtotal 18 1 6 8 3 36 Nonprofessional Court/Police 9 0 0 3 1 13 Union 14 1 1 2 2 20 Clergy 7 0 0 4 1 12 Subtotal 30 1 1 9 4 45 Total 48 2 7 17 7 81 54 EXPERIENCE WITH TREATMENT the 6 experiences involved the union official him- self. Five of the 12 clergy reported similar experi- ences, and in 4 of the 5 cases the clergyman him- self was the recipient of the help. The profession- al group had more personal experience with men- tal health treatment, and for all categories of re- ferral agents the respondent himself was the most likely to have been the one receiving such treat- ment. Reasons Given for Treatment Experiences Although the numbers within each referral cate- gory are quite small, table 88 presents the types of reasons given by each of the five categories of referral agents. Overall, 14 of the 33 treatment experiences involved marital problems or prob- lems with children. Additionally relevant is the fact that 10 of the 33 reported experiences in- volved general mental problems, the individual being dissatisfied with himself or having difficulty in getting along with other people. Sources of Help Table 89 presents the sources cited as having provided the reported treatment. While the num- bers in this table are quite small, they do reveal that 10 of the 16 professional referral agents who reported treatment experiences cited a psychia- trist or a mental health clinic as the source of treatment. This compares with only 2 of the 15 nonprofessional referral agents who reported the same source. Mental health care professionals were used in the majority of treatment experi- ences reported by professional referral agents and were infrequently used by those nonprofessional TABLE 88.—Referral Agents Who Reported Problems: Type of Problems Getting Marriage/ Along Dis- Family With satisfied Mental No Health ~~ Work Children Problems Drugs Others With Self Problems Other Response Total Professional Medical 0 0 1 1 1 0 1 2 1 7 14 Nonmedical 1 1 4 1 0 1 0 2 2 10 22 Subtotal 1 1 5 2 1 1 1 4 3 17 36 Nonprofessional Court/Police 0 1 0 1 0 0 0 1 1 9 13 Union 0 0 0 4 1 1 0 0 0 14 20 Clergy 0 1 1 1 0 0 1 1 0 7 12 Subtotal 0 2 1 6 1 1 1 2 1 30 45 Total 1 3 6 8 2 2 2 6 4 47 81 TABLE 89.—Referral Agents Who Reported Problems: Sources of Help for Their Problems Non- Psychiatrist psychiatric or Mental Medical Social No Clergy Health Clinic Practitioner Counselor Agency Others Response Total Professional Medical 0 5 0 0 0 0 9 14 Nonmedical 3 5 2 3 0 0 1 22 Subtotal 3 10 1 0 0 20 36 Nonprofessional Court/Police 0 1 0 0 1 2 9 13 Union 1 1 2 0 2 0 14 20 Clergy 4 0 0 0 0 1 7 12 Subtotal 5 2 2 0 3 3 30 45 Total 8 12 4 1 3 3 50 81 55 THE REFERRAL AGENTS referral agents who reported treatment experi- ences. Four of the five clergymen who reported treatment experiences said that other clergymen had been the source of help in alleviating the problem. Twenty-seven of those who reported treatment experiences said the treatment received had helped to alleviate the problem, and there was lit- tle difference between any of the referral catego- ries in their evaluation of the treatment received. Section IX: Referral Agents’ Experience With Referral Activities Several items were included in the interview to measure the referral agents’ actual experiences in the performance of the referral role. The first of these was related to how often the referral agents were asked for their advice about personal or emotional problems. As can be seen in table 90, over half of the referral agents reported they were often asked for such advice, over one-fourth were sometimes asked for their advice, and only two were never asked for such advice. All but two of the referral agents reported having had some de- gree of experience in advising others about their personal or emotional problems. This group can be viewed as having had one or more opportuni- ties to assist troubled individuals to seek profes- sional help. The referral agents’ experiences in two specific referral activities were also examined. A series of four questions each were presented relating to referring troubled individuals to a psychiatrist and to a mental health clinic. About three of every four referral agents re- ported having at one time or another suggested to a person seeking advice that he should see a psy- chiatrist. Among the professionals, all the physi- cians and 17 of the 22 nonmedical personnel re- ported having offered such advice. Among the nonprofessionals, 7 of the 12 clergymen, 18 of the 20 union officials, and 9 of the court and police personnel responded in a similar manner. Not only did the referral groups as a whole have the opportunity to make referrals, but many of them when presented with that opportunity at least suggested a psychiatrist (table 91). Consider- ing only those who ever suggested that a person seek treatment from a psychiatrist, about half (31 out of 59) offered the name of a specific psy- chiatrist (table 92), over two-thirds (41 out of 58) reported that the person actually went to a psy- chiatrist (table 93), and about the same proportion (41 out of 53) reported that it was their recom- mendation that actually prompted the person to 20 to a psychiatrist (table 94). While this overall pattern may appear to be promising from the view of a potentially effective referral-to-treatment system, there are variations between the referral categories. It is not surpris- ing that physicians were the most actively in- volved in referrals to a psychiatrist, but it is sur- prising that not more of the nonmedical profes- sionals had ever suggested to a troubled individual that he should see a psychiatrist and, that of those of this group who did, less than half were able to give the troubled individual the name of a specific psychiatrist. Considering the referral ex- periences of the nonprofessionals, it appears that their actions mainly consisted only of offering troubled individuals generalized suggestions about what they should do. The suggestions that help should be sought from a psychiatrist were more of a motivational dimension than a beginning step TABLE 90.—How Often Referral Agents Were Asked for Their Advice About Mental or Emotional Problems Almost Often Sometimes Never Never Total Professional Medical 8 4 2 0 14 Nonmedical 12 8 2 0 22 Subtotal 20 12 4 0 36 Nonprofessional Court/Police 6 4 2 1 13 Union 8 5 6 1 20 Clergy 8 3 1 0 12 Subtotal 22 12 9 2 45 Total 42 24 13 2 81 EXPERIENCE WITH REFERRAL TABLE 91.—Referral to a Psychiatrist: Have You Ever Suggested a Person Go to a Psychiatrist? TABLE 94.—Referral to a Psychiatrist: Did That Person Go to a Psychiatrist on Your Recommendation? Don’t No Yes No Total Yes No Know Response Total Professional Professional Medical 14 0 14 Medical 12 0 2 0 14 Nonmedical 17 5 22 Nonmedical 1 2 2 7 22 Subtotal 31 5 36 Subtotal 23 2 4 7 36 Nonprofessional Nonprofessional Court/Police 9 4 13 Court/Police 7 0 0 6 13 Union 13 7 20 Union 5 1 4 10 20 Clergy 7 5 12 Clergy 6 1 0 5 12 Subtotal 29 16 45 Subtotal 18 2 4 n 45 Total 60 21 81 Total 41 4 8 28 81 TABLE 92.—Referral to a Psychiatrist: Did You Give the Person the Name of a Specific Psychiatrist? Yes No No Response Total Professional Medical 12 2 0 14 Nonmedical 7 6 22 Subtotal 19 1 6 36 Nonprofessional Court/Police 5 4 4 13 Union 2 1 7 20 Clergy 5 2 5 12 Subtotal 12 17 16 45 Total 31 28 22 81 TABLE 93.—Did That Person Go to a Psychiatrist? Don’t No Yes No Know Response Total Professional Medical 1 0 3 0 14 Nonmedical 12 2 1 7 22 Subtotal 23 2 4 7 36 Nonprofessional Court/Police 6 1 3 5 13 Union 8 1 b 6 20 Clergy 7 0 0 5 12 Subtotal 21 2 6 16 45 Total 44 4 10 23 81 in the activities that would result in getting the troubled individual to treatment. While motivation and support are necessary referral activities, the referral role encompasses more. Without specific knowledge of the profes- sional sources of mental health care, the potential agent of referral is hindered in assisting people. Motivation is important, but without possessing and offering information about how to get to treatment and the specific sources of treatment available, the actions of the potential referral agents can be considered no more than general- ized advice-giving. In order to be effective, the referral role should include being able to recognize situations that could benefit from professional treatment, being in a position of esteem so that people with trou- bles feel they can and should ask for assistance, being able to motivate and direct people when they are in states of confusion, and having knowl- edge of and offering specific alternatives to the help-seeker. The nonprofessionals and nonmedical profes- sionals cannot be considered to be effective sources of referral to professional mental health treatment. While the potential is there, in that those with problems apparently do feel the refer- ral agents are people to whom they can turn for advice about personal problems, without guidance the efforts of these categories of referral agents to help others will probably continue, as in the past, to be ineffective. The fact that five of the nonmedical professionals, seven of the union officials, five of the clergymen and four of the court and police personnel (one-third of all refer- ral agents) have never suggested that an individual seek help from a psychiatrist, and the further fact that among these same groups a number of those who did suggest a psychiatrist as a source of help did nothing more than other general advice, demonstrates that these potential sources of refer- ral were not functioning effectively. THE REFERRAL AGENTS Further evidence can be seen in the referral agents’ responses to questions about their experi- ences in suggesting that troubled individuals should seek help at a mental health clinic. More than half of the referral agents reported having suggested to others that they should go to a men- tal health clinic for help (see table 95), but the response patterns within each of the referral cate- gories reveal unpromising findings. Among the professionals, almost one-third said that they had never suggested to anyone that he or she should seek help from a clinic. Three of the physicians and seven of the nonmedical per- sonnel were unable to report such experiences. These findings suggest an ineffective referral oper- ation even among the professionals, whose formal TABLE 95.—Referral to a Mental Health Clinic: Have You Ever Suggested a Person Go to a Mental Health Clinic? Yes No No Response Total Professional Medical 1 3 0 14 Nonmedical 13 7 2 22 Subtotal 24 10 2 36 Nonprofessional Court/Police 12 1 0 13 Union 3 17 0 20 Clergy 6 6 0 12 Subtotal 21 24 0 45 Total 45 34 2 81 roles often include assisting, guiding, and direct- ing those with problems to sources of remedy. Among the nonprofessionals, only 3 of the 20 union officials and 6 of the 12 clergymen reported ever having suggested that a person seek help at a mental health clinic. These groups are also con- sidered to have been less than fully involved in an effective referral operation. Twelve of the 13 court and police personnel reported that they had at one time or another suggested a mental health clinic as a source of remedy for troubled indivi- duals. Nine of this group suggested that a psy- chiatrist could provide help for troubled people. These response patterns are not indicative of a positive referral-to-treatment involvement, since most of these reported experiences include situa- tions in which the courts or their agents became aware of the individuals’ problems after a crisis, a law violation, or in the case of juveniles, after the court was required to enter into supervision of the juvenile. Referrals to treatment within these situa- tions are often not for the purpose of health maintenance or health-problem prevention. They are most likely to be a form of social-crisis inter- vention in which diagnosis and treatment occur not as the result of an individual’s coming to the resolution that he or she needs help. The fact that the police-court referral category reported having been active testifies more to the lack of an effec- tive community system of mental health mainte- nance in which individuals are referred to profes- sional treatment prior to the development of a cri- sis of such magnitude that the police and courts are required to intervene. With regard to the other items related to the referral agents’ experience in referring people to a mental health clinic, the findings are again sugges- tive of the potential for an effective referral sys- tem and evidence that such a system at present does not fully exist. Table 96 shows that all of those professional referral agents who suggested that a person seek help at a mental health clinic were able to give the troubled person the name of a specific clinic. Only one of the union officials and four of the clergymen were able to do so. Yet it appears that, in those instances in which a specific clinic was suggested, the troubled individual did actually make contact with that clinic. As can be seen in table 97, almost all of those who were given the name of a specific clinic actually visited that clin- ic. Further, the referral agents who had suggested specific clinics unanimously reported that the troubled individuals they had counseled sought help from the recommended clinics, primarily on the basis of recommendations (see table 98). A hypothetical situation involving a troubled individual turning to the referral agent for advice was presented to each of the referral agents, and TABLE 96.—Referral to a Mental Health Clinic: Did You Give the Person the Name of a Specific Mental Health Clinic? Yes No No Response Total Professional Medical 1 0 3 14 Nonmedical 13 0 9 22 Subtotal 24 0 12 36 Nonprofessional Court/Police 12 0 1 12 Union 1 2 17 20 Clergy 4 1 7 12 Subtotal 17 3 25 45 Total a4 3 37 81 EXPERIENCE WITH REFERRAL TABLE 97.—Referral to a Mental Health Clinic: Did That Person Go to a Mental Health Clinic? Don't No Yes No Know Response Total Professional Medical 9 0 1 4 14 Nonmedical 13 1 7 22 Subtotal 22 1 2 11 36 Nonprofessional Court/Police 10 0 1 2 13 Union 2 1 1 16 20 Clergy 4 0 0 8 12 Subtotal 16 1 2 26 45 Total 38 2 4 37 81 TABLE 98.—Referral to a Mental Health Clinic: Did That Person Go to a Mental Health Clinic on Your Recommendation? they were asked what they would do if they were confronted with that situation. Table 99 shows the reactions of the referral agents to the situation presented. The most frequent overall reactions to the problem presented were either to handle the problem themselves or to refer the individual to a mental health care professional. Overall, 68 of the referral agents offered either of these responses. Yet, a separate analysis of the frequency with which each of these two responses was offered by the professionals and nonprofessionals shows the professionals to be less likely to try to resolve the problem themselves than they are to refer the person to a mental health care professional (11 to 18), while among the nonprofessionals the reverse was true (25 to 14). Although there is overall about an equal division between those referral agents who would attempt to resolve the problem themselves and those who would refer the indivi- dual to professional care, there appears to be a greater tendency among the professionals to make a referral and among the nonprofessionals to try to help resolve the problem themselves. Don’t No The responses of the referral agents to one Yes No Know Response Total genera] question about the frequency with which } troubled individuals asked for their advice and to Professional 3 ' « Medical 2 0 1 a 12 two series of questions measuring the referral Nohmenical 13 0 1 8 22 agents’ experience in referring people to a psy- Subtotal 22 0 2 12 36 chiatrist or a mental health clinic reveal that, while = the potential is present for an effective referral Norprafessionat system involving individuals occupying a variety Gourt/Potice i ; 9 > = of community roles, such a system does not now Clergy a 0 0 8 12 exist. The vast majority of the referral group has Subtotal 16 0 1 28 45 had the opportunity to advise others. They are, therefore, viewed as being in positions to effect Total cd 0 3 40 3 referrals to professional treatment, and this is a TABLE 99.—What Referral Agents Would Do if a Troubled Individual Sought Their Help Attempt to Refer Refer to Suggest That Resolve the to Mental Refer to a Social Friends or Problem Health Family Work Refer to Family Themself Professional Physician Agency Clergy Could Help Other Total Professional Medical 4 9 0 1 0 0 0 14 Nonmedical 7 9 1 2 1 1 1 22 Subtotal 1 18 1 3 1 1 1 36 Nonprofessional Court/Police 4 8 0 1 0 0 0 13 Union 12 4 2 0 0 1 1 20 Clergy 9 2 0 0 0 0 1 12 Subtotal 25 14 2 1 0 1 2 45 Total 36 32 3 4 1 2 3 81 59 THE REFERRAL AGENTS potential strength. But fewer of the professionals than would be expected had actual referral experi- ences and, among nonmedical professionals, the union officials, and the clergy who reported such experiences, a number of these experiences were limited to supportive or motivational contacts only. The active involvement of the courts in re- ferral activities was seen as being evidence of the lack of an effective health maintenance and crisis prevention system. Development of such an ef- fective system could be furthered to a considera- ble degree by the involvement of the other poten- tial referral agents in more effective referral activ- ities. The potential for an effective community-wide referral system can also be seen in the referral agents’ responses to two related questions. Table 100 shows that the overwhelming majority of the referral agents considered watching for possible signs of emotional problems and referring such individuals to professional help as being part of the responsibilities of their positions. While the fact that five of the union officials did not so view their role does offer some opposing evidence, it may reasonably be concluded that the strength and direction of the response patterns of the other referral groups are suggestive of the potential pre- sent for the referral agents’ acceptance, and therefore potential performance of the referral role. As can be seen in table 101, the majority of the referral agents felt that actually engaging in refer- ral activities would not jeopardize their relation- ship with the troubled individual. The responses to these two items indicate a strong potential for the development of an effective referral system. The referral agents not only view the performance of the referral role as a legitimate part of their positions but they perceive that others tend to view them in a similar manner. TABLE 100.—Do You Think Its Part of Your Job to Watch for Possible Signs of Emotional Problems and Refer the Individual to Professional Help? Yes No No Response Total Professional Medical 14 0 0 14 Nonmedical 21 0 1 22 Subtotal 35 0 1 36 Nonprofessional Court/Police 7 2 0 13 Union 15 B 0 20 Clergy 10 1 1 12 Subtotal 36 8 1 45 Total 71 8 2 81 TABLE 101.—Do You Think Recognizing a Mental Health Problem and Referring the Individual to Treatment Would Jeopardize Your Position With That Person? Yes No No Response Total Professional Medical 3 1 0 14 Nonmedical 1 19 2 22 Subtotal 4 30 2 36 Nonprofessional Court/Police 0 13 0 13 Union 4 15 1 20 Clergy 2 10 0 12 Subtotal 6 38 7 45 Total 10 68 3 81 CHAPTER 4: THE PROVIDERS Section |: Representation of Various Fields Mental health care can be provided by indivi- duals from various fields and within several set- tings, and the 72 mental health care providers in- cluded in this study reflect these variations. Twenty-eight of this group were practicing psy- chiatrists, nine of whom were engaged solely in private practice. Of the other psychiatrists, 14 held staff positions with hospitals or clinics, and 10 of these positions involved supervision of oth- er professionals. In addition, 5 other psychiatrists held consulting positions with social agencies or hospitals in addition to engaging in private prac- tice. The nonpsychiatric providers included 10 psy- chologists, 2 directors of psychiatric nursing staffs, 16 professional social workers, 6 case workers, 9 counselors, and 1 special-education teacher. Considering the total provider group, about 33 percent of their positions involved both providing treatment and performing administrative duties, about 25 percent were solely administra- tors, and over 40 percent were solely involved with treatment activities. Further, nearly all of the providers held full-time positions. The provider group, therefore, represents a wide range of mental health care experiences. They were selected because they were representa- tive of various professional fields, held positions with different types of mental health facilities, and provided care in a private practice setting as well. Section Il: Awareness of Available Services As was expected, the providers were knowl- edgeable about the existing mental health facilities in the study area. When asked to give the names of existing facilities, the majority of the providers named more than four such facilities. While the range of number of facilities named was from 1 to 19, 22 of the providers named between 6 and 10 services, and 6 were able to name between 11 and 19 (see table 102). It is clear that as a group the providers were quite knowledgeable about the mental health facilities in the Pontiac area. All of the psychiatrists were able to name two or more of their colleagues who are in private practice. It is interesting, however, that all but seven of the nonpsychiatric providers were able to name two or more psychiatrists who had a pri- vate practice in the study area and that only three of this group were not able to name at least one such professional practitioner (see table 103). TABLE 102.—Awareness of Mental Health Facilities Eleven- Aware Of: One Two Three Four Five Six-Ten Nineteen Total Psychiatrists 0 3 1 9 8 6 1 28 Nonpsychiatric Providers 1 1 4 9 8 16 5 44 Total 1 4 18 16 22 6 72 TABLE 103.—Awareness of Psychiatrists in Private Practice Aware Of: One Two Three Four-Seven Don’t Know Total Psychiatrists 0 20 4 4 0 28 Nonpsychiatric Providers 4 28 5 4 3 44 Total 48 9 8 3 72 THE PROVIDERS Section lll: Evaluation of Available Services Table 104 presents the providers’ responses to the question of whether they felt services in the study area were adequate. The providers were found to be dissatisfied with the existing services. Those providers who said that they felt the serv- ices available were inadequate outnumbered the providers who felt that the services were ade- quate (44 to 24). The psychiatrists were found to be split between those who felt the services avail- able were adequate and those who felt that the services were not adequate. Among the nonpsy- chiatric providers, those who felt the services available were not adequate outnumbered by a margin of almost three to one those who viewed these services as adequate. There was reservation as to the adequacy of the available mental health facilities. Those providers who were negative about the adequacy of existing mental health facilities were asked what they felt were the existing inadequa- cies. Their responses to this question can be seen in table 105. Three main reasons were offered by these providers. Sixteen of the 43 providers said either that they felt the number of existing facili- ties to be inadequate to meet the needs of the community, or that the quality of the existing fa- cilities was less than adequate. Eight of the provi- ders offered the belief that there were too few professionally trained personnel. The third reason involved evaluations of the delivery of services and centered on comments indicating that people were simply not well informed about the channels to be followed. Over half of those providers re- sponding cited a belief that the quantity or quality of services available were inadequate to the needs of the community, or that the number of available mental health care professionals was inadequate. TABLE 104.—Evaluations of the Available Mental Health Facilities Consider Services Consider Services Don't Know/ Adequate Inadequate No Response Total Psychiatrist 13 13 2 28 Nonpsychiatric Providers 11 31 44 Total 24 44 4 72 TABLE 105.—Reasons Cited for Negative Evaluations of Available Mental Health Facilities Quantity or Quality of Poor No Facilities Service Poor Inadequate Other Response Inadequate Delivery Treatment Personnel Unspecified Total Psychiatrist 15 5 3 0 4 1 28 Nonpsychiatric Providers 14 1" 8 44 Total 29 16 11 2 72 Section IV: Awareness of Insurance Benefits As with both the workers and the referral agents, the providers were asked whether or not they thought the workers were eligible for six provisions of the mental health benefits. The ma- jority in both the psychiatric and nonpsychiatric categories was sure that the workers or their de- 62 pendents were eligible for each of the six provi- sions (see table 106). Hospitalization The providers’ awareness level of the provision for hospitalization was found to be high, but there was an observed difference between the aware- ness levels of the two provider groups. The psy- chiatrists were almost unanimously aware of workers’ eligibility for hospitalization for mental AWARENESS OF BENEFITS TABLE 106.—Providers’ Awareness of Workers’ Mental Health Benefits Not Sure But Don’t Think Sure Workers Sure Workers Think They They Are But Are Not Don't Are Covered Are Covered Not Sure Covered Know Total Hospitalization Psychiatrist 26 1 0 0 1 28 Nonpsychiatric Providers 35 6 1 0 2 44 Total 61 1 3 72 Psychological Testing Psychiatrist 20 5 0 0 3 28 Nonpsychiatric Providers 35 7 0 2 44 Total 55 12 5 72 Treatment by Psychiatrist in Private Practice Psychiatrist 27 0 0 0 1 28 Nonpsychiatric Providers 33 4 2 1 4 44 Total 60 1 72 Dependents Treated by a Psychiatrist in Private Practice Psychiatrist 25 2 0 0 0 27 Nonpsychiatric Provider 31 4 1 0 3 39 Total 56 1 66 Treatment at a Mental Health Clinic or Center Psychiatrist 26 1 0 0 1 28 Nonpsychiatric Providers 36 6 0 44 Total 62 72 Dependents Treated at a Mental Health Clinic or Center Psychiatrist 26 1 0 0 0 27 Nonpsychiatric Providers 36 0 0 2 42 Total 62 2 69 or emotional problems. Twenty-six of the 28 psy- chiatrists said they were sure that the workers were eligible. Among the nonpsychiatric provi- ders, 35 of the 44 were sure that the workers were eligible, while an additional 6 responding thought that the workers were eligible. While both groups were found to have a high level of aware- ness, the psychiatrists were more definite in their responses. Psychological Testing Providers were also quite aware of the provi- sion for psychological testing, as 25 of the 28 psychiatrists at least thought that the workers were eligible, and 20 of the 28 psychiatrists were sure that the workers were eligible. Among the nonpsychiatric providers, 35 of the 44 were sure 63 that the workers were eligible, while 42 at least thought that the workers were eligible. Further evidence of the high level of awareness of both the psychiatric and nonpsychiatric providers for the psychological-testing provision is that none of either group thought or were sure that the work- ers were not eligible. Treatment by a Psychiatrist in Private Practice Among the psychiatrists, 27 of the 28 were sure that the workers were eligible for treatment by a psychiatrist in private practice, while among the nonpsychiatrists 7 of the 44 either said they didn’t know, thought the workers were not eligible, or were sure that the workers were not eligible. While the fact that 33 of the nonpsychiatrists THE PROVIDERS were sure that the workers were eligible indicates a high level of awareness among this group, the pattern among the nonpsychiatric providers indi- cates a lower level of awareness as compared with the psychiatrists and also indicates the pres- ence of some misunderstandings. Treatment at a Mental Health Clinic or Center In response to the question on treatment at a mental health clinic or center, the providers again displayed their rather high level of awareness of the workers’ benefits. Twenty-six of the psy- chiatrists were sure that the workers were cov- ered, and 36 of the 44 nonpsychiatric providers responded in a similar manner. In addition, among the nonpsychiatric providers, 42 of the 44 thought that the workers were eligible. This pattern indi- cates that, while both groups can be said to have a high level of awareness of workers’ eligibility, the psychiatrists were more definite in their opin- ions. The Eligibility of the Workers’ Dependents The providers reported being sure that the workers’ dependents were eligible for treatment by a psychiatrist in private practice and for treat- ment at a mental health clinic or center. Fifty-six of the 66 providers were sure that workers’ de- pendents were eligible for treatment by a psy- chiatrist in private practice, and 62 of the 66 at least thought that the workers’ dependents were eligible for this provision. With regard to treat- ment at a mental health clinic or center, 62 of the 60 providers indicated that they were sure that the workers’ dependents were eligible and 67 of the 69 thought that the dependents were eligible for this treatment. The providers were seen as being aware that workers and their dependents were eligible for prepaid mental health care. Slight variations were observed between the psychiatrists and nonpsy- chiatrists in their awareness of each of the six provisions. A higher proportion of the psychia- trists than of the nonpsychiatrists reported being sure that the workers or their dependents were eligible for each of the six provisions. While the nonpsychiatric providers had a lower proportion of being sure, the vast majority of this group thought that the workers or their dependents were eligible for each of the provisions. While there are differences between the response patterns of the two provider groups, these differences are not considered to be as important as the response pat- tern for the total provider segment, which indi- cates a high level of awareness of each of the six benefit provisions. Not only were the providers found to be well informed about the benefits, they were also found to be able to identify sources from which additional relevant information could be obtained (see table 107). When the providers were asked their percep- tions of the workers’ awareness of mental health benefits, they were split between those who thought the workers were somewhat aware of their mental health benefits and those who thought the workers knew very little about them. While the overall result of this response pattern is a perception that the workers are not very well informed (see table 108), the providers perceived TABLE 107.—Identified Sources of Additional Information About UAW Mental Health Benefits Psychiatrist Agency Insur- Union or Mental Company Admin- ance Don’t Source Health Clinic Hospital Source istration Carrier Know Total Psychiatrist 3 0 0 0 4 17 4 28 Nonpsychiatric Providers 3 5 2 1 27 44 Total 6 5 2 2 5 a4 72 TABLE 108.—Providers’ Perception of How Much Workers Know About Their Benefits Greut Deal Some Very Little Don’t Know Total Psychiatrist 1 15 11 1 28 Nonpsychiatric Provider 19 22 1 44 Total 3 34 33 2 72 64 AWARENESS OF BENEFITS that the workers were slightly better informed than either of the other two groups. While the majority of the workers felt that other workers knew very little about their mental health benefits, and a similar response pattern was seen among the referral agents, the providers indicated that they perceived workers to be slightly more knowl- edgeable. This result could be explained by the fact that the workers with whom the providers have had contact were those workers who had decided to seek professional help and thus may, prior to entering treatment, have explored the possibility of being eligible for mental health ben- efits. Providers were asked what could be done to improve means of informing the workers of their benefits. The overwhelming response of the provi- ders to this question reveals their perception of the need for the union to: provide lectures or dis- cussions at local meetings, make better utilization of the union publications, or set up a special office to disseminate information about the bene- fits to the union members. These responses can be seen in table 109. Two of the psychiatrists and two of the nonpsychiatric providers said there was no need to inform the workers better because even if the workers had such knowledge they wouldn’t utilize professional mental health serv- ices. Table 110 presents the sources from which the providers report having first learned about mental health benefits. Psychiatrists or a mental health clinic constituted the most frequently cited source; 28 of the providers gave this source, and no other source was mentioned by more than eight providers. Included in the less frequently cited sources were the UAW, social work agen- cies, and the insurance carrier. Six providers had never heard of the UAW benefits. The providers were also asked their opinions related to prepaid mental health care. Their opin- ions can be seen in table 111, which shows that 45 of the 69 providers offered positive opinions, 16 were neutral on the matter, and 8 offered negative TABLE 109.—What Could Be Done to Better Inform Workers About Their Benefits Union Should Union Should Set Up a Union No Need Provide More Provide Lectures Utilize Utilize Office for Dis- Because It Don’t Know Information & Discussions Mass Union Pub- seminating Would Not or (General) at Meetings Media lications Information Help Other Total Psychiatrist 7 6 0 7 3 2 3 28 Nonpsychiatric Providers 7 19 3 7 4 2 2 44 Total 14 25 14 7 4 5 72 TABLE 110.—Sources From Which the Providers First Heard of UAW Mental Health Benefits Psychiatrist Non- Family or Mental psychiatric Social Member Never Mass Union Health Medical Work Insurance or Don't Heard Media Source Clinic Practitioner Agency Carrier Friend Know Total Psychiatrist 1 1 7 4 2 1 5 0 7 28 Nonpsychiatric Providers 5 2 1 14 0 4 2 4 12 44 Total 6 3 8 18 19 72 TABLE 111.—Opinions of Having Prepaid Mental Health Care Positive Neutral Negative No Response Total Psychiatrist 14 6 2 28 Nonpsychiatric Providers 31 2 1 44 Total 45 3 72 65 THE PROVIDERS opinions. Three out of four of the nonpsychiatric providers offered positive opinions, and only two viewed the benefits in a negative light. Among the psychiatrists, just over half offered positive opin- ions, while six members of this group expressed a negative opinion. While most of the providers expressed either a positive opinion about the ex- istence of mental health benefits or were neutral on the matter, a small number, mainly psychia- trists, were found to have negative opinions about prepaid mental health benefits. Another related item asked the providers if they perceived any deficiencies in the mental health benefits. In table 112, the responses to this item indicate that over half of the respondent providers felt that the benefits did not cover enough of the cost of treatment. Less frequently cited draw- backs were the belief that the benefits did not in- clude enough services and that people are not well informed about the benefits. Eighteen of the providers responded that they didn’t perceive of anything wrong with the benefits. While almost half of the providers cited a belief that the bene- fits did not cover enough of the cost of treatment, about one-third thought the benefits were ade- quate as constituted. TABLE 112.—Perceived Deficiencies in the UAW Mental Health Benefits Does Not People Cover Does Not Not Well Nothing Don’t Enough of Include Informed Wrong Know the Costs Enough About With or No of Treatment Services Benefits Other Benefits Response Total Psychiatrist 12 1 3 3 7 2 28 Nonpsychiatric Providers 18 1 11 9 44 Total 30 6 4 18 1 72 Section V: Definition of Need for Mental Health Treatment The same eight hypothetical problem situations presented to the workers and referral agents were also presented to the providers, but the manner of presentation differed. While the workers and re- ferral agents were asked, ‘‘Do the following need mental health treatment?” and ‘“Who could best help alleviate the problems presented?’’ the provi- ders were presented with a more detailed set of instructions. That is, they were told that while it was assumed a psychiatrist could provide help for any mental or emotional disturbance, that level of expertise might not be required for all such situa- tions. Someone else with less expertise may offer a service which may be adequate to provide relief in a number of situations. In accordance with this difference in instruction, the providers, when asked about who could provide assistance in alle- viating the problems presented, were instructed to consider who could provide adequate help in each of the situations. Thus, for the eight situations, the workers and referral agents were asked who could best provide help, while the providers were asked who could provide adequate help in each case. Any differences in the responses of the 66 workers or referral agents when compared with the providers are considered to reflect conserva- tive estimates of differences in opinion or defini- tion. Situation 1 “A working man watches television from the time he gets home from work until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment?”’ Table 113 presents the providers’ definitions of the need for treatment in this situation. Five out of seven of the providers viewed this situation as requiring treatment. Eight of this group defined situation 1 as not requiring treatment, and 13 of the providers did not offer an opinion about the need for treatment indicated in situation 1. Com- paring the psychiatrists’ responses with the re- sponses of the nonpsychiatric providers, we see that a higher proportion of the nonpsychiatric providers defined this situation as requiring treat- ment. Thirty-four of the 44 nonpsychiatrists re- sponded in this manner. While the difference is rather slight, it does indicate a variation between the two groups in their tendency to define situa- tion 1 as requiring or not requiring mental health treatment. DEFINITIONS OF NEED TABLE 113.—Providers’ Definitions of Situation 1 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 17 4 7 28 Nonpsychiatric Providers 34 4 6 44 Total 51 13 72 In response to the question of who could pro- vide adequate help in relieving the problem pre- sented in situation 1, the providers overall most frequently cited two sources of help (see table 114). Thirty-three of the 72 providers cited a counselor or a social worker as being adequate, and an additional 20 were found to view psy- chiatrists or a mental health clinic as being the source of adequate help. This overall response pattern does not reflect an important distinction in the views of the psychiatrists compared with nonpsychiatric providers. In examining the re- sponses of the two provider groups separately, there was a tendency within each group to select individuals in positions similar to their own as being able to provide adequate help. There was a tendency among psychiatric personnel to cite psy- chiatric personnel as the source of adequate help, and there was a tendency among the nonpsychia- tric providers to name persons in positions similar to their own. Ten of the 28 psychiatrists cited in- dividuals in positions similar to their own as the source of adequate help for situation 1, while 27 of the nonpsychiatric providers cited counselors or social workers as their choice for the source who could provide adequate care. A similar pat- tern was seen among the professional referral agents who demonstrated a tendency to select in- dividuals in positions similar to their own as the best source of remedy for the problems present- ed. Further, this tendency is also apparent in varying degrees in the providers’ responses to each of the following situations: Situation 2 “A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment?’ By a margin of over two to one, the providers defined this situation as requiring mental health treatment (see table 115). Forty-five of the 72 providers responded that situation 2 requires men- tal health treatment. There is a slight difference in the response patterns between the two provider categories. The nonpsychiatric personnel were found to have a higher proportion defining the sit- uation as requiring treatment than did the psy- chiatrists. Among the psychiatrists the ratio of TABLE 114.—Situation 1, Who Could Provide Adequate Help? Don't Psychiatrist Non- Know Family or Mental Psychiatric Counselor or No No or Health Medical or Social Response One Friends Clergy Clinic Practitioner Worker Others Total Psychiatrist 1 1 1 6 10 2 6 1 28 Nonpsychiatric Providers 4 0 2 10 0 27 1 44 Total 5 1 3 20 2 33 2 72 TABLE 115.—Providers’ Definitions of Situation 2 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 16 9 3 28 Nonpsychiatric Providers 29 10 5 44 Total 45 19 72 67 THE PROVIDERS those defining this situation as requiring or not requiring treatment was under two to one (16 to 9), while among the nonpsychiatric providers the same comparison revealed a response ratio of almost three to one (29 to 10). Over one-third of all providers cited a psy- chiatrist or mental health clinic as their choice of source of help. Additionally, 18 of the providers said that they thought that a counselor or social worker could provide adequate care for the prob- lem. The pattern of citing positions similar to their own is evident from the examination of the differences between the responses of the psy- chiatrists and the nonpsychiatric providers. Thir- teen of the 28 psychiatrists cited a psychiatrist or mental health clinic, while 17 of the 44 nonpsy- chiatric providers cited counselors or social work- ers as being able to provide adequate care. These differences can be seen in table 116, which further reveals that, while three of the psychiatrists viewed nonpsychiatric medical professionals as being able to provide adequate care, none of the nonpsychiatric providers responded in this man- ner. In addition to the tendency to name persons in professional positions similar to their own as being able to provide care, among the nonpsychia- tric providers there was almost an even split be- tween those who cited a psychiatrist or mental health clinic and those who cited a counselor or social worker. Situation 3 “A husband and wife are having martial prob- lems and seldom see each other because they both work and they work on different shifts. Do you think they need mental health treat- ment?”’ Table 117 presents the responses of the provi- ders to situation 3 which indicate that the provi- ders defined this situation by a margin of over two to one, as requiring treatment. While, by a margin of about four to one, the psychiatrists viewed this situation as requiring treatment, the nonpsychiatric providers were less likely to define the problems presented in situation 3 as requiring mental health treatment. Twenty-six of the 44 defined situation 3 as requiring treatment, while 16 defined this situation as not requiring treat- ment. Considering the responses of the providers to the question of who could provide adequate help, table 118 reveals that counselors or social workers were the most frequent source cited, both overall and within each of the provider categories; 33 of the 44 nonpsychiatric providers and 12 of the 28 psychiatrists offered these responses. While four of the psychiatrists cited psychiatrists or a mental health clinic as a source of adequate help and two of this group cited nonpsychiatric medical practi- tioners, only one of the nonpsychiatric providers cited psychiatrists or a mental health clinic, and TABLE 116.—Situation 2, Who Could Provide Adequate Help? Don’t Psychiatrist Non- Counselor Know or Mental psychiatric or or No No Need Self or Health Medical Social Response for Help Friends Clergy Clinic Practitioner Worker Foreman Total Psychiatrist 3 3 1 1 13 3 1 3 28 Nonpsychiatric Providers 3 2 4 0 16 0 17 2 44 Total 6 5 29 3 18 5 72 TABLE 117.—Providers’ Definitions of Situation 3 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 22 6 0 28 Nonpsychiatric Providers 26 16 2 44 Total 48 22 2 72 DEFINITIONS OF NEED TABLE 118.—Situation 3, Who Could Provide Adequate Help? The Psychiatrist Non- Counselor Couple or Mental psychiatric or Union/ No Need Them- Health Medical Social Manage- No for Help selves Clergy Clinic Practitioner Worker ment Other Response Total Psychiatrist 1 4 3 4 2 12 1 1 0 28 Nonpsychiatric Providers 1 3 2 1 0 33 Z 0 2 44 Total 2 7 5 5 45 8 1 2 72 no members of this group cited nonpsychiatric medical practitioners. Situation 4 “A 12-year-old boy lies, steals, and skips school. Do you think he needs mental health treatment?”’ The responses of the providers to this situation can be seen in table 119, which reveals near unan- imous agreement, both overall and within the two provider categories, that the problem presented in this situation requires mental health treatment: 67 of the 72 providers so defined situation 4, and 27 of the 28 psychiatrists and 40 of the 44 nonpsy- chiatric providers responded in this manner. The tendency for the two provider groups to cite individuals in positions similar to their own as being able to provide adequate care is again evi- dent in the responses of the two provider groups to the question of who could provide adequate help for the problem in situation 4 (see table 120). Among the psychiatrists, 19 out of 28 cited a psy- chiatrist or mental health clinic as the source of adequate help, while 16 of the 44 nonpsychiatric providers cited counselors or social workers. While it is true that an additional 17 of the nonpsy- chiatric providers cited psychiatrists or a mental health clinic as a source of adequate help, this fact does not diminish the response tendency of both groups to define their own professions as being adequate to provide care. The tendency is most pronounced among the psychiatrists, where 19 of the 28 cite persons in positions similar to their own as being able to provide at least ade- quate care for the problem. Situation 5 “A person always refuses to ride in elevators. Do you think this person needs mental health treatment?’ The providers’ perceptions of the need for treatment indicated in this situation can be seen in TABLE 119.—Providers’ Definitions of Situation 4 Treatment Required Treatment Not Required Total Psychiatrist 27 1 28 Nonpsy chiatric Providers 40 44 Total 67 72 TABLE 120.—Situation 4, Who Could Provide Adequate Help? Psychiatrist Non- Counselor or Mental psychiatric or Health Medical Social School Don’t Know Family Clinic Practitioner Worker Officials Other Total Psychiatrist 1 1 19 2 1 4 0 28 Nonpsychiatric Providers 0 1 17 0 16 9 1 44 Total 1 2 36 17 13 1 72 69 THE PROVIDERS table 121, which indicates that the providers were evenly divided between those who perceived this situation as requiring mental health treatment and those who did not feel that treatment was indicat- ed. This overall response pattern is not indicative of either of the two provider categories when their responses are viewed separately. While a majority of the psychiatrists, 19 out of 28, indicat- ed their belief that treatment was needed, only 17 of the 44 nonpsychiatric providers responded sim- ilarly. Twenty-three members of this group de- fined situation 5 as not requiring treatment. The sources identified by the providers as being able to provide adequate care for the problem presented in situation 5 can be seen in table 122. The most frequently cited source of help was the psychiatrist or mental health clinic, followed by counselors or social workers. While the nonpsy- chiatric providers were about evenly split between those who cited a psychiatrist or mental health clinic and those who cited a counselor or social workers, among the psychiatrists 18 out of 28 cit- ed a psychiatrist or mental health clinic, and none of this group viewed a counselor or social worker as the source of help. Situation 6 “A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treat- ment?”’ The providers’ perceptions of the need for men- tal health treatment are presented in table 123, which reveals that four out of every seven provi- ders defined situation 6 as requiring treatment (Thirty-nine out of the 72 providers so defined situation 6). While a majority within both of the provider categories defined situation 6 as requiring treatment, this pattern appears stronger among the psychiatrists than among the nonpsychiatric providers. While 15 of the 28 psychiatrists defined situation 6 as requiring treatment and only 9 de- fined the situation as not requiring treatment, the difference is not as great among the nonpsychia- tric providers, since only 24 of this group defined the situation as requiring treatment and 20 defined the situation as not requiring treatment. Table 124 indicates that responses center around three sources. Twenty-six of the providers cited counselors or social workers as being able to TABLE 121.—Providers’ Definitions of Situation 5 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 19 8 1 28 Nonpsychiatric Providers 17 23 4 44 Total 36 31 72 TABLE 122.—Situation 5, Who Could Provide Adequate Help? Psychiatrist Non- Counselor No One or Mental psychiatric or Don’t Know or No Need Health Medical Social or for Help Self Clinic Practitioner Worker No Response Total Psychiatrist 3 1 18 2 0 4 28 Nonpsychiatric Providers 5 2 14 15 8 44 Total 8 3 32 15 12 72 TABLE 123.—Providers’ Definitions of Situation 6 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 15 9 4 28 Nonpsychiatric Providers 24 20 0 44 Total 39 29 72 70 DEFINITIONS OF NEED provide adequate help. Twenty-three expressed the view that family members or friends could be of assistance, and 13 cited psychiatrists or mental health clinics. Examination of the responses with- in each of the provider categories indicates some important differences between the two groups. While nine of the psychiatrists cited a psychiatrist or mental health clinic as being able to provide adequate help, only four of the nonpsychiatric providers viewed this source in a similar manner. In fact, among the nonpsychiatric providers, 19 cited a counselor or social worker and 16 cited family members or friends as being a source of adequate help. Situation 7 ‘““A man cannot seem to hold a job very long because he drinks so much. Do you think he needs mental health treatment?” The providers’ responses to this item can be seen in table 125, which reveals that within each of the provider categories the majority of the providers viewed the problem presented in this situation as requiring treatment. Only three of the providers did not respond in this manner. There was nearly unanimous agreement that the problem presented in situation 7 required mental health treatment. With regard to the sources that could provide adequate help for the problem presented in situa- tion 7, the providers were found to mainly rely on two sources of mental health treatment (See table 126). Thirty-nine providers cited social agencies such as Alcoholics Anonymous or other alcohol- ism treatment programs as their choice to provide help for the problem presented, while an addition- al 28 providers cited a mental health clinic or a psychiatrist. Comparison of the responses of the two provider categories reveals that, while both of these sources were cited rather frequently, more of the nonpsychiatric providers cited a so- cial agency than a psychiatrist or mental health clinic. Among the psychiatrists the reverse was true. While the two sources were frequently cited by each of the two groups of providers, the psy- chiatrists were more likely to view psychiatric treatment as being the source of adequate help, while the nonpsychiatric providers were more likely to recommend alcoholism programs under the auspices of a social agency. Situation 8 ‘“A young man is always getting into fights and often gets into trouble on the job. Do you think he needs mental health treatment?’’ As can be seen in table 127, about six out of every seven providers viewed this situation as requiring mental health treatment. Among the psychiatrists, 22 of the 28 responded in this man- ner and, while one of this group felt that treat- ment was not required, an additional 5 did not make a judgment on the matter. Among the nonpsychiatric providers, 39 of the 44 were found to view situation 8 as requiring mental health treatment, and only 4 responded that the problem presented in this situation was one for which treatment was not indicated. TABLE 124.—Situation 6, Who Could Provide Adequate Help? The Psychiatrist Non- Counselor No One Troubled Family or Mental psychiatric or or Woman or Health Medical Social No No Need Herself Friends Clergy Clinic Practitioner Worker Other Response Total Psychiatrist 2 0 7 1 9 1 7 0 1 28 Nonpsychiatric Providers 0 1 16 1 4 0 19 2 1 44 Total 2 1 23 2 13 1 26 2 2 72 TABLE 125.—Providers’ Definitions of Situation 7 Treatment Required Treatment Not Required Total Psychiatrist 28 0 28 Nonpsychiatric Providers 41 3 44 Total 69 72 71 THE PROVIDERS TABLE 126.—Situation 7, Who Could Provide Adequate Help? Psychiatrist Non- Or Mental psychiatric Social Health Medical Agency / No One Friends Clinic Practitioner A.A. Total Psychiatrist 1 1 15 1 10 28 Nonpsychiatric Providers 0 0 13 2 29 44 Total 1 1 28 3 39 72 TABLE 127.—Providers’ Definitions of Situation 8 Treatment Don’t Know Treatment Required Not Required or No Response Total Psychiatrist 22 1 5 28 Nonpsychiatric Providers 39 4 1 44 Total 61 6 72 Table 128 presents the sources which the provi- ders felt could offer adequate help for the prob- lems presented in situation 8. A psychiatrist or a mental health clinic was cited by about half of the providers, and a counselor or social worker was cited by another third, but there are variations in the response patterns between the two provider categories. Among the psychiatrists, 19 of the 28 cited a psychiatrist or mental health clinic, while only 3 were found to view a counselor or social worker as being able to provide adequate help. Among the nonpsychiatric providers, 20, or just less than half, were found to view a counselor or social worker as being able to provide adequate help, while an additional 16 responded that a psy- chiatrist or mental health clinic could provide adequate help. These response patterns again indi- cate the tendency for the providers, when asked to offer their opinions about sources of adequate help, to recommend individuals in their own pro- fessions. Considering all eight situations, the views of the two provider groups were not in full accord. The psychiatrists’ and nonpsychiatric providers’ re- sponse patterns were similar in only three cases (situations 4, 7, and 8). In response to situations 1 and 2 the nonspsychiatric groups were more likely to perceive a need for treatment, while the reverse was true for situations 3 and 6. The two provider groups differed further in their views of the need for treatment indicated in situation 5. The majori- ty of the psychiatrists felt treatment was needed, but the majority of the nonpsychiatrists held an opposite view. Opposing views were also evident in the sources of help suggested by the two provi- der groups. There was a definite tendency for each group to offer responses indicating that ade- quate help could be provided by individuals in positions similar to their own. TABLE 128.—Situation 8, Who Could Provide Adequate Help? Psychiatrist Non- Counselor or Mental psychiatric or Health Medical Social Don't Know/ Clergy Friends Clinic Practitioner Worker Union Employer No Response Total Psychiatrist 0 2 19 2 3 1 0 1 28 Nonpsychiatric Providers 1 0 16 0 20 1 2 4 44 Total 1 2 35 2 23 2 2 5 72 DEFINITIONS OF NEED Providers’ Perceptions of the Motivation to Seek Treatment Four items were used to measure the providers’ perceptions of the motivation to seek treatment. Tables 129 and 130 indicate that, while the provi- ders felt that individuals should not wait for a cri- sis to occur before seeking professional help, they did believe that people do wait for such a crisis to occur before they seek help. The providers felt that the final motivation for people to seek help occurs when individuals finally realize or admit to themselves they have problems for which profes- sional treatment could be an effective alternative. While this response was the most frequently cit- ed, two other responses lend support to the fact that the providers perceive people as generally seeking help only after a crisis occurs or when they feel there is, in fact, no alternative left. Fourteen of the providers felt that people general- ly wait until they get into trouble or a crisis oc- curs, and 10 of the providers said that people seek treatment only after they feel it is the only alternative remaining for them (See table 131). providers said that the promotion of knowledge of mental health would encourage people with prob- lems to seek help sooner. Ten of the providers expressed a view that if people were made more aware of the mental health services available they would obtain treatment earlier in the course of a problem. TABLE 129.—Should People Wait for a Crisis to Occur Before Seeking Help? Don't Yes No Know Total Psychiatrist 0 27 1 28 Nonpsychiatric Providers 1 43 0 44 Total 1 70 1 72 TABLE 130.—Do People Wait for a Crisis to Occur Before Seeking Help? The last item in this section deals with the y N Boris Toul views of the providers about what would encour- os ° Row ote age people with mental or emotional problems to Payers 26 2 0 28 seek help earlier. The providers’ views in this Nonpsydhiainic matter can be seen in table 132. Their views were Providers 43 0 1 a4 not dissimilar from the respective views of the ToL 5 0 1 72 workers and referral agents. Fifty-three of the 72 oa TABLE 131.—Perceived Sources of Final Motivation to Treatment Get Into Self- Trouble, Only realization Family Affects a Crisis Alternative of Problems Involved Referred Job Occurs Left Other Total Psychiatrist 12 2 3 1 4 6 0 28 Nonpsychiatric Providers 20 3 4 2 10 4 1 44 Total 32 5 7 14 10 1 72 TABLE 132.—What Would Encourage People With Mental or Emotional Problems to Seek Help Early in the Duration of Problem? Promote Make Promote Promote Knowledge Services Knowledge Knowledge of Mental More of Mental of Nothing Health in Avail- Health Referral Can Be General able Services Services Done Other Total Psychiatrist 16 3 6 1 1 1 28 Nonpsychiatric Providers 37 1 4 1 1 0 44 Total 53 4 10 2 2 1 72 THE PROVIDERS Section VI: Identification of Potential Obstacles to Treatment The same obstacles that were presented to the workers and referral segments were also present- ed to the providers. The providers’ evaluations of the degree to which each of the potential obsta- cles inhibits people from seeking treatment are presented in table 133. The providers felt that the fear of being considered crazy, the fear of others learning about them being in treatment, and the fear of talking to a psychiatrist were all factors that strongly inhibit people from seeking treat- ment. The feeling for males, that asking for help is a sign of weakness, the feeling that people should be able to handle their own problems, and the perceived cost of treatment were also consid- ered strong deterrents to treatment-seeking. TABLE 133.—Providers’ Identification of Potential Obstacles to Treatment Very Some- Very Not At Don’t Know or Much what Little All No Response Total No transportation Psychiatrist 0 8 16 4 0 28 Nonpsychiatric Provider 6 10 18 9 1 44 Total 6 18 34 13 1 72 Would miss favorite TV program Psychiatrist 0 5 12 10 1 28 Nonpsychiatric Provider 2 8 18 14 2 44 Total 2 13 30 24 3 72 Afraid people would think Psychiatrist 18 8 2 0 0 28 he is crazy Nonpsychiatric Provider 35 9 0 0 44 Total 53 17 2 0 72 Cost of a babysitter Psychiatrist 1 15 10 2 0 28 Nonpsychiatric Provider 1 26 17 0 0 a4 Total 2 41 27 0 72 The feeling they can handle Psychiatrist 10 16 2 0 0 28 their own problems Nonpsychiatric Provider 31 1 1 1 0 44 Total 41 27 3 1 0 72 Afraid to talk to a psychiatrist Psychiatrist 13 12 2 1 0 28 Nonpsychiatric Provider 29 13 2 0 0 44 Total 42 25 4 1 0 72 Not knowing they need help Psychiatrist 15 12 1 0 0 28 Nonpsychiatric Provider 18 22 4 0 0 44 Total 33 34 0 0 72 Embarrassment Psychiatrist 12 13 3 0 0 28 Nonpsychiatric Provider 24 19 1 0 0 44 Total 36 32 4 0 0 72 Not knowing services are Psychiatrist 6 15 5 1 1 28 available Nonpsychiatric Provider 16 23 0 0 44 Total 22 38 10 1 1 72 Not knowing they are Psychiatrist 14 9 4 1 0 28 covered by insurance Nonpsychiatric Provider 25 19 0 0 0 44 Total 39 28 4 1 0 72 74 IDENTIFICATION OF OBSTACLES TABLE 133.— (Cont'd.) Providers’ Identification of Potential Obstacles to Treatment Very Some- Very Not At Don’t Know or Much what Little All No Response Total Worrying about what Psychiatrist 10 16 1 1 0 28 might happen Nonpsychiatric Provider 23 18 3 0 0 44 Total 33 34 4 1 0 72 The feeling that asking for help Psychiatrist 14 10 3 0 1 28 is a sign of weakness for Nonpsychiatric Provider 26 16 2 0 0 44 males Total 40 26 5 0 1 72 The fear that others will Psychiatrist 16 1 0 1 0 28 learn about it Nonpsychiatric Provider 30 12 2 0 0 44 Total 46 23 2 1 0 72 The feeling that just talking Psychiatrist 6 16 5 1 0 28 will do no good Nonpsychiatric Provider 16 23 4 1 0 44 Total 22 39 2 72 The fear it will affect his job Psychiatrist 9 14 4 1 0 28 Nonpsychiatric Provider 18 15 1 0 0 44 Total 27 29 15 1 72 Section VII: Providers’ Perception of the Workers’ Problem Areas The providers were asked for their perceptions of the problem areas which cause workers or their families the most emotional difficulty. Table 134 reveals the providers’ first four responses to this question. While there are variations within the response patterns for each of the first four prob- lem areas mentioned, problems centering around marriage were the most frequently perceived problems of workers and their families. Three other problem areas were cited: work-related problems, problems centering around children, and problems with alcohol. The providers were asked for their perceptions of the characteristics of factory work, in their opinion, were responsi- ble for or aggravate the emotional problems of workers and their families. The responses to this item can be seen in table 135, which indicates that the providers perceived the monotony or lack of variety in factory production-line employment as responsible for or aggravating the emotional prob- lems of workers and their families. Included among the less frequently cited perceived charac- teristics of factory work were problems centering around the shift and the length of hours worked, 73 the workers’ lack of feeling needed or important, and the workers’ lack of a feeling of accomplish- ment. The providers were found to view factory work as being a rather monotonous enterprise that requires long hours and does not permit workers to identify either with their jobs or the products they produce. They felt that these dimensions were related to the emotional problems of the workers. Section VIII: Providers’ Experience in Treating Those Eligible for the UAW Mental Health Benefits The providers were asked what proportion of their cases were eligible for the United Auto Workers’ mental health benefits. Table 136, which presents the providers’ responses to this item, indicates a response pattern that was not unex- pected, since the providers’ practices were locat- ed in an area heavily populated by UAW mem- bers. Among the psychiatrists, 18 of the 26 re- sponding said that persons eligible for the benefits constituted over 30 percent of their patients, and 18 of the 43 nonpsychiatric providers responded in a similar manner. The lower proportion of nonpsychiatric providers is due largely to the fact THE PROVIDERS TABLE 134.—Perception of Workers’ Problem Areas First Second Third Fourth Cumulative Mentioned Mentioned Mentioned Mentioned Frequency Health 1 a4 2 3 20 Work 16 6 6 5 33 Income 0 4 3 0 7 Parents 2 1 1 2 6 Children 15 10 5 2 32 Marriage 14 23 8 11 56 Alcohol 3 8 16 8 35 Drugs 0 5 2 5 12 Loneliness 2 4 1 3 10 Sex 3 0 12 2 17 Getting Along With Others 1 3 6 6 16 Being Dissatisfied With Themselves 2 2 8 17 29 Suffering a Loss 2 1 1 5 9 Not Knowing What To Do With Leisure Time 1 0 0 0 1 No Response 0 1 1 3 5 Total 72 72 72 72 288 TABLE 135.—Providers’ Perceptions of the Characteristics of Factory Work Which Are Responsible for or Aggravate the Emotional Problems of Workers and Their Families Lack of Monotony Lack of Feeling Shift & Social Physical Production of Job; Feeling of Ac- Number Conditions Conditions Don’t Know Line Work Job Lacks Needed or complish- of Hours Low of Work of Work Nothing or in General Variety Important ment Worked Income Place Place Other Wrong No Response Psychiatrist 1 10 1 0 7 1 1 2 2 1 2 Nonpsychiatric Providers 2 18 6 5 1 1 1 Total 3 28 7 5 13 2 3 2 4 2 3 TABLE 136.—Estimated Proportion of Clients Who Were Eligible for the UAW Mental Health Benefits Less than 30% Between 30% & 60% Over 60% No Response Total Psychiatrist 8 10 8 2 28 Nonpsychiatric Providers 25 13 5 1 44 Total 33 23 13 3 72 that several of this group provide services that were not included within the benefit provisions. The provider group as a whole must be considered to have had a great deal of experience in provid- ing mental health services to those individuals who are eligible for the mental health benefits. 76 The providers were asked about the expecta- tions of the blue-collar patients regarding mental health treatment and whether or not these expec- tations were similar to or different from those of their other patients. As can be seen in table 137, the providers were about evenly divided between EXPERIENCE WITH TREATMENT TABLE 137.—Are the Treatment Expectations of Blue-Collar Patients Different From Those of Other Patients? Yes Somewhat No No Response Total Psychiatrist 16 2 10 0 28 Nonpsychiatric Providers 16 9 18 1 44 Total 32 1 28 1 72 those who felt that the expectations of blue-collar patients were different from those of their other patients and those who felt that there was no dif- ference between the expectations of the two groups. Further, 11 of the providers said there was some difference between the two groups’ expectations, and there were only slight variations between the response patterns within the two provider categories. As to the typical expectations of blue-collar pa- tients regarding treatment (See table 138), about two-thirds of those responding said that a typical expectation of this group was for fast results, and only four providers responded by saying that this group had expectations that were normal and rea- sonable. Other less frequent responses include the expectation that a change in feelings or emotions can occur without treating underlying problems and expecting the total involvement of the thera- pist in the problems of the patient. Combining the responses from tables 137 and 138, blue-collar patients are seen as expecting quick results with- out becoming fully involved in treatment, and this expectation is viewed by many of the providers as being more common to their blue-collar patients than to their other patients. The providers were asked to identify their most frequent sources of referral for UAW members and their families as well as what, if anything, these referral sources do that inhibits the referral process. It is clear from table 139 that three main referral-to-treatment sources were identified. Twenty-six of the providers said that the school system was their most frequent source of referral and, while 20 said that the family physician pro- vided most of their referrals for UAW members and their families, an additional 11 said that the most frequent referral source for this group was self-referral. Where 20 of the nonpsychiatric providers cited the school system as their most frequent source of referral, only 6 of the psy- chiatrists named this source. While 13 of the psy- TABLE 138.—Typical Expectations of Blue-Collar Patients Regarding Treatment Expect Parents Resist Expect Change Stereotyped Fast Involvement In Feelings Negative Normal Results, in Their Expect Total Without Treat- Attitudes Other; Reasonable Instant Children’s Involvement ing Underlying Toward No Expectations Cure Treatment of Therapist Problems Treatment Response Total Psychiatrist 1 20 1 0 3 2 1 28 Nonpsychiatric Providers 23 44 Total 4 43 4 6 4 8 72 TABLE 139.—Most Frequent Sources of Referral to Treatment for UAW Members and Their Families Patients’ Self- School Family Family and Court referral System Physician Friends System Employer Union Other Total Psychiatrist 3 6 13 1 1 1 1 2 28 Nonpsychiatric Providers 8 20 7 1 3 1 1 3 44 Total ; §i) 26 20 2 4 1 2 6 72 77 THE PROVIDERS chiatrists cited the family physician as their most frequent source, only 7 of the nonpsychiatric providers similarly identified this source. The nonpsychiatric providers reported to be more like- ly to receive referrals from school officials, while the family physician was the most frequently cit- ed source of referrals among the psychiatrists. These responses indicate a division of labor be- tween the medical and nonmedical providers of mental health care. With regard to the actions of the most frequent referral sources which inhibit the referral process, table 140 reveals that 31 of the providers reported that their most frequent referral sources do not in any way inhibit the referral process. However, 15 providers said that their referral sources don’t recognize problems soon enough, and an addition- al 11 said that their referral sources inhibit the referral process by demonstrating support for negative attitudes toward treatment. Some of the most frequent sources of referral were viewed as not only delaying referrals until other alternatives were explored but also as negatively affecting troubled individuals’ motivation to become com- pletely involved in treatment when they eventual- ly come in to contact with mental health profes- sionals. The providers were further questioned about the actions of their less frequent referral sources which inhibit the referral process. As can be seen in table 141, the most frequently cited problem with this group was that these less fre- quent referral sources were unfamiliar with the services available. The providers felt that this situation was the result of a lack of a coordinated system of refer- ral to treatment. Some additional inhibiting fac- tors were identified less frequently by the provi- ders. These include the fact that some referral sources attempt to resolve the problems them- selves, many do not recognize problems as being amenable to professional treatment, some are ig- norant about professional treatment, and some tend to promote negative attitudes. In summary, while the school system is seen as the dominant referral source for the nonpsychia- tric providers, the family physician was most fre- quently cited as the dominant source of referral to the psychiatrists. Some of the most frequent sources of referral to professional treatment were seen by the providers as not recognizing problems soon enough or, in fact, promoting negative atti- tudes toward mental health treatment. The pro- viders perceived their less frequent sources of re- ferral to be generally unfamiliar with the mental health services available, attempting themselves to resolve the problems, and because of their general ignorance about professional treatment promoting negative attitudes toward receiving such care. TABLE 140.—Actions of the Providers’ Most Frequent Referral Sources Which Inhibit the Referral Process Provide Support for Negative Attitudes Delay in Treatment Due to Referral Sources Don’t Recognize Problems Soon Nothing Toward Treatment Being Overburdened Enough Other Total Providers 31 11 4 15 i i) 72 TABLE 141.—Actions of Less Frequent Referral Sources Which Inhibit the Referral Process Ignorant About Professional Unfamiliar With Attempt to Treatment and Service/Lack Resolve Don't Promote Nega- of System Problems Recognize Don’t No tive Attitudes Coordination Themselves Problems Other Know Response Total Psychiatrist 3 6 3 3 4 1 8 28 Nonpsychiatric Providers 7 20 6 2 3 0 6 44 Total 10 26 9 5 7 1 14 72 78 TREATMENT CHARACTERISTICS Section IX: The Treatment Characteristics of the Providers’ Practice The providers were asked several questions re- lated to the length of treatment for the resolution of mental health problems and their experiences with various treatments. As can be seen in table 142, the vast majority, both overall and within each of the two provider categories, responded that 30 percent or less of their clients were in- volved in group therapy solely. Further, only six of the providers said that between 30 percent and 60 percent of their cases were in group therapy only, and another five said that group therapy was used as a singular treatment mode in over 60 per- cent of their cases. Group therapy was, therefore, found to be infrequently employed as the sole treatment method. However, group therapy was found to be more frequently used with other treatments. Thirty-four of the providers said that 30 percent or less of their clients received such combined treatment, while 26 of the providers said that over 60 percent of their cases received such care. The response patterns within the two provider categories indicate that among the nonpsychiatric providers there was an even split (18 to 18) between those who said that 30 percent or less of their cases received group therapy in combination with other treatment methods and those who said that over 60 percent of their cases received such treatment. These responses can be seen in table 143, which further reveals that twice as many of the psychiatrists (16 to 8) said that 30 percent of their cases were involved in group therapy in combination with other treatment methods, as compared with those psychiatrists who said that over 60 percent of the clients were so involved. While a large number of providers reported that only a small proportion of their cas- es were involved in group therapy in combination with other treatment methods, there were also many providers who said that over 60 percent of their cases involved group therapy in conjunction with other treatment methods. The nonpsychiatric providers were divided evenly between those who reported that a small proportion of their cases received such combined treatment and those who reported that a majority of their cases received such treatment. The psychiatrists were found to employ group therapy in conjunction with other treatment modes less frequently. The providers were also questioned about the proportion of their patients who required the ad- ministration of psychotropic drugs. As can be seen in table 144, the vast majority of the provid- ers (57 out of 72) stated that such treatment was offered as the primary treatment in less than 30 percent of their cases. As was expected, 41 of the 44 nonpsychiatric providers said that in 30 percent of their cases psychotropic drugs were used as the primary treatment. However, psychotropic drugs were found to be more frequently used as an aid to therapy (See table 145). Nineteen of the providers reported that in over 60 percent of their cases psychotropic drugs were used in conjunc- tion with other treatment modalities, and 20 of the providers said that such treatment was provided for between 30 percent and 60 percent of their cases. While the administration of psychotropic drugs was not often reported as the sole form of TABLE 142.—Estimated Proportion of Cases Using Group Therapy Only 30% or Less Between 30% and 60% Over 60% No Response Total Psychiatrist 24 1 1 2 28 Nonpsychiatric Providers 35 4 0 44 Total 59 6 72 TABLE 143.—Estimated Proportion of Cases in Group Therapy in Combination With Other Treatment Methods 30% or Less Between 30% and 60% Over 60% No Response Total Psychiatrist 16 3 8 1 28 Nonpsychiatric Providers 18 8 18 0 44 Total 34 1 26 1 72 79 THE PROVIDERS TABLE 144.—Estimated Proportion of Cases Where the Administration of Psychotropic Drugs Was the Primary Treatment 30% or Less Between 30% and 60% Over 60% Total Psychiatrist 16 7 5 28 Nonpsychiatric Providers 41 0 3 44 Total 57 7 8 712 TABLE 145.—Estimated Proportion of Cases Where Psychotropic Drugs Were Used as an Aid to Therapy 30% or Less Between 30% and 60% Over 60% Total Psychiatrist 9 9 10 28 Nonpsychiatric Providers 24 Ti 9 44 Total 33 20 19 72 treatment offered, especially among the nonpsy- chiatric providers, drug therapy was more often used in conjunction with other treatment. Several related items were presented regarding the providers’ perceptions of the required dura- tion of mental health treatment. As can be seen in table 146, about half (34) of the providers re- sponded that between 30 percent and 60 percent of their cases required short-term therapy. While 19 of the providers said that over 60 percent of their cases required short-term therapy, an addi- tional 15 reported that 30 percent or less of their cases required such treatment. Examination of the response patterns within the two provider groups reveals that the majority in both provider catego- ries said that only short-term therapy was re- quired in over 30 percent of their cases. Since there are various definitions for short- term therapy, the providers were asked to esti- mate the average duration of treatment for such cases. The providers offered varied definitions for the meaning of short-term therapy (See table 147). Sixteen of the providers offered responses in terms of a specific number of treatment sessions, while the remainder responded to this question in terms of specified lengths of time. While 17 of the providers (5 psychiatrists and 12 nonpsychiatric providers) said that the average duration of treat- ment for short-term cases was over 24 weeks, 11 of the providers said that the average length of treatment time for short-term cases was between 16 and 24 weeks, 16 responded that the average length was between 8 and 16 weeks, and 6 said that such treatment required less than 8 weeks. With regard to those who responded in terms of specific number of sessions, 10 providers said that short-term cases on the average required only 10 sessions or less, and the remaining 6 said that short-term cases required between 10 and 20 sessions. Within a general range, the providers offered varied definitions as to the specific aver- age length of time required for short-term thera- py. However, even with this variation the majori- ty of the providers felt that the average short- term case required approximately up to 6 months of treatment. Another method of ascertaining the providers’ definitions of the length of time required for short-term therapy is by examination of the provi- ders’ definitions of the average duration of treat- ment required for long-term cases. These defini- tions can be seen in table 148, and it is evident TABLE 146.—Proportion of Cases Requiring Only Short-Term Therapy 30% or Less Between 30% and 60% Over 60% No Response Total Psychiatrist 4 13 10 1 28 Nonpsychiatric Providers 1 21 44 Total 15 34 19 4 72 80 TREATMENT CHARACTERISTICS TABLE 147.—Estimated Average Length of Treatment for Short-Term Cases Less Than 8 to 17 to Over 10 Sessions 11 to No 8 Weeks 16 Weeks 24 Weeks 24 Weeks or Less 20 Sessions Response Total Psychiatrist 2 7 3 5 5 3 3 28 Nonpsychiatric Providers 4 9 8 12 5 3 3 44 Total 6 16 1 17 10 6 6 72 TABLE 148.—Estimated Average Length of Treatment for Long-Term Cases Upto 6 6to 12 1to2 2to 4 Over 4 No Months Months Years Years Years Response Total Psychiatrist 2 7 10 5 1 3 28 Nonpsychiatric Providers 4 17 12 2 44 Total 6 24 22 6 5 72 that they further support the finding that 6 months was the average length of time required for short- term therapy. Only six of the providers felt that the average length for a long-term case was less than 6 months. While the majority, both overall and within each of the two provider categories, felt that the average duration of treatment for long-term cases was either between 6 and 12 months or between 1 and 2 years, nine of the providers said that such treatment would require between 2 and 4 years of therapy, and an addi- tional six said that over 4 years of treatment would be required. Thus, while there are again wide variations in the definitions offered, it can be said that the majority of the providers felt that the average duration of treatment for their long- term cases was between 6 months and 2 years. The providers were asked to offer their esti- mates of the proportion of cases which show sub- stantial improvement after 13 full sessions. This item is important, as it relates directly to the out- patient provisions of the UAW mental health ben- efits. From utilization experience it has been ob- served that the maximum dollar amount of the coverage is reached approximately at the point at which the treatment has extended over 13 ses- sions. This item was therefore at least an indirect measure of the effectiveness of the outpatient benefit limitations. As can be seen in table 149, it was the experience of the providers questioned that 13 sessions were generally not enough to re- solve mental health problems. Almost half of the providers responded that 13 full sessions provided substantial improvement of the patient in only 30 percent or less of their cases. Only 14 of the providers said that substantial improvement was seen in over 60 percent of their cases. It is the experience of the providers that 13 full sessions were inadequate for the majority of their cases. Several studies of the use of such benefits have rendered rather uniform findings. One uniformity is the average number of services received by the users of service, and that figure generally ranges between seven and nine services. This result is TABLE 149.—Estimated Proportion of Cases Which Show Substantial Improvement After 13 Full Sessions 30% or Less 30% to 60% Over 60% No Response Total Psychiatrist 12 8 7 1 28 Nonpsychiatric Providers 23 1 7 3 44 Total 35 19 14 4 72 81 THE PROVIDERS verified by the Duggan-Glasser study of the UAW experience in Michigan from 1966-1969, by Av- net in New York in 1962,4 and more recently the American Psychiatric Association’s summary of studies in 1972.5 A maximum annual benefit of 13 full outpatient visits is lower than the benefit initially included in the UAW-negotiated mental health plan. On the basis of 1965 provider charges, the program made possible a maximum of 20 full outpatient visits per year. The inflation in costs reduced the total number of such services covered to 13. What goes into the calculation of an average are values ranging from one service through many services. As the bulk of the users of service have in fact used very few services, then the “upper limit”’ of 13 services is hardly providing adequate care for the more seriously troubled of the ambulatory cases. The numbers of cases who require, say, 20 sessions are forced to bear the full burden of the cost of the last 7 sessions. For those requiring 25 services, the financial consideration is even great- er. While the provider comments on the short- comings of a 13-session maximum benefit are impressionistic rather than statistical, they would appear to have considerable weight in the light of the erosion of the original benefit owing to infla- tionary charge factors. fits for which the UAW workers and their families are eligible and about the adjustments they make when their clients are limited by the restrictions of the benefits. The vast majority of the providers (51 to 72) felt that the $400 limit was not adequate for most outpatient cases. Table 150 indicates that, while the response patterns within each of the two provider groups support this finding, the psychiatrists were found to be more in agreement on this issue than were the nonpsychiatrists. Among the psychiatrists, 22 of the 28 said that the $400 limit was not adequate for most outpatient cases, while among the nonpsychiatric providers only 29 of the 44 responded in a similar manner. While all of the psychiatric providers offer serv- ices which are included within the benefit provi- sions, several of the services offered by the nonpsychiatric providers are not covered. The providers were also asked what adjust- ments they make when a patient is limited to a $400 maximum per year. Their responses to this question can be seen in table 151. While a range of responses was offered by each of the provider groups, the responses of the nonpsychiatric pro- viders reveal a tendency toward three responses. TABLE 150.—Is $400 Limit Adequate for Most Outpatient Cases? . . ‘ : Don’t Section X: Providers’ Experience With Yes No Know Total and Evaluation of the Prepaid Mental Health Program Psychiatrist 3 22 3 28 Nonpsychiatric y : fd Providers 14 29 1 44 The providers were questioned about the limita- tions they are aware of in the mental health bene- Total 17 51 4 72 TABLE 151.—What Adjustments Are Made Where Patient Is Limited to $400 Per Year? Reduce Inform Refer to No Irrelevant Continue Number Patient Public Adjust- to to See Reduce of Treatment Ahead Clinic or No ment Treatment Patient Cost Sessions of Time Hospital Other Response Total Psychiatrist 5 0 3 5 4 4 4 1 2 28 Nonpsychiatric Providers 6 3 8 19 3 0 2 1 44 Total 11 3 1 24 4 2 72 3. Duggan, T.J., and Glasser, M.A. Effects of Prepayment on Use of Psychiatric Care, Report to the Advisory Committee of the National Institute of Psychiatric Care, 1971. 4. Reed, Louis S.; Meyers, Evelyn S.; and Scheidemandel, Patricia L. Health Insurance and Psychiatric Care: Utilization and Cost, Washington, D.C.: American Psychiatric Association, 1972. 5. Avnet, Helen H. Psychiatric Insurance: Financing Short-Term Ambulatory Treatment, New York: Group Health Insurance, Inc., 1962. 82 EVALUATION OF MH PROGRAM Nineteen of this group said that they reduced the cost of treatment, six said that they made no ad- justment, and eight replied that they continued to see the patient even though the patient had reached the limit of his benefit provisions. Among the psychiatrists, on the other hand, six different responses were offered with about equal frequen- cy. Five of the psychiatrists said they reduced the cost of treatment, and an additional five said they made no adjustment whatsoever. Four of the psy- chiatrists said they reduced the number of the treatment sessions, and an additional four said that, in such cases, they referred the patient to a public clinic or hospital. Four others said they merely informed the patient ahead of time, plac- ing the responsibility for payment on the patient, and another three psychiatrists said they contin- ued to see the patient. The providers were asked whether their blue- collar patients continued in treatment beyond the limit of their coverage. Table 152 shows that it was the experience of the providers questioned that the workers do continue in treatment beyond the limits of their coverage. Forty-two of the pro- viders said that the workers continue in treat- ment, and 22 responded that blue-collar workers do not continue in treatment beyond the limits of their coverage. With regard to the preferences the providers have for mental health benefits to either specify a specific dollar amount or to specify a specific number of visits (See table 153), the psychiatrists were found to be evenly split in their views (12 to 83 12), while more of the nonpsychiatric providers were found to prefer the specification of a specific number of visits over the specification of maximum dollar amount. Nine of the providers (four psy- chiatrists and five nonpsychiatric providers) said that they preferred that the benefits specify a combination of a number of visits and a specific dollar amount. TABLE 152.—Do Workers Continue in Treatment Beyond Limit of Coverage? Don’t Know or Yes No No Response Total Psychiatrist 16 9 3 28 Nonpsychiatric Providers 26 13 44 Total 42 22 72 TABLE 153.—Preference for Benefits to Cover a Number of Visits or a Dollar Amount Combi- Number nation of Dollar of the Don't Visits Amount Two Know Total Psychiatrist 12 12 4 0 28 Nonpsychiatric Providers 21 16 44 Total 83 28 72 CHAPTER 5: COMPARISON OF THE WORKERS, REFERRAL AGENTS, AND PROVIDERS Three of the previous chapters have centered upon separate studies of the workers, referral agents, and providers. This chapter compares the findings of these three surveys. For a mental health care delivery system to operate effectively, the three segments of the system must at least share common definitions of the functions each other segment is to perform, have some aware- ness and acceptance of their own roles, possess a basic knowledge of sources of help, and agree on the usefulness of mental health care. When such a system operates successfully, problems are de- tected early, treated, and it is hoped, resolved. However, there are many points at which the sys- tem may fail. Section I: Knowledge of Available Services The awareness of available sources of help is one of the most fundamental requisites for the operation of a need-referral-treatment system. Yet over half of the workers and about one-fifth of the referral agents were unable to name at least one of the mental health facilities which operate in the Pontiac area (See table 154). These findings indicate the existence of a potentially strong de- terrent to treatment. Not only are self-referrals inhibited when a troubled individual is unaware of sources of help; a further deterrent exists when a large proportion of those to whom troubled indivi- duals might likely turn for advice are unaware of sources of help. While it is clear that awareness of treatment sources does not necessarily mean that treatment would be sought or suggested, the lack of such knowledge does indicate a potential obstacle to treatment. Section Il: Evaluation of Available Services The three groups’ evaluations of the available services are presented in table 155. These were based upon the quality of care provided and the adequacy of the number of existing facilities. While about one-third of each group expressed a positive evaluation, there were differences in the rates of negative evaluations. One-third of the workers felt services were inadequate, and over half of the referral agents and over 60 percent of the providers responded similarly. These findings reflect the large proportion of workers who were unaware of the existence of the services. TABLE 154.—Comparative Knowledge of Available Mental Health Facilities, in Percentage Could Not Named Named Named Named Four Number of Name Any One Two Three or More Respondents Workers 53.3 23.3 130 7.8 26 447 Referral Agents 22.2 8.6 16.1 14.8 38.3 81 Providers 0.0 1.4 5.6 6.9 86.1 72 TABLE 155.—Comparative Evaluation of Available Mental Health Services, in Percentage Don't Know or Number of Positive Negative No Response Respondents Workers 81.1 30.0 38.9 447 Referral Agents 34.6 54.3 1.1 81 Providers 333 61.1 5.6 72 85 COMPARISON OF WORKERS, AGENTS, AND PROVIDERS Section Ill: Knowledge of the Benefits The data reflecting the three groups’ awareness of the four major provisions of the workers’ men- tal health benefits are presented in table 156. The providers were found to be quite aware of the benefit provisions, while the workers and referral agents expressed a lower level of awareness. Hospitalization There are important differences among the three groups’ awareness of the workers’ eligibility for the hospitalization provision. Over 80 percent of the providers were sure of the workers’ eligi- bility, but only about 40 percent of the referral agents and just over one-third of the workers re- sponded the same. While none of the providers were sure the workers were not eligible, about 5 percent of the referral agents and 3 percent of the workers were definite in their convictions that the workers were not eligible. It is also important to note that the proportion of workers and referral agents who could not offer an opinion about the workers’ eligibility was respectively five and four times as great as the proportion of providers who could not offer an opinion. The providers were well informed about the hospitalization provision of the mental health benefits. The same cannot be said of the workers or referral agents. Psychological Testing There were important differences in the three groups’ awareness of the workers’ eligibility for psychological testing when prescribed by a physi- cian. Three-fourths of the providers were sure of the workers’ eligibility, while just over one-fifth of the referral agents and under one-fifth of the workers responded the same. Even with the addi- tion of those workers or referral agents who thought the workers were eligible, neither the workers nor referral agents were well informed about this provision. About 20 percent of the workers and 10 percent of the referral agents were sure or thought the workers were not eligi- ble, and about 40 percent of each of these groups were unable even to offer an opinion. None of the providers thought or were sure the workers were not eligible, and 7 percent could not offer an opin- ion. Treatment by a Psychiatrist in Private Practice The workers and referral agents also demon- strated a lower level of awareness than the pro- viders regarding the workers’ eligibility for treat- TABLE 156.—Comparative Awareness of Mental Health Benefits, in Percentage Think Sure Don’t Know Sure Think They They No Number of They Are They Are Are Not Are Not Response Respondents Hospitalization Workers 34.9 23.3 13.2 29 25.7 447 Referral Agents 43.2 19.8 12.4 4.9 19.7 81 Providers 84.7 9.7 1.4 0.0 4.2 72 Psychological Testing Workers 16.8 21.3 15.2 5.1 41.6 447 Referral Agents 22.2 29.6 7.4 3.7 371 81 Providers 76.4 16.7 0.0 0.0 6.9 72 Treatment by a Psychiatrist in Private Practice Workers 20.6 14.3 17.7 14.5 32.9 447 Referral Agents 30.9 17.3 13.6 6.2 32.1 81 Providers 83.3 5.6 2.8 1.4 6.9 72 Treatment at Mental Health Clinic or Center Workers 18.6 20.8 14.5 4.3 41.8 447 Referral Agents 28.4 22.2 13.6 37 32.1 81 Providers 86.1 9.7 0.0 0.0 4.2 72 86 KNOWLEDGE OF BENEFITS ment from a psychiatrist in private practice. Only about 20 percent of the workers and about 30 percent of the referral agents were sure of the workers’ eligibility for this provision, and only about half of the referral agents and about one- third of the workers at least thought the workers were eligible. About 15 percent of the workers were sure they were not eligible for this provi- sion. Nearly 90 percent of the providers at least thought the workers were eligible for such treat- ment. Treatment at a Mental Health Clinic or Center The workers and referral agents were also found to be less aware of the benefit covering treatment at a clinic or center. About 19 percent of the workers and about 30 percent of the refer- ral agents were sure that the workers were eligible for such treatment. About 86 percent of the pro- viders were sure that the workers were eligible for this benefit. While none of the providers thought or were sure the workers were not eligible, about one-fifth of the workers and 17 percent of the re- ferral agents offered either of these two respon- ses. While only about 4 percent of the providers were unable to offer an opinion, over 40 percent of the workers and about one-third of the referral agents lacked enough information even to offer an opinion. A large proportion of both the workers and re- ferral agents were found to be unaware of the workers’ eligibility for mental health benefits. Even though the benefits actually remove a major portion of the financial burden associated with mental health care, this burden may continue to exist for those who are unaware of the benefits. The cost of treatment could be a major considera- tion among workers who might otherwise seek professional help for themselves or for members of their families. The referral agents who are unaware of the workers’ eligibility might consider professional help beyond the means of the work- ers. There are other inhibiting factors associated with a perceived high cost of treatment, but a potentially strong obstacle to treatment exists in the need-referral-treatment system because of the low level of awareness found among workers and referral agents. Section IV: Definition of Need for Treatment The decision to seek mental health treatment is frequently based upon other than obvious consid- erations. While physical problems are often diffi- 87 cult to detect, especially in their early, less symp- tomatic stages, once symptoms develop or a trau- ma occurs the affected individual quite frequently seeks help. Mental health problems are often more subtle and lack the life-and-death urgency of a broken limb, a puncture wound, or a respiratory problem. In order to facilitate the delivery of mental health care it is essential that all segments in a mental health care delivery system hold simi- lar views of the usefulness of mental health treat- ment. The workers’, referral agents’, and providers’ definitions of the eight situations are presented in table 157. Situation 1 “A working man watches television from the time he gets home from work until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment?’ The workers and referral agents held similar views regarding the need for treatment indicated in situation 1. Just under two-thirds of these groups felt treatment was required. A slightly higher proportion of the providers felt treatment was required, and about one-fifth were unable to offer an opinion. Only about 3 percent of the workers and 7 percent of the referral agents could not decide if treatment was required. These re- sponse patterns indicate that, while the workers and referral agents were relatively definite in their views, the providers more often felt additional information was required before a decision could be made. The differences between the three groups were most evident in the proportion re- sponding that treatment was not required. Almost one-third of the workers and over one-fourth of the referral agents defined situation 1 in this man- ner, as compared with only 10 percent among the providers. Situation 2 “A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment?”’ While the workers and providers held similar views about the necessity for treatment indicated in the problem presented, the referral agents viewed this situation differently. Over 60 percent of the workers and providers felt that treatment was required. Just under 50 percent of the referral agents responded the same. These findings indi- cate that a difference exists between the referral agents and the other two groups, and this differ- ence could act to inhibit a referral to treatment for problems similar to situation 2. COMPARISON OF WORKERS, AGENTS, AND PROVIDERS TABLE 157.—Comparative Definition of Need for Mental Health Treatment, in Percentage Don’t Know Treatment Treatment or Number of Required Not Required No Response Respondents Situation 1 A working man watches television from the time he gets home from work until he goes to bed and refuses to talk to his family. Do you think he needs mental health treatment? Situation 2 A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment? Situation 3 A husband and wife are having marital problems and seldom see each other because they both work on different shifts. Do you think they need mental health treatment? Situation 4 A 12-year-old boy lies, steals, and skips school. Do you think he needs mental health treatment? Situation 5 A person always refuses to ride elevators. Do you think this person needs mental health treatment? Situation 6 A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treatment? Situation 7 A man cannot seem to hold a job very long because he drinks so much. Do you think this person needs mental health treatment? Situation 8 A young man is always getting into trouble on the job. Do you think this person needs mental health treatment? Workers 65.8 30.8 3.4 447 Referral Agents 65.4 27.2 7.4 81 Providers 70.8 11.1 18.1 72 Workers 63.6 30.2 6.2 447 Referral Agents 49.4 43.2 7.4 81 Providers 62.5 26.4 11.3 72 Workers 16.2 80.9 2.9 447 Referral Agents 49.4 44.4 6.2 81 Providers 66.7 30.6 2.7 72 Workers 58.2 37.6 4.2 447 Referral Agents 69.1 23.5 7.4 81 Providers 23.1 6.9 0.0 72 Workers 22.4 73.7 4.9 447 Referral Agents 235 72.8 3.7 81 Providers 50.0 43.1 6.9 72 Workers 17.4 78.7 3.9 447 Referral Agents 22.2 70.4 7.4 81 Providers 54.2 40.3 5.5 72 Workers 83.0 13.4 3.6 447 Referral Agents 81.5 13.6 4.9 81 Providers 95.8 4.2 0.0 72 Workers 72.2 21.9 5.9 447 Referral Agents 79.0 13.6 7.4 81 Providers 84.7 7.0 8.3 72 Situation 3 The workers overwhelmingly responded that this “A husband and wife are having marital prob- situation would not require treatment, while the lems and seldom see each other because they vast majority of the providers defined this situa- both work and they work on different shifts. tion as requiring treatment. A middle position was Do you think they need mental health treat- taken by the referral group, as they were about ment?”’ evenly split between those who felt treatment was 88 DEFINITIONS OF NEED required and those who felt the situation did not warrant treatment. Situation 4 “A 12-year-old boy lies, steals, and skips school. Do you think he needs mental health treatment?’’ The providers overwhelmingly viewed the prob- lem presented in this situation as requiring mental health treatment, as over 90 percent so respond- ed. There was less agreement among the referral agents and workers. Over one-third of the work- ers and about one-fourth of the referral agents defined situation 4 as not requiring treatment. While a majority of each group defined this situa- tion as requiring treatment, a solid minority of the workers and referral agents dissented. Situation 5 ‘“A person always refuses to ride elevators. Do you think this person needs mental health treat- ment?”’ Over 70 percent of the workers and referral agents felt that treatment was not required, while half of the providers stated that treatment was required. Situation 6 “A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treatment?’’ About 80 percent of the workers and 70 percent of the referral agents defined situation 6 as not requiring treatment, while over 50 percent of the providers felt treatment was required. Situation 7 ‘““A man cannot seem to hold a job very long because he drinks so much. Do you think this person needs mental health treatment?”’ The drinking and employment problems indicat- ed in this situation were viewed by over 80 per- cent of each group as requiring treatment. These response patterns may be due to the obvious cri- sis nature of the problems presented. The three groups were in agreement with regard to their definition of this situation. Situation 8 ‘“A young man is always getting into fights and often gets into trouble on the job. Do you think this person needs mental health treatment?’ Over 70 percent of each group responded that treatment was needed. However, while only 7 89 percent of the providers defined this situation as not requiring treatment, the proportion of referral agents and workers who held this view was re- spectively two and three time as high. While the referral agents and workers were found to hold similar views about four of the pre- sented problems, in two of these cases their views were in opposition to the majority of the pro- viders. The findings reported in this section offer strong support for the existence of barriers to treatment. If the workers and referral agents do not feel that a problem requires professional at- tention, it is irrelevant that the providers hold a different view. Even in cases where the workers and providers agree on the efficacy of treatment (it should be recalled that the two provider groups did not fully agree), if those from whom the workers are likely to seek advice are not of a sim- ilar mind, the need-referral-treatment process again breaks down. Section V: Identification of Potential Obstacles to Treatment The comparison of the three groups’ percep- tions of the degree to which 15 potential barriers inhibit people from seeking treatment is presented in table 158, which reveals that the three groups were found to disagree frequently both in the in- hibiting strength of several factors and in the area of whether or not the factors were barriers to treatment. The response patterns involved within each of the three groups indicate a lack of agree- ment even among the members of the same group. I. Indicators of Stigma Embarrassment Only half of the providers felt that being em- barrassed would ‘‘very much’ inhibit a person from seeking treatment. Almost 60 percent of the workers and about 70 percent of the referral agents responded in this manner. Afraid To Be Considered Crazy While 80 percent of the referral agents felt that the fear of being considered crazy would ‘‘very much’ inhibit a person from seeking treatment, 60 percent of the workers and just over 70 per- cent of the providers considered this factor in the same manner, None of the providers felt that being considered crazy would in no way inhibit help-seeking, but over 7 percent of the workers and about 4 percent of the referral agents ex- pressed this view. TABLE 158.—Comparative Identification of Potential Obstacles to Treatment, in Percentage COMPARISON OF WORKERS, AGENTS, AND PROVIDERS Very Some- Very Not At Don’t Know or Number of Much what Little All No Response Respondents Not knowing services Workers 38.3 25.9 20.8 14.6 0.4 447 are available Referral Agents 33.3 49.4 13.6 25 1.2 81 Providers 30.5 52.8 13.9 1.4 1.4 72 Not knowing they are covered Workers 67.1 19.7 8.3 4.0 0.9 447 by insurance Referral Agents 65.4 30.9 37 0.0 0.0 81 Providers 54,1 38.9 5.6 1.4 0.0 72 Worrying about what Workers 43.2 33.8 15.7 6.7 0.6 447 might happen Referral Agents 59.3 35.8 1.2 3.7 0.0 81 Providers 45.8 47.2 5.6 1.4 0.0 72 The feeling that asking for Workers 41.2 30.6 17.5 10.0 0.7 447 help is a sign of weakness Referral Agents 56.8 32.1 11.1 0.0 0.0 81 for males Providers 55.6 36.1 6.9 0.0 1.4 72 The fear that others will Workers 58.8 27.3 8.7 4.7 0.6 447 learn about it Referral Agents 66.7 28.4 1.2 3.7 0.0 81 Providers 63.9 31.9 2.8 1.4 0.0 72 The feeling that just talking Workers 29.9 41.2 20.6 7.4 0.9 447 will do no good Referral Agents 32.1 49.4 18.5 0.0 0.0 81 Providers 30.6 54.1 125 2.8 0.0 72 The fear it will affect Workers 34.5 29.8 20.1 15.4 0.2 447 his job Referral Agents 43.3 44.4 4.9 7.4 0.0 81 Providers 37.5 40.3 20.8 1.4 0.0 72 No transportation Workers 11.6 16.3 43.2 28.9 0.0 447 Referral Agents 12.3 23.5 43.2 21.0 0.0 81 Providers 8.3 25.0 47.2 18.1 1.4 72 Would miss favorite Workers 7.2 11.41 30.9 50.1 0.7 447 TV program Referral Agents 7.4 27.2 38.3 27.2 0.0 81 Providers 2.8 18.1 41.7 33.3 4.1 72 Afraid people will Workers 60.6 22.8 8.7 7.4 0.4 447 think he is crazy Referral Agents 80.2 12.4 25 3.7 1.2 81 Providers 73.6 23.6 2.8 0.0 0.0 72 Cost of a babysitter Workers 5.6 21.7 45.7 26.6 0.4 447 Referral Agents 4.9 44.4 34.6 16.0 0.0 81 Providers 2.8 56.9 375 2.8 0.0 72 The feeling they can Workers 49.2 30.4 13.0 6.3 11 447 handle their own problems Referral Agents 71.6 21.0 37 25 1.2 81 Providers 56.9 37.6 4.1 1.4 0.0 72 Afraid to talk to a Workers 48.8 29.8 11.1 9.6 0.7 447 psychiatrist Referral Agents 58.1 33.3 3.7 3.7 1.2 81 Providers 58.3 34.7 5.6 1.4 0.0 72 Not knowing they Workers 62.4 22.6 8.7 4.7 1.56 447 need help Referral Agents 70.4 22.3 4.9 1.2 1.2 81 Providers 45.8 47.3 6.9 0.0 0.0 72 IDENTIFICATION OF OBSTACLES TABLE 158.—(Cont’d.) Very Some- Very Not At Don’t Know or Number of Much what Little All No Response Respondents Embarrassment Workers 56.6 31.3 9.2 2.2 0.6 447 Referral Agents 69.1 24.7 3.7 25 0.0 81 Providers 50.0 44.4 5.6 0.0 0.0 72 The Fear That Others Will Learn About It There were slight variations among the three groups’ perceptions of this potential barrier. About 60 percent of both the workers and the providers and two-thirds of the referral agents felt that fear that others will learn about a person’s being in treatment would ‘‘very much’ inhibit treatment-seeking. However, about 13 percent of the workers said that such a consideration would have ‘‘very little’ or no effect upon a person’s. decision to seek help, while a much lower propor- tion of the providers and referral agents held a similar view. The Fear It Will Affect His Job This factor was viewed as being at least ‘‘some- what” of a barrier to treatment by almost 90 per- cent of the referral agents, about 80 percent of the providers, and almost two-thirds of the work- ers. Over 15 percent of the workers felt that this consequence of being in treatment would have no effect upon a decision to seek help. Being Afraid to Talk to a Psychiatrist The referral agents and providers similarly viewed this barrier. About 60 percent of each of these groups felt that being afraid to talk to a psychiatrist would ‘‘very much’ inhibit people from seeking treatment, and about one-third said that such a concern would be ‘‘somewhat’’ inhi- biting. However, less than half of the workers viewed this factor as ‘‘very much’’ of a barrier, and 21 percent said that they felt that this concern would have ‘‘very little’” or no effect on a per- son’s decision to enter a treatment situation. Asking for Help Is a Sign of Weakness for Males There were important differences between the workers’ responses to this item and the views expressed by both the referral agents and the providers. While 10 percent of the workers felt that this factor would not inhibit a person from seeking treatment, none of the providers or refer- ral agents held a similar view. About 55 percent 91 of both the providers and referral agents felt that this concern would ‘‘very much’’ inhibit a person from going for treatment. In contrast, only about 40 percent of the works offered this response. The Feeling They Can Handle Their Own Problems Over 70 percent of the referral agents thought that the feeling that people can handle their own problems would be ‘‘very much” of a deterrent to treatment. Only about 57 percent of the providers and less than half of the workers expressed a sim- ilar view. While almost one-fifth of the workers expressed the opinion that this factor would have only ‘very little’” or no effect on the decision to seek help, only about 6 percent of both the refer- ral agents and the providers felt that way. Il. Knowledge Factors Not Knowing Services Are Available Over 80 percent of both the providers and re- ferral agents and almost two-thirds of the workers felt that a lack of awareness about available serv- ices would be at least ‘somewhat’ of a barrier to treatment. The difference between the workers’ response pattern and the pattern of responses offered by the referral agents and providers was due to the relatively high proportion of workers (35.4 percent) who felt this factor would have “very little” or no strength as a barrier to treat- ment. Not Knowing They Need Help Over 60 percent of the workers and about 70 percent of the referral agents felt that this factor would be ‘‘very much’ of a deterrent to treat- ment and less than half of the providers respond- ed in a similar manner. The providers were more likely than either of the other two groups to view the lack of awareness that help was needed as ‘somewhat’ of a barrier. While all three groups viewed this factor as a barrier to treatment, the workers and referral agents felt it had a greater deterrent strength than the providers. COMPARISON OF WORKERS, AGENTS, AND PROVIDERS Worrying About What Might Happen The general apprehension which a person often feels when deciding to seek help frequently in- volves an anxiety associated with his not knowing what to expect. All three groups felt that this concern had ‘‘somewhat’ of a deterrent value, while there were differences among the groups with respect to this factor’s deterrent strength. About 60 percent of the referral agents felt it was “very much’ a deterrent to treatment. Less than half of both the providers and workers held a sim- ilar view. Not Knowing They Are Covered by Insurance If workers are unaware of their eligibility for mental health benefits, then the three groups felt that the perceived costs involved were likely to prevent or at least hinder the help-seeking proc- ess. Over 90 percent of each group felt this fac- tor had at least some deterrent value. The Feeling That Just Talking Will Not Help The dominant response within each of the three groups was that this factor would be ‘‘somewhat’’ of a deterrent to seeking treatment. Over 40 per- cent of the workers and about half of the referral agents and providers offered this response. About one-third of each group felt that this lack of un- derstanding of the treatment process would have “very much” of an inhibiting effect upon seeking help. Ill. Inconvenience Factors No Transportation Lack of available transportation was not seen as being a strong barrier to treatment by any group. The dominant response for each group was that such problems would have ‘‘very little’’ ef- fect upon a person’s decision to seek treatment. Would Miss a Favorite Television Show This problem, even when presented in a way in which the comparative values of the two events were thought to be obviously weighted toward the treatment choice, was viewed as being at least “somewhat” of a deterrent by over one-third of the referral agents and one-fifth of both the pro- viders and workers. The Cost of a Babysitter Only a small proportion of each group thought the cost of a babysitter would ‘‘very much’ pre- vent a person from seeking treatment. The domi- nant response among the refferal agents and pro- viders was that this factor would ‘‘somewhat’ 92 inhibit treatment-seeking, while the dominant re- sponse among the workers was that this factor would have ‘very little’’ deterrent value. A sub- stantial proportion within each group offered a response which differed from these dominant responses. The three groups were frequently found to disa- gree about the relative strength of the presented potential obstacles to treatment. Even the re- sponse patterns within the three groups indicate a lack of agreement. These findings reveal more about the lack of an organized mental health care delivery system than a consensus of the problems that must be overcome so that the help-seeking process can function smoothly. Even with these response variations, all of the potential obstacles except those involving prob- lems of inconvenience were seen as having at least some inhibiting strength. These findings could form a basis for efforts designed to facili- tate the process of getting people with problems to treatment. Section VI: The Identification of Workers’ Problem Areas The workers, referral agents, and providers were presented with a list of problem areas, and each group was asked to identify those areas which they felt caused the workers the most prob- lems. Table 159, presenting the first and second areas cited by each of the three groups, reveals that the three differed in their perceptions of the workers’ problems. One-fifth of the referral agents identified problems related to alcohol as causing workers difficulty. Less than 5 percent of the workers offered this response. While about one-fifth of the referral agents and about 40 per- cent of the providers viewed problems involving marriage and children as the basis for the work- ers’ problems, only about 10 percent of the work- ers cited these areas. There was some degree of agreement among the three groups in their perception of work-related problems; however, 16 percent of the workers and about 12 percent of the referral agents mentioned income as a cause for workers’ problems. None of the providers mentioned this. Over one-fourth of the referral agents and over 40 percent of the providers cited marital problems or problems involving the workers’ children, while less than 13 percent of the workers men- tioned these problems. Less than 4 percent of the workers felt that alcohol or drugs caused their group problems, while almost one-third of the IDENTIFICATION OF PROBLEM AREAS TABLE 159.—Comparison of Workers’ Problem Areas, in Percentage In- Health Work Alcohol Drugs come Marriage ren Child- Loneli- ness Getting Problem Dissat- Along With No isfaction With Suffering Leisure Problem Number of Parents With Self Others a Loss Time Sex Reported Respondents First Problem Area Mentioned Workers 29.3 145 2.9 0.2 15.9 4.7 6.0 1.1 29 4.7 0.7 3.4 3.1 09 96 447 Referral Agents 6.2 23.5 19.8 12 123 17.3 1.2 0.0 0.0 9.9 6.2 0.0 0.0 1.2 12 81 Providers 15.3 22.2 4.2 0.0 0.0 19.4 20.8 2.8 28 2.8 1.4 2.8 1.4 42 0.0 72 Second Problem Area Mentioned Workers 31 119 27 0.7 15.4 5.1 7.8 25 3.1 8.9 25 3.8 3.6 25 0.0 447 Referral Agents 2.5 6.2 17.3 136 11.1 21.0 6.2 25 1.2 7.4 8.6 12 0.0 00 1.2 81 Providers 5.6 83 11.4 69 56 319 13.9 5.6 1.4 2.8 4.2 1.4 0.0 00 14 72 referral agents and about one-fifth of the provi- ders mentioned them. The workers stressed problems associated with employment, income, and health; while marital problems, problems involving children, and drugs and alcohol were the dominant responses of the providers and referral agents. These findings indi- cate that the three groups differ in their under- standing of the areas which cause workers diffi- culty. Section VII: Attitudes Toward Mental Health Eight statements related to the mental health field were presented to the three groups and each respondent was asked to agree or disagree with each statement. The statements and response pat- terns are presented in table 160, where it can be seen that the three groups differed in their views on several items but expressed agreement on oth- ers. The most important area of disagreement lies in the finding that less than half of the providers felt that ‘“‘most family doctors can help patients with emotional problems,” while about two-thirds of the referral agents and about three-fourths of the workers agreed with this statement. Another item for which response differences were noted was the statement that ‘“‘people are usually the last ones to recognize the sign of mental illness in members of their own families.”” About two-thirds of both the workers and the referral agents agreed with this statement, but only about half of the providers agreed. One-fourth of the workers disagreed with the statement that ‘‘if a mental patient is treated in a 93 general hospital or clinic instead of a mental hos- pital there will be less of a stigma against the per- son.”” Over 83 percent of both the referral agents and the providers agreed with this statement. While just over half of the referral agents agreed with the statement that ‘‘most people would not like to work next to a person who has been a mental patient,” only about 43 percent of both the workers and the providers responded in a similar manner. Although the three groups were themselves divided in their views of this state- ment, a higher proportion of the referral agents agreed rather than disagreed with this statement. The opposite was true among the workers and providers. Over 84 percent of each group agreed that ‘“‘ev- eryone should learn to recognize the early signs of mental illness,”” and about 70 percent of each group agreed that ‘“‘most people become mentally ill to avoid the difficult problems of everyday life.”” The vast majority of the three groups felt that most people are uneasy about mental illness. It should be noted that while 15 percent of the workers and about 18 percent of the referral agents disagreed with the belief that ‘‘keeping up a normal community life helps the chances for the improvement of a mental condition,’ none of the providers held a similar view. Over 90 percent of this group agreed with the statement, and the remainder were unable to offer an opinion. The identified segments of the conceived mental health care delivery system appeared to be gener- ally out of touch with each other. Systemic bar- riers were found to exist in that the three groups frequently differed in their definitions of problem situations, had different levels of awareness about both the available mental health services and the workers’ mental health benefits, held different COMPARISON OF WORKERS, AGENTS, AND PROVIDERS ions regarding several attitude statements. Any or all of these factors could inhibit the delivery of mental health care to troubled individuals. views regarding the strength of potential deter- rents to treatment, differed in their perceptions of workers’ problem areas, and held different opin- TABLE 160.—Comparative Attitudes Toward Mental Health, in Percentage Don’t Know or Number of Agree Disagree No Response Respondents Everyone should learn to recognize the Workers 93.1 6.7 0.2 447 early signs of mental illness. Referral Agents 90.2 8.6 1.2 81 Providers 84.7 7.0 8.3 72 People are usually the last ones to recognize Workers 68.7 29.3 2.0 447 the signs of mental illness in members Referral Agents 64.2 34.6 1.2 81 of their own family Providers 51.4 40.3 8.3 72 Most people become mentally ill to avoid Workers 72.5 22.6 4.9 447 the difficult problems of everyday life. Referral Agents 70.4 28.4 1.2 81 Providers 69.5 22.2 8.3 72 Most family doctors can help patients Workers 74 1 22.4 3.5 447 with emotional problems. Referral Agents 65.5 33.3 1.2 81 Providers 48.6 43.1 8.3 72 Most people would not like to work next Workers 43.4 54.1 2.5 447 to a person who had been a mental Referral Agents 51.9 43.2 4.9 81 patient. Providers 43.1 48.6 8.3 72 Keeping up a normal community life Workers 81.0 15.4 3.6 447 helps the chances for the improve- Referral Agents 80.3 18.5 1.2 81 ment of a mental condition. Providers 91.7 0.0 8.3 72 If a mental patient is treated in a general Workers 71.8 25.1 3.4 447 hospital or clinic instead of a mental Referral Agents 84.0 14.8 1.2 81 hospital there will be less of a stigma Providers 83.4 8.3 8.3 72 against the person. Mental illness tends to repel most people. Workers 86.6 11.9 15 447 Referral Agents 91.1 9.9 0.0 81 Providers 81.9 9.8 8.3 72 94 CHAPTER 6: SUMMARY AND CONCLUSIONS In the preceding chapters we have followed the format of presenting first the data separately for workers, potential sources of referral, and pro- viders of service. This was followed by a compos- ite comparison of the data for these three groups. In this last chapter we attempt to draw out an overview and a summary of these data. Our format here singles out the dominant themes in each of the seven major categories of data: knowledge of local resources, evaluation of local resources, knowledge of UAW benefits, situ- ations defined as requiring treatment, identified obstacles to receiving treatment, perceptions of prevalent problems, and attitudes toward mental health treatment. In analysis of these data, the prevalent theme puts focus on whatever patterns of differences appear among the three groups. However, the emphasis of this presentation is placed not on the presence of these differences alone but rather on their implications for the re- ferral and treatment process. This emphasis con- centrates on sources of obstacles to treatment. With regard to knowledge of facilities or serv- ices available, the pattern of responses for the three groups is extremely simple to describe. The vast majority of the providers of service (86 per- cent ) were able to name at least four of the local facilities. A very large proportion of the workers (77 percent) were at best able to name no more than one facility, and most of them were not able to name even one. The referral agents were al- most exactly midway between these two extremes in their awareness of treatment resources It is of questionable utility for providers of service to know all of the local treatment re- sources when the vast majority of the working population are so poorly informed. This is more significant in view of the medium level of knowl- edge of resources manifested by the referral agents. In the context of obstacles to treatment, this group in particular appears to be crucial as the vital link in bringing together the troubled worker with an appropriate treatment resource. This point may be amplified as follows: Workers do not know about mental health re- sources in the community. Providers of services are well informed. This suggests that the worker getting to any resource is probably in contact with 95 someone who knows about a variety of local serv- ices, including specialized facilities which may be most appropriate for dealing with specific types of mental or emotional problems. Between these two groups is a moderately informed stratum of refer- ral agents. Because of their chosen proximity to the troubled individual, their knowledge or ignor- ance plays a vital role, first, in simply being able to refer, or not being able to refer, the individual to treatment, and, second, in being able to refer the person to an appropriate service. This group, potential referral agents, requires attention to transfer their potential role to an ac- tual role. Within any local community the number of treatment resources is limited, and these re- sources can be listed with relative ease. Potential referral agents, as defined, are also identifiable. Providing them with information on resources and periodically renewing or updating these listings is a more promising avenue than attempting to in- form an entire working population. As to the evaluation of available mental health facilities by the three groups, there is again a rather simple pattern of responses to describe. About one-third of each group rated these re- sources in a positive manner. Only the workers had a large proportion of respondents with no opinion on this item (about 40 percent). A majori- ty of the other two groups expressed a negative evaluation of local resources. The more involved a group is in mental health treatment, the more negative that group evaluates the available re- sources. The fact that over 60 percent of the providers expressed a negative view of the local facilities may be viewed as a positive sign. It suggests that the group most involved in treatment is not satis- fied with the current situation. This circumstance can serve as a spur to improve the number and quality of current mental health services. It does not suggest that providers generally have a nega- tive outlook in the actual provision of service. The same response among the potential referral agents suggests a different direction. The fact that this group has a negative view of current mental health resources implies a serious obstacle to re- ferring workers and their families to treatment. If this group of referrers has a negative evaluation SUMMARY AND CONCLUSIONS of resources, it is highly unlikely that they will refer problem cases to those resources. The rea- sons for the negative position could relate to ei- ther the quantity or the quality of those re- sources; either way, the majority of this group probably would not refer cases to treatment, or at least would not do so with any degree of positive- ness. They might more readily discourage indi- viduals from obtaining professional help. The third area centers on the three groups’ awareness of the basic provisions of the mental health benefits available to UAW members and their families. The providers of service were well aware of these benefits. Even the “Don’t Know’ responses of this group can be rationalized as the responses of individual providers who may rely on office assistants to manage the details of pay- ment for services, especially in a group facility with public support. However, both workers and referral agents knew considerably less about these benefit provisions than the providers, the referral agents being only somewhat more knowledgeable about the benefits than the workers. The fact that providers of service are well in- formed does not facilitate the treatment of work- ers, especially in view of the ethical restrictions on advertising. Their awareness does ensure that workers will receive the financial consideration they are entitled to when they do get to treat- ment. However, the degree of difference in awareness between the workers and providers does not suggest a well-paved and frequently trav- elled link between potential users of service and the providers of service. If potential sources of referral are unaware of the workers’ eligibility for prepaid mental health services, their concern for the workers’ financial problems may easily dissuade them from making referrals, even if they are aware of appropriate resources. The data here point to the middle stra- tum, the potential sources of referral, as the weak link in the process of getting people into treat- ment. The three categories discussed above all have some relationship to the matter of knowledge about the mental health delivery system in the community. In each instance the data point to the sources of referral as a weakly informed but po- tentially useful link of that system. The problem cited suggests that they be the target of informa- tion, for with that information they can facilitate the treatment process while without the necessary information they may easily be considered unwit- tingly inert members in the treatment system. This information must be of at least the three va- rieties discussed above: knowledge of prepaid 96 benefits; knowledge of resources available, both public and private; and knowledge about what those resources are attempting and planning to do as well as what they are in fact accomplishing. The next area includes the three groups’ defi- nitions of problem situations. Three problem situations—constant television watching, excessive drinking, and fighting on the job—actually elicited quite similar responses from the three groups. The situation of a man talking to machines was viewed by a similar proportion of the workers and providers of service as requiring treatment, but a smaller proportion of the referral agents was found to share this view. The remaining situations disclosed large discrepancies between workers and providers, the referral personnel usually re- sponding in the same vein as the workers. With the exception of one item (the 12-year-old who lies and steals), only one-sixth to one-fourth of the workers defined the situations as requiring treatment, while at least one-half of the providers thought treatment was required. These items re- ferred to what might be viewed as more subtle forms of behavior in the context of mental health. The implications of these comparisons are sig- nificant. The responses actually disclosed a form of polarization in that there appear to be situa- tions equally agreed upon by all groups as requir- ing treatment. These items are rather obvious behavioral problems involving some form of ex- cess. However, another range of situations clearly differentiated the perceptions of workers from providers of service. This set of problems largely embraces everyday behavior, such as husband and wife working different shifts and the working woman not feeling appreciated. The greatest dis- crepancy was over 50 percent in the definition of need for treatment for the husband and wife working different shifts, two-thirds of the provid- ers and only one-sixth of the workers agreeing that this situation required help. These items document a significant fact in terms of obstacles to treatment. The obvious forms of behavioral problems are recognized by the workers; the more subtle signs of problematic situations go undefined. This finding points to a need for greater sensitivity on the part of workers to the efficacy of treatment in situations in which the behavioral manifestations are less than of a crisis nature, especially typical family-living situa- tions. The three groups’ opinions of the extent to which the presented obstacle items would prevent workers from seeking treatment have a direct bearing upon the effective operation of a need- referral-treatment system. Although there were SUMMARY AND CONCLUSIONS some response variations among the three groups, at least a majority of each group viewed 4 of the 15 factors as ‘‘very much’ preventing workers from seeking treatment. Three of these four fac- tors were related to stigma, and the fourth factor involved a lack of awareness among workers that they are eligible for the mental health benefits. These findings verify a widely held belief that the fear of being stigmatized and the perceived costs of treatment have a definite inhibiting effect upon treatment-seeking. Eight of the 11 remaining obstacle items were viewed by the vast majority of the three groups as at least acting to ‘‘somewhat’’ inhibit workers from seeking treatment. In fact, only the practical problem of lack of transportation, cost of a baby- sitter, and a scheduling conflict between a treat- ment session and a favorite television show were not viewed in this manner. These findings suggest that a number of factors have the potential strength to prohibit workers from seeking treat- ment. While it is unlikely that any single factor would present, in reality, an independent obstacle to treatment, it is probable that two or more of the factors would function together to inhibit treatment-seeking. This result suggests that each of the factors identified as at least somewhat inhi- biting would comprise only a portion of what must be considered a formidable set of inhibiting influences. In 14 out of the 15 items, the proportion of re- ferral agents who said the factor would ‘‘very much” prevent workers from seeking treatment was higher than the proportion of providers or workers who held that view. This pattern indi- cates that the referral agents tended to overesti- mate the preventive strength of the obstacles. The referral group might then hesitate before acting in a referral role. If, for example, they perceive workers to be extremely concerned about a belief that people can handle their own problems, then they would be less than likely to volunteer suggestions for seeking help. Even in situations where workers ask for their advice, the fact that referral agents tend to overestimate the workers’ resistance to seeking treatment could easily com- plicate the referral process. The focus of attention again rests on the re- sponses of the referral group. At the least their views about the preventive strength of the obsta- cle items indicate that they were not aware of how workers viewed the identified obstacles to treatment, a result that implies a lack of commu- nication between the referral agents and workers. Yet these responses imply, further, that the refer- ral group might hesitate to become involved in 97 referral activities and, even where they do, they could inhibit a referral to treatment by transmit- ting their perceptions to the workers. A comparison of the three groups identification of the problems which cause workers the most difficulty suggests two interpretations. First, while the providers very frequently cited marriage and family problems as causing workers difficulty, and although the referral agents cited this problem area about half as frequently, this same area was viewed as a problem by only a few of the work- ers. In fact the workers stated that health and income concerns caused them the most difficulty. These response differences perhaps indicate that, by the time workers or their family members re- ceive professional help for their problems, a shift occurs in the content areas within which the prob- lems become manifest. This outcome suggests that preventive measures and health-maintenance practices are not being employed—that, instead of being resolved while they are manifested in the practical adjustments of the worker, problems lin- ger until they appear as dynamic difficulties af- fecting the relationships between family members. A second interpretative theme is evident from the comparative frequency with which the three groups cited drugs and alcohol problems. The re- ferral agents clearly perceived these areas as causing workers problems, while a far smaller proportion of both the workers and providers cit- ed these areas. These findings indicate that nei- ther the providers nor the workers themselves expressed a concern about workers’ drug or alco- hol problems, while the referral agents were quite aware of the extent of these problems. If the re- ferral agents’ perceptions are accepted and there is evidence to support their views, then these re- sponse variations manifest a denial of these prob- lems among the workers and indicate that these problems are not to any large extent included within the presenting symptomatology of those workers who have had professional contacts with the providers. These responses reveal that poten- tially serious problems are not being treated with- in a mental health setting. The response patterns for the eight attitude items demonstrate among the three groups a de- gree of disparity that could hinder the delivery of professional mental health care to the eligible consumer group. While it is true that the vast majority of the three groups agreed with the state- ments that ‘“‘everyone should learn to recognize the early signs of mental illness,” ‘‘keeping up a normal community life helps the chances for the improvement of a mental condition,” and ‘‘most people become mentally ill to avoid the difficult SUMMARY AND CONCLUSIONS problems of every day life,” these items can be considered ‘‘cultural truisms.”” However, the re- sponse to the remaining five attitude items indi- cate variations that are worthy of note. The workers and referral agents were found overwhelmingly to view the family doctor as an appropriate source of help for patients with emo- tional problems, while less than half of the pro- viders were in agreement with this perception. These responses suggest a potential barrier to treatment of a form that is provided by a mental health professional. The fact that the family doc- tor is perceived as an appropriate source of men- tal health care by the potential consumers, and that this view is reinforced by the referral agents, suggests that a direct referral to a mental health professional is unlikely. It would follow that the eligible consumer group would expect to receive appropriate care from the family doctor, and this expectation could interfere with their family doc- tor subsequently suggesting a referral to a mental health professional. Three items can be viewed as indicators of the stigma associated with receiving care for mental or emotional problems. These are: ‘‘Mental illness tends to repel most people; ‘If a mental patient is treated in a general hospital or clinic instead of a mental hospital, there will be less stigma against the person;”’ and ‘‘Most people would not like to work next to a person who had been a mental pa- tient.” In response to each of these items, the referral agents showed the highest proportion in agree- ment. This pattern suggests that the referral group, more than the other groups, displayed a heightened concern for the process of stigmatiza- tion. Since the referral agents were shown to be more concerned with the stigma associated with receiving treatment, their actions while in the re- ferral role could have an inhibiting effect. They might be hesitant to suggest that a troubled per- son seek treatment or might transmit their nega- tive impressions to others when their advice is sought. In any case the referral agents’ demon- strated concern would surely not facilitate the effective operation of a need-referral-treatment system. The response patterns for the final attitude item are suggestive of a tendency for those close to a troubled individual to deny the need for attention or, at least, be less than likely to admit to such a need. While about two-thirds of the workers and referral agents agreed that ‘people are usually the last ones to recognize the signs of mental illness in members of their own family,” only about half of the providers so responded. In an interpreta- 98 tion of the implications of these findings, there is a clear tendency for those close to a troubled per- son to be unsupportive of his seeking help until after his problems increase in severity. The fact that those who are experienced in offering mental health care did not hold the same conviction as the workers or referral agents indicates that the issue rests with an admission of a need for treat- ment rather than with a recognition of that need. This situation could hardly be expected to encour- age troubled people to seek help. Numerous obstacles were found to exist in the pathways to prepaid mental health care. To a large extent these obstacles derive from the dif- ferences identified among the three groups within each of the seven major areas investigated. In other cases the perceptions, attitudes, beliefs, ac- tions taken, and awareness levels of the workers and referral agents viewed independently were found to inhibit the effective operation of a need- referral-treatment system. The findings of this study indicate the lack of, and the problems pro- hibiting, the establishment of a coordinated com- munity-wide system of mental health care deliv- ery that functions to provide early detection and referral of troubled workers and their families and professional attention to their individual needs. These findings have significance for the current scene. Recent trends indicate a tremendous growth of mental health coverage under prepay- ment or some form of private insurance plan. Yet, as this study has demonstrated, the fact that millions of Americans have become eligible for mental health benefits does not necessarily mean a substantial increase in early service utilization among those in need of care. Mental health bene- fits are not the same as general medical benefits. They provide coverage for a form of health care which potential users frequently consider nones- sential, or at least postponable. The recent in- creases in the number of Americans eligible for mental health benefits are laudable, but additional efforts are required before the goal of early detec- tion and treatment can be achieved. Accordingly, employers and unions representing workers have an obligation to do more than negotiate collective- bargaining agreements which include coverage for mental health services. They must become in- volved in efforts to improve ways to inform work- ers about their coverage. Employers could conduct information programs to inform employees about their mental health benefits, yet, with a few notable exceptions, such programs have not been conducted. In normal economic times, the turnover rate is high among blue-collar workers. New employees are almost SUMMARY AND CONCLUSIONS never informed about their mental health benefits except through a few sentences included in a mul- tipaged booklet covering numerous employee benefit programs. Such a situation is hardly con- ducive to employees becoming familiar with their mental health benefits, even at a cursory level. As demonstrated by the Amalgamated Clothing Workers Union, those unions whose members are concentrated in relatively few locations have been able to achieve widespread understanding of their mental health program through informal communi- cations. But large international unions such as the UAW, with members located in 34 States and 77 principal cities, have much greater communication problems. Information programs using printed materials, films, and orientation sessions for union referral agents have provided relatively thin cover- age because information programs on prepaid mental health care must compete with those of hundreds of other union-negotiated benefits. The insurance carriers (Blue Cross-Blue Shield and commercial insurance companies) could pro- vide those eligible for mental health coverage with detailed information about the use of their bene- fits. But the insurance carriers have apparently felt no responsibility for any special activity ei- ther to inform subscribers of benefits to which they are entitled or to interpret how the benefits might be used. To the best knowledge of the au- thors, none of the insurance carriers that write these benefits for nationally negotiated union con- tracts has done anything about informing or ex- plaining them to subscribers. With the practical limitations inherent in nation- wide union-sponsored education programs and the unwillingness of employers or insurance carriers to become involved, the mental health profes- sions, especially psychiatry, represent the best hope for improving access to prepaid mental health care. It is time for these professions to become more actively involved in community- wide systems of early detection, referral, and treatment. Efforts could be directed toward edu- cating potential sources of referral. To this end, community conferences could be conducted dur- ing which psychiatrists could educate referrers about detecting problems, when to refer, and the types of treatment provided by the existing men- tal health facilities within their community. Fur- ther, the mental health professions could educate the general public through mass-media programs 99 and could work with organizations representing subscriber groups in joint educational efforts. Unfortunately, American psychiatry does not appear to be clear about its own role or responsi- bility in this regard. After 1966 and 1967, when a number of psychiatrists joined with the UAW to conduct interpretation and information sessions, the psychiatrists’ interest in such efforts dimin- ished. There has since been little evidence that organized psychiatry is prepared to take the initia- tive or to put necessary time and effort into edu- cational programs either for the public as a whole or for selected groups of potential referral agents. In at least one instance, a State psychiatric so- ciety determined that it would not participate in union education efforts unless those psychiatrists participating in the program were paid their usual fees for the time they spent in these activities. Such a position by the profession expresses an attitude of detachment that seems contrary to the goal of improved mental health for Americans. The mental health professions are needed. By tak- ing a leadership role in efforts designed to better inform the general public, and particularly agents of referral, they can be of immense help in re- moving many of the obstacles in the pathways to the effective use of prepaid mental health care identified in this study. Prepaid or insured mental health care has come a long way in the last 10 to 15 years. Yet, effec- tive use of covered services has not been achieved, especially for members of working-class families. Currently, in the view of most informed observers, the prospects are bright for some form of national health insurance program being adopt- ed in the near future. Most proposals now before the Congress include some form of mental health coverage. In a few of the bills the benefits are substantial. However, the fact that more people will be covered will be less meaningful if the ben- efits 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 of awareness of coverage iden- tified in this study may provide the basis of an attempt at their reduction. 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American Sociological Review, XXI, 1956, pp. 472-479. Kornhauser, Arthur. The Mental Health of the Industrial Worker: An Analysis and Review. New York: Wiley, 1965. Lemkau, P.V., and Crocetti, G.M. An urban population’s opinion and knowl- edge about mental health. American Journal of Psychiatry, CXVIII, 1962. pp. 692-700. Locke, B.Z.; Krantz, G.; and Kramer, M. Mental diseases in the senium at mid-century: First admissions to Ohio State public mental hospitals. Ameri- can Journal of Public Health, L, 1960. pp. 998-1012. McDermott, J.F.; Harrison, S.I.; Schrager, J.; and Wilson, P. Social class and mental illness in children: Observations of blue collar families. American Journal of Orthopsychiatry, XXXV, 1965. pp. 500-508. Miller, S.M., and Mishless, E.G. Social class, mental illness, and American psychiatry: An expository review. Millbank Memorial Fund Quarterly, XXXVII, 1959. pp. 174-199. National Opinion Research Center, confidential Forecast of the Results of the Survey of ‘‘Popular Thinking in the Field of Mental Health.” N.O.R.C., University of Chicago, Survey 272, 1952. Nunnally, J.C. Popular Conceptions of Mental Health. New York: Holt, 1961. Overall, B., and Aronson, H. Expectations of psychotherapy in patients of lower socioeconomic class. American Journal of Orthopsychiatry, XXXIII, 1963. pp. 421-430. Phillips, Derek L., Rejection: A possible consequence of seeking help for men- tal disorders. American Sociological Review, XXVIII, 1963. pp. 963-972. 102 BIBLIOGRAPHY Reed, Louis S.; Meyers, Evelyn S.; and Scheidemandel, Patricia L. Health Insurance and Psychiatric Care: Utilization and Cost. Washington, D.C.: American Psychiatric Association, 1972. Riessman, Frank J. Mental Health of the Poor. Edited by J. Cohen and A. Pearl. London: The Free Press of Glencoe, 1964. Siegel, N.; Kohm, R.L.; and Pollack, M. Social class, diagnosis, and treatment in three psychiatric hospitals. Social Problems, X, 1962. pp. 191-196. Spitzer, Stephan P., and Denzin, Norman K., eds. The Mental Patient: Studies in the Sociology of Deviance. New York: McGraw-Hill, 1968. Srole, L.; Langner, T.; Michael, S.; Opler, M.; and Rinnee, T. Mental Health in the Metropolis: The Midtown Manhattan Study. New York: McGraw-Hill, 1962. Star, Shirley A. “The Public Ideas About Mental Illness.” Paper presented at the Fifth Annual Meeting of the National Association for Mental Health, Indianapolis, Nov. 4, 1955. Thibant, J.W., and Kelly, H.H. The Social Psychology of Groups. New York: Wiley 1959. Wechsler, Henry. Social Psychology and Mental Health. New York: Holt, Rinehart and Winston, Inc., 1970. 103 APPENDIX TYPICAL INTERVIEW SCHEDULE USED IN THE STUDY Michigan Health Project MH 2037301 & Social Security Research Institute Fall, 1972 1. INTERVIEWER’S: Name: 2. Your Interview No.: Address: 3. Date: Soc. Sec. No.: 4. Length of Interview: (Minutes) INTERVIEWER: List all persons, including children now living in the dwelling unit by their relation to head. (a) (b) © (© (e) Marital Status Indicate R List all persons in DU by of Persons by “v” relation to Head Sex Age over 17 1. HEAD OF HOUSEHOLD 2 3. 11. 12. 105 APPENDIX THE PURPOSE OF THIS VISIT IS TO GET THE BENEFIT OF YOUR EXPERIENCE AND YOUR OPINIONS ON VARIOUS HEALTH QUESTIONS. THERE ARE NO RIGHT OR WRONG ANSWERS. EVERYTHING YOU SAY, OF COURSE, IS STRICTLY CONFIDENTIAL. 1. In regard to quality and quantity of service, do you feel there are adequate mental health services available in the Pontiac area at present? 5. NO| [9. DK] (Go to Q. 2) la. Do you find anything wrong or 1b. What do you find wrong or missing with the services? missing with the services? 2. Can you give the names of any outpatient mental health clinics, counseling agencies, drug or alcohol clinics in the Pontiac area? 1. YES [5.NO f—> (Skip to Q. 4) 2a. What are the names: CATHOLIC SOCIAL SERVICES (OAKLAND COUNTY) CHILD GUIDANCE CLINICS (OAKLAND COUNTY) FAMILY AND CHILDREN’S SERVICES (OAKLAND COUNTY) PONTIAC GENERAL COMMUNITY MENTAL HEALTH CLINIC PONTIAC STATE HOSPITAL PRE AND AFTER CARE CLINIC (FAIRLAWN) O040go0oogd PONTIAC STATE HOSPITAL COMMUNITY PSYCHIATRY DIVISION (OUTPATIENT CLINIC) PONTIAC OSTEOPATHIC HOSPITAL ALCOHOL CLINIC ALCOHOLICS ANONYMOUS ST. JOSEPH MERCY HOSPITAL ALCOHOLISM PROGRAM METHADONE CLINIC (CITY OF PONTIAC) ST. JOSEPH MERCY HOSPITAL DRUG ABUSE PROGRAM O00 0000g3d OTHER: 106 “oe he APPENDIX 3. For first four (4) agencies R names in Q. 2, fill out a box below. AGENCY NAME: (w) Does (agency) have a waiting list? [ 1. YES | [ 5.NO | [ 9. DK | (If Yes) How long is the waiting list? (x) What types of cases does (agency) handle? 9. DK AGENCY NAME: (w) Does (agency) have a waiting list? | 1. YES | [ 5.NO | [ 9. DK | (If Yes) How long is the waiting list? (x) What types of cases does (agency) handle? 9. DK AGENCY NAME: (w) Does (agency) have a waiting list? 1. YES (If Yes) How long is the waiting list? (x) What types of cases does (agency) handle? 9. DK AGENCY NAME: (w) Does (agency) have a waiting list? [ 1. YES] 5. NO 9. DK (If Yes) How long is the waiting list? (x) What types of cases does (agency) handle? 9. DK 4. Please give me the name of a psychiatrist who has a private practice in the Pontiac area? (Ask for full name) Name: [9.DK > (Skip to Q. 5) 4a. Can you give me the name of another? Name: 9. DK 107 APPENDIX WE HAVE A FEW QUESTIONS ABOUT HEALTH INSURANCE BENEFITS. WOULD YOU PLEASE ANSWER WITH ONE OF THE RESPONSES ON THIS CARD. (HAND R CARD “A”) 5. Under their health benefits are UAW members eligible for hospitalization for a mental or emotional problem? . SURE THEY ARE | 2. THINK THEY ARE, BUT NOT SURE | [ 3. DON'T THINK THEY ARE, BUT NOT SURE | 5. SURE THEY ARE NOT 9.DK | Y (Skip to Q. 7) 6. How much of the cost of hospitalization for a mental or emotional problem is covered by insurance? 9. DK 7. Under their health benefits are UAW members eligible for psychological testing prescribed by a physician? 1. SURE THEY ARE [ 2. THINK THEY ARE, BUT NOT SURE | | 3. DON’T THINK THEY ARE, BUT NOT SURE [ 5. SURE THEY ARE NOT | [= (Skip to Question 9) 8. How much of the cost is covered if a UAW member has psychological testing? 108 APPENDIX 9. Under their health benefits, are UAW members eligible for treatment of emotional problems by a private psychiatrist? 1. SURE THEY ARE 2. THINK THEY ARE, BUT NOT SURE | Y (Skip to Q. 11) | 3. DON’T THINK THEY ARE, BUT NOT SURE | | 5. SURE THEY ARE NOT | | (Skip to Q. 13) 10. How much of the cost is covered by insurance if a UAW member goes to a private psychiatrist? | If answer to Q. 10 is “DK,” omit Q. 12. 11. Under their health benefits, are dependents of UAW members eligible for treatment of mental or emotional problems by a private psychiatrist? 1. SURE THEY ARE | 2. THINK THEY ARE, BUT NOT SURE | | 3. DON'T THINK THEY ARE, BUT NOT SURE | | 5. SURE THEY ARE NOT | (Skip to Question 13) 12. How much of the cost is covered by insurance for the dependent at a private psychiatrist’s office? 109 APPENDIX 13. Under their health benefits, are UAW members eligible for treatment of mental or emotional problems at a mental health clinic or center? 1. SURE THEY ARE | 2. THINK THEY ARE, BUT NOT SURE | (Ship to Q. 15) { [ 3. DON'T THINK THEY ARE, BUT NOT SURE | | 5. SURE THEY ARE NOT | | Y (Skip to Q. 17) 14. How much is paid for by this insurance if a UAW member goes to a mental health clinic or center? If answer to Q. 14 is “DK,” omit Q. 16. | 15. Under their health benefits, are dependents of UAW members eligible for treatment of mental or emotional problems at a mental health clinic or center? 1. SURE THEY ARE [ 2. THINK THEY ARE, BUT NOT SURE | [ 3. DON’T THINK THEY ARE, BUT NOT SURE | 5. SURE THEY ARE NOT | | (Skip to Question 17) 16. How much of the cost is covered by insurance for the treatment of the dependent at a mental health clinic or center? 9. DK 17. How did you first hear about the UAW mental health benefits? 110 APPENDIX 18. Do you know of any drawbacks to the UAW mental health benefits? 9. DK 19. Where would you go for specific information about mental health care insurance? 9. DK 20. What are your own opinions on having mental health care covered by insurance? (Probe: “Why is that?””) 21. How much do you think UAW members know about their mental health benefits, a GREAT DEAL, SOME, or VERY LITTLE? | 1.GREATDEAL| [2.SOME | |3. VERY LITTLE | | 9.DK 22. What do you think could be done to better inform UAW members of their mental health benefits? 22a. What has been done at your local to inform union members of their mental health benefits? 9.DK 111 23. APPENDIX Do people like the following NEED mental health treatment? A. A working man watches television from the time he gets home from work until he goes to bed, and refuses to talk to his family. Do you think he needs mental health treatment? [ 2. YES WITH QUALIFICATIONS | | 6.NO WITH QUALIFICATIONS | a. Who do you think could BEST help in this situation? A man talks constantly to the machines in the factory where he works. Do you think he needs mental health treatment? [ 2. YES WITH QUALIFICATIONS | [ 6. NO WITH QUALIFICATIONS b. Who do you think could BEST help in this situation? 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? [ 2. YES WITH QUALIFICATIONS | [ 6. NO WITH QUALIFICATIONS | c. Who do you think could BEST help in this situation? A 12 year old boy lies, steals and skips school. Do you think he needs mental health treatment? | 2. YES WITH QUALIFICATIONS | [ 6. NO WITH QUALIFICATIONS | d. Who do you think could BEST help in this situation? A person always refuses to ride in elevators. Do you think this person needs mental health treatment? 1. YES | | 2. YES WITH QUALIFICATIONS | [ 6. NO WITH QUALIFICATIONS | 9. DK e. Who do you think could BEST help in this situation? A woman works at a job every day and goes home to cook and clean the house at night and feels no one appreciates what she does. Do you think this person needs mental health treatment? [ 2. YES WITH QUALIFICATIONS | 5.NO [ 6. NO WITH QUALIFICATIONS | f. Who do you think could BEST help in this situation? 112 24. APPENDIX A man cannot seem to hold a job very long because he drinks so much. Do you think this person needs mental health treatment? [ 1. YES [ 2. YES WITH QUALIFICATIONS | 5.NO [ 6. NO WITH QUALIFICATIONS | g. Who do you think could BEST help in this situation? A young man is always getting into fights and often gets into trouble on the job. Do you think this person needs mental health treatment? [ 2. YES WITH QUALIFICATIONS | 5.NO [ 6.NO WITH QUALIFICATIONS | h. Who do you think could BEST help in this situation? To what extent do you think the following reasons might keep people from going for help for emotional and mental problems? After 1, read each reason; please answer with one of the responses on this card. (Hand R Card “B”) (a) (b) ©) (@ (e) (®) (® (0) No transportation. [1.VERY MUCH| [2. SOMEWHAT | |[3.VERY LITTLE | [ 5.NOT AT ALL | Would miss favorite T.V. program. [T.VERYMUCH] [2.SOMEWHAT | [3.VERY LITTLE | [5.NOT AT ALL | Being afraid that people will think he is crazy. [I.VERYMUCH| |2.SOMEWHAT | [3.VERYLITTLE| [5.NOT AT ALL | The cost of getting a babysitter. [1.VERYMUCH| [2.SOMEWHAT | [3.VERYLITTLE| [5.NOT AT ALL | The notion of being able to handle their own problems by themselves. [1.VERYMUCH| [2.SOMEWHAT | [3.VERYLITTLE | [5.NOT AT ALL | Being afraid to talk to a psychiatrist. [1.VERY MUCH| [2.SOMEWHAT | [3.VERYLITTLE| [5.NOTATALL] Not knowing they need help. [1.VERYMUCH| [2.SOMEWHAT | [3.VERYLITTLE| [5.NOT AT ALL | Embarrassment. [1.VERY MUCH] [2.SOMEWHAT | [3.VERY LITTLE | | 5.NOT AT ALL | 113 25. 26. 27. (i) 0) (k) 0 (m) GQ) (© APPENDIX Not knowing that such services are available. [1.VERYMUCH| [2.SOMEWHAT | |3.VERY LITTLE | [5.NOTAT ALL | The expense of treatment, not knowing they are covered by insurance. [1.VERYMUCH| [2.SOMEWHAT | [3.VERY LITTLE | [5.NOT AT ALL | Worrying about what might happen if he goes for help. [I.VERYMUCH| [2.SOMEWHAT | [3.VERY LITTLE | [5.NOT AT ALL | Males feel they must be strong and asking for help shows weakness. | 1. VERY MUCH | |[2.SOMEWHAT | [3.VERY LITTLE] [ 5. NOT AT ALL The fear that others will learn about it. | I.LVERY MUCH | |[2.SOMEWHAT | [3.VERY LITTLE] Feeling that just talking will not do any good. | I. VERY MUCH | |[2.SOMEWHAT | | 3. VERY LITTLE] The fear that it will affect his job. | 1. VERY MUCH | [| 2.SOMEWHAT | [3.VERY LITTLE] 5.NOT AT ALL 5.NOT AT ALL 5.NOT AT ALL Do you know of any other reasons that seem to keep workers from getting professional help for mental or emotional problems.? What types of reasons do you feel finally make people decide to seek help? Do you think people should wait until a crisis occurs, either in the family, at school, or on the job, before they seek help in solving problems? 114 28. 30. 31. 32. APPENDIX Do you think people usually DO wait for a crisis to occur before going for help? What do you think would encourage people with mental or emotional problems to seek professional help sooner? If you wanted to go to a mental health clinic or psychiatrist once a week, what difficulties, if any, would that cause YOU? Would you be able to go? [ 1. YES p~SkiptoQ.32) [5.NO w la. Why not? Would you please look over this list and tell me which four areas you think have caused you the most problems in the past five years? (Hand R Card “C-a”) A. YOUR HEALTH H. DRUGS B. YOUR WORK [1. LONELINESS C. YOUR INCOME J. SEX D. PARENTS | K. GETTING ALONG WITH PEOPLE | E. CHILDREN | L. BEING DISSATISFIED WITH YOURSELF | F. MARRIAGE [ M. SUFFERING A GREAT LOSS | if G. ALCOHOL [ N. NOT KNOWING WHAT TO DO WITH FREE TIME | 115 APPENDIX 33. Is there anything else not on this list that you feel has caused you a lot of trouble? 34. Let's suppose you had a lot of personal problems and you're very unhappy all the time. Let’s suppose you've been that way for a long time and it isn’t getting any better. What do you think you’d do about it. If “Outside Professional Source’ mentioned in Q. 34, skip to Q. 35. If “Outside Professional Source” NOT mentioned in Q. 34. | 34a. Suppose these problems didn’t get better no matter what you tried to do about them yourself, and you felt you had to have some outside help. Do you know of anyone of any place where you could go for help? [ 5. NO J (Skip to Q. 34c). 34b. Where would you go? 34c. Do you know of anywhere you might go, or anyone you might talk to, in order to find out where to go for help? Where is that? 116 35. 36. 37. 38. 39. 40. APPENDIX If you had a personal emotional problem that was really bothering you, would you go talk it over with your shop committeeman? (Go to Q. 36) 5.NO 35a. Why not? If you had a personal emotional problem that was really bothering you, would you go talk it over with your foreman? 1. YES (Goto Q.37) 5.NO 36a. Why not? If you had a personal emotional problem that was really bothering you, would you go talk it over with the company nurse or company doctor? 1. YES (Go to Q. 38) 5.NO 37a. Why not? If someone next to you on the job started acting in a strange manner, whom would you report it to? 1. FOREMAN 2. COMMITTEEMAN 5. WOULD NOT REPORT IT | 8. OTHER How often would you say that you have been asked by other persons for advice about their personal mental or emotional problems — OFTEN, SOMETIMES, ALMOST NEVER, or NEVER? I.OFTEN | | 2.SOMETIMES | | 3. ALMOST NEVER | [| 5.NEVER | (Skip to Q. 42) Let’s take the most recent time anyone asked you for such advice—which of these best describes your relationship to the person who came to you? (Hand R Card “D”") 1. WIFE — HUSBAND 5. OTHER RELATIVE 2. OTHER IMMEDIATE FAMILY (Parents, Children) 6. FRIEND 3. CO-WORKER [ 8. OTHER | 4. ACQUAINTANCE (Specify) 117 41. 42. 43. 44. 45. 46. 47. 48. 49. APPENDIX How did you handle the situation? Have you ever suggested that a person go to a psychiatrist to get help for his emotional problems? I. YES 5.NO (Skip to Q. 46) 4 Did you give that person the name of a specific psychiatrist? 1. YES 5.NO Did you give that person a telephone number to call? 1. YES 5.NO Did that person go to a psychiatrist? 1. YES 5.NO 9. DK (Go to Question 46) + 45a. Did he go on your recommendation? 1 YES 5.NO 9.DK Have you ever suggested that a person go to a mental health clinic to get help for his emotional problems? 1. YES 5.NO (Skip to Q. 50) fi | Did you give that person the name of a specific mental health clinic? 1. YES 5.NO (Go to Q. 48) H 47a. What clinic was that? Did you give that person a telephone number to call? 1. YES 5.NO Did that person go to a clinic? 1. YES 5.NO 9. DK Go to Question 50) —4 49a. Did he go on your recommendation? 1. YES 5.NO 9. DK 118 APPENDIX 50. Have you ever suggested that a person go anywhere else for help with his emotional problems? [5.NOF—=(Go 10 Q. 51) 50a. Where was that? 51. Have you ever known someone who you thought needed to get professional help for an emotional problem, but you did not suggest that he go get help? (Go to Q. 52) Sla. Why not? 52. Once a person seeks professional help, how long, in your opinion, does it usually take to solve his emotional troubles? 9.DK 53. Would you be willing to advise your friend or relative or fellow worker to seek professional help for an emotional problem? 5.NO 9. DK 54. Do you think recognizing a mental health problem and referring the person to treatment would hurt your relationship with that person? 19 APPENDIX SOMETIMES WHEN PEOPLE HAVE PROBLEMS IN MARRIAGE, OR ON THE JOB, OR WITH THEIR CHILDREN THEY GO SOMEPLACE FOR HELP. SOMETIMES THEY GO TO A DOCTOR OR A MINISTER, SOMETIMES THEY GO TO A SPECIAL PLACE FOR HANDLING PERSONAL PROBLEMS — LIKE A SOCIAL AGENCY OR CLINIC. 55. How about you—have you or anyone in your family ever gone anywhere like that for advice and help with any personal problems? [5.NO — (Go t0 Q. 56) 55a. What was that about? 55b. Where did (you) (the person) go for help? (Probe for specific names of social agencies or doctors.) 55c. How did (you) (the person) happen to go there? 55d. What did they do—how did they try to help (you) (the person)? 55e. How did it turn out—do you think it helped (you) (the person) in any way? | After Qs. 55a-55e are asked, skip to Q. 57. | 56. (Ask ONLY if “No” to Q. 55): Can you think of anything that’s happened to you or your family, any problems you've had in the past where going to someone like this might have helped in any way? (Skip to Q. 56¢) 56a. What do you have in mind—what was it about? 120 57. APPENDIX 56b. What did you do about it? 56¢. Who do you think might have helped you with that? 56d. Why do you suppose that you didn’t go for help? | After Q. 56a-56d are asked, skip to Q. 57. | 56e. (If “No” to Q. 56): Do you think you could ever have a personal problem that got so bad that you might want to go someplace for help—or do you think you could always handle things like that yourself? Here are some statements about mental illness and health. Please say if you mainly AGREE, or mainly DISAGREE with each one. A. Mental illness is an illness like any other. 1. AGREE 5. DISAGREE B. Everyone should learn to recognize the early signs of mental and emotional problems. 5. DISAGREE C. People are usually unwilling to recognize the signs of a mental iliness in members of their own family. 1. AGREE 5. DISAGREE D. There is no way to know that a person has an emotional problem until he gets into trouble. 1. AGREE 1. AGREE 5. DISAGREE | 121 APPENDIX . Not much can be done for an emotional problem. 1. AGREE 5. DISAGREE . People would not become mentally ill if they avoided bad thoughts. 1. AGREE 5. DISAGREE . Most mental patients continue to show signs of their illness long after they leave the hospital. : 1. AGREE 5. DISAGREE . Although they usually aren’t aware of it, many people become mentally ill to avoid the difficult problems of everyday life. 1. AGREE 5. DISAGREE ] . No one should ever go to a mental health clinic unless there is just no other way to take care of him properly. 1. AGREE 5. DISAGREE . Most family doctors can be of help to patients with emotional problems. 1. AGREE 5. DISAGREE . Most people would not like to work next to a person who had been a patient at a mental health clinic. 1. AGREE 5. DISAGREE . The type of treatment for mental conditions that relies mainly on talking is probably useless. 1. AGREE 5. DISAGREE . Kindness and understanding from others can usually head off a mental illness. 1. AGREE 5. DISAGREE . One of the main causes of mental illness is lack of moral strength or will power. 5. DISAGREE 1. AGREE . Keeping up a normal life in the community, as far as possible, helps the chances for improvement of mental condition. 5. DISAGREE 1. AGREE . Most people would not like to share an apartment with a person who had been a patient of a psychiatrist. 1. AGREE 5. DISAGREE . If a mental patient is treated in a general hospital or clinic instead of a mental hospital, there will be less of a stigma or black mark against the person. 1. AGREE 5. DISAGREE 122 APPENDIX R. Most people tend to be sympathetic toward someone who has a physical illness, but when it comes to mental illness, most people tend to be standoffish. [ 1. AGREE | [ 5. DISAGREE | S. Do you feel that way yourself? [ 5. DISAGREE | 58. Finally, is there anything else that you would like to add to what we have been discussing about this whole subject of mental health? NOW BEFORE WE END, WE'D LIKE TO GET A LITTLE BACKGROUND INFORMATION. 59. How long have you lived in the Pontiac area? 1. 0-6 MONTHS 2.7-12 MONTHS 3.13-24 MONTHS| 4.2+-5 YEARS 5.5+9 YEARS 6.9+-15 YEARS 7.15+-20 YEARS 8.20+ YEARS If R says “All My Life” check (20+ YEARS) and omit Q. 61 and Q. 62. | 60. How long have you lived at your present address? 1.0-6 MONTHS 2.7-12 MONTHS 3.13-24 MONTHS 4.2+5 YEARS 5.5+9 YEARS 6.9+-15 YEARS 7.15+-20 YEARS 8.20+ YEARS 61. Where did you live before coming to Pontiac? 62. Why have you settled in the Pontiac area? 123 63. APPENDIX What is the highest grade of schooling you completed? GRADE SCHOOL HIGH SCHOOL COLLEGE GRADUATE WORK loo] [or] [oz] [os] foa]|| [oo] [10] [5] [15] [14 | fis | [17] 65. 66. 67. 68. 49, los | [os | [oz] [os] [i] [2] 63a. Do you have a high school diploma or its equivalent? 63b. 63c. 63d. What was your major or specialization? Do you have a degree? [1. YES] What degree is that? Y Have you had any other schooling or training? 5.NO (Go to Q. 65) 64a. What other schooling did you have? Where did you live mostly while you were growing up? (Ages 0-16) City and State (or County, if not U.S.A.): Was that in a large city, a suburb of a large city, a small city, a small town, or in the country? | 1.LARGE CITY| [2.SUBURB| [3.SMALLCITY | |4.SMALL TOWN | [5.COUNTRY What was your father’s main occupation while you were growing up — what sort of work did he do? (Be specific) Are you presently married, widowed, divorced, separated, or have you never married? | 1. MARRIED | [2. WIDOWED | [3.DIVORCED | |4.SEPARATED | |5.NEVER MARRIED In what year were you born? 124 APPENDIX 70. Is your religious preference Protestant, Jewish, Roman Catholic or something else? [PROTESTANT | [JEWISH | (Reformed, Conservative, or Orthodox) [ 8. OTHER (Church or Denomination) (Specify) 71. In the past year, have you attended church service more than once a week, once a week, two or three times a month, once a month, less than once a month, or not at all? [1. MORE THAN ONCE A WEEK _ | [4. ONCE A MONTH_| [2. ONCE A WEEK| [6. LESS THAN ONCE A MONTH | 3. TWO OR THREE TIMES A MONTH| 5.NOT AT ALL | 72. Would you give a brief history of your work in the auto industry, for example what plants, how long, what jobs, and so on? 73. What is your current job title? (Be specific) 74. Is that skilled, semi-skilled, or unskilled? 1.SKILLED| [2.SEMI-SKILLED| [3.UNSKILLED| [8.0THER 75. What things do you particularly like about the job? 125 APPENDIX 76. What things don’t you like about the job? 77. Are you a member of the UAW Union? I. YES [9.DK | 78. What position do you hold within the union? (Be specific) 5. NONE 79. How frequently have you attended the membership meetings of your UAW Local in the past 12 months? 1. ATTENDED ALL MEETINGS | 3. ATTENDED FEW MEETINGS | [2. ATTENDED MOST MEETINGS | ~~ [4. ATTENDED NO MEETINGS | 4. ATTENDED ABOUT HALF OF THE MEETINGS | ¥¥%x4 * * + STOP * * kk kk 126 APPENDIX By Observation Only X1. X2. X3. X4. XS. X6. X7. X8. R’s Race? I.WHITE| [2.BLACK| |OTHER | (Specify) Sex or R? [FEMALE | How many interruptions were there during the interview? As evidenced in the interview, R was: 1. VERY COOPERATIVE | 2. SOMEWHAT COOPERATIVE | 3. MOSTLY UNCOOPERATIVE | R’s level of interest in the interview was: [1. HIGH [2. MODERATE | [3.LOW | Who was present during the interview? Describe the structure in which R’s DU is located. 1. TRAILER ; ROW (OR TOWN) HOUSE (3 OR MORE UNITS | IN AN ATTACHED ROW, EACH WITH ITS 2. DETACHED SINGLE OWN OUTSIDE ENTRANCE FAMILY HOUSE | 6. APARTMENT HOUSE (5 OR MORE UNITS [3. 2-FAMILY STRUCTURE | 7. APARTMENT IN A PARTLY 4. DETACHED 34 COMMERCIAL STRUCTURE FAMILY STRUCTURE THUMBNAIL SKETCH: Anything else about the respondent or the interview situation that seems important. Yr U.S. GOVERNMENT PRINTING OFFICE : 1977 O—236-040 127 DHEW Publication No. (ADM) 76-383 Printed 1977 nn C0291k5817 rr—— a