The Family As a Consumer of Mental Health Services

THE FAMILY AS A CONSUMER OF MENTAL HEALTH SERVICES

Thomas L. Woods, Administrative Staff Coordinator, Division of Child Psychiatry, University of Chicago

[I wish to acknowledge the suggestions made by Mrs. Lynn Drew and Dr. Zanvel Klein in the preparation of this paper.]

It is optimistic to see professionals in both the business and the mental health fields collaborating. Working together, the two disciplines can perhaps create increasingly humane and increasingly efficient products and services for their respective consumers. In line with building the bridge between mental health and business, this paper focuses on examination of the family as a consumer of psychiatric services. More specifically, the processes and stages involved in a family's decision to seek psychiatric help are outlined and compared with those involved th the consumption of traditional economic goods and services.

Focus on the consumer is particularly timely since McKinlay (1972), in his excellent review of the literature on utilization of health and welfare services, has emphasized that researchers have been preoccupied with the study of delivery systems and organizational behavior, while excluding the study of the behaviors of clients in using the service systems. In addition, Fisher and Turner (1970) have noted that little is known about the interpersonal dynamics involve d in the process df deciding to seek help. Because of such limited knowledge about help-seeking behaviors, discussion will be a composite of clinical experience and extrapolations from research not directly related to the present topic.

PRODUCT CONSUMPTION

Consider the activities involved in the purchase of a product--such as a bicycle for a child. Before purchasing the consumer must have a perceived need for this particular item. This involves the creation of demand. While a child's demand can initially stimulate and later highly influence what the parents will demand, the parents generally retain the responsibility, authority, and capacity for the ultimate decision about what will be purchased. Power in a family is ascribed to the parents, not to the children (Parsons, 1955). Besides the child's desires, however, a parent's preference for a child's toy can be strongly influenced by the parent's peers and relatives, product costs, product availability, and the emotional responses, both conscious and unconscious, towards the desired item.

Factors involved in the choice of a particular toy such as a bicycle, are functions of other variables such a&the parents' experiences and memories of their own childhood, general health motivations, the degree of pleasure in seeing their child happy, status and prestige in comparing their child's possession and development in relation to other children, restitution or replacements for some act or feeling the parent was previously unable to provide the child, and vicarious experiences of living through the child's enjoyment. Thus, purchase decisions are usually comprised of multiple motivations which may be individually contradictory.

Once the parent or parents have formulated the general type of item to be purchased, a specific brand or model must then be determined. The assessment of types of bicycles, for instance, may include comparing size, weight, safety, repairability, resale value, warranties, guaranties, and durability. The cost is also an important consideration in product choice. Besides monetary cost, such as purchase price, carrying charges, interest and depreciation, there are also non-monetary costs of opportunity, time, and effort. For example, the parent may need to become involved in the child's use of the bicycle, teaching him how to ride, insuring his safety as he learns to use it, and playing a host of other roles in the child's interaction with the toy.

After the type and brand has been determined, the place of purchase must be selected. If the same product can be procured at a number of retailers, factors such as distance, convenience, reputation, status, and consumer services become important variables.

Besides examining the stages in decision making, we need to study the levels of interaction within and outside of the family matrix. Each stage of decision can contain various levels of interaction between the following: (1) parents; (2) parents, friends, and peers; (3) parents and extended family; (4) -child and parent(s); (5) child and sibling; (6) child and his peers; (7) child and extended family; (8) parent and product distributor; and (9) child and product distributor.

Each level of interaction can be analyzed in terms of its particular needs, wants, and values. Agreement may or may not exist between the different levels of interaction and a hierarchy of request, feedback, and revised request is constructed for each specific product desire. Rules for decision-making evolve and become institutionalized within each particular family system. Certain members may perform specialized functions in the decision making process. For example, Parsons (1955) maintains that the father's role is an instrumental one, in that he provides for the family and is the primary link with institutions outside the family group. The mother is primarily engaged in intra-family affairs and serves to regulate family interactions. Current revisions of the woman's role in middle class society, however, may be altering the power balances in the family towards a more shared responsibility of roles.

Each family also may have a patterned style of decision focus. Families with a strong extended family relationship, for instance, may be highly influenced in their purchase decisions by elders who reside outside of the nuclear family. Other families may seek clues from peers and friends within their social network to orient their decisions. Still other family groups, having an inverted focus of decision, could base their purchasing demands largely upon the requests of the children. When placed on a continuum, decision rules could span from adult-oriented to child-centered foci, while the ultimate decision still could remain with the parental authorities. Changes in a child's age, status, education, size, or ability may be grounds for alteration of previous purchase decision rules. Concomitantly, changes in the parents' age, income, employment, status, among other variables, could also affect decision rules. As a child grows older, better educated and more capable of self-direction , the parents will generally refer a greater number of decision choices to the child.

THE CONSUMPTION OF PSYCHIATRIC SERVICES

The factors enumerated above are ones which must be considered in understanding a family as a consumer of traditional products. How do these factors relate to the family as a consumer of psychiatric services? As in the purchase and consumption of products, the family which ultimately decides to utilize psychiatric services must pass through a series of stages in the process of reaching a final decision. These stages can be summarized as the following: (1) problem awareness, (2) definition of the problem as emotional, (3) desire to seek mental health service, (4) determination of type of mental health service needed, (5) search for desired mental service, and (6) commitment to a particular service.

In the first stage, problem awareness, the family must perceive symptoms, behaviors, or interpersonal relationships within the family as a problem, i.e. experience them as uncomfortable. We know that people perceive symptoms differently so that some individuals may have high anxiety, while others show no concern for the same group of symptoms (Mechanic, 1962). When a particular group of symptoms is easily identifiable and relatively devoid of danger, it is usually considered to be a routine. Unless, however, if the symptoms occur less frequently in the population and are perceived as dangerous, they are likely to create a greater sense of concern (Mechanic, 1962).

Some parents may not be sensitive to a child's "problem" unless it interferes with the family's functioning, i.e. a severe behavioral disorder involving disobedience, physical and verbal aggressiveness, destructiveness, temper tantrums, or running away. other parents, however, may consider more subtle difficulties in a child's development to be problems. They may be concerned if their child is shy, nervous, or acts detached, even though he is not causing any overt disturbance for the other family members.

The child's age is also related to the parents' awareness of problems. Some behaviors are normal at one age and abnormal at another age. The temper tantrum of a 2 1/2 year old child would be considered a normal development response to frustration, where at age 8 tantrums could possibly signify immaturity and lack of self-control. If a particular behavior continues past a certain age the parents may become concerned. In determining what is "normal" or age-appropriate behavior, parents may compare their child with siblings, other children in the neighborhood, or informally survey the opinions of friends, relatives, and associates. Parents may also use the memories of their own childhood as benchmarks for normality. Clearly the mass media can play a role in determining mental health norms as well as alerting citizens to problem syndromes. Public Health Education is important at this point and may be compared to advertising or other demand stimulating marketing activities.

Even if the parents define the child as having a problem, they may not see it as an emotional problem. Rather they could perceive the symptoms as basically related to educational, medical, legal, religious, sociological or economic factors (McKinlay, 1970; Stoeckle, 1963). Thus, after becoming aware of a problem the next decision level is to define the problem as emotional or psychological.

In the process of making this decision, the parent(s) may rely on their own knowledge or consult with the child's school teacher, pediatrician, minister, or some other "expert" who may assist them in defining the problem. If the parents believe, or are led to believe, that the problem is not psychologically based, they may act on their assumption and seek avenues of alleviation like educational enrichments, medical examinations or religious training. If these alternatives then fail to bring relief, the problem may be redefined as psychological. Thus, parents can determine that a child has an emotional problem by making their own assessment, relying on the judgment of authority, or by accepting a psychological definition after other solutions prove fruitless or misguided.

Even if the parents accept the notion that their child has a psychological problem, they may prefer coping with the difficulty themselves rather than seeking help at a mental health service. For some, accepting help may be inconsistent with the family's tradition of independence and rugged individualism, or they may believe that the problem will resolve itself with time and expect the child to grow out of it. During this period, the parents maintain a wait and see attitude, hoping that their interventions or the mere passage of time will resolve the situation. The parents may try giving the child extra attention, change their style of discipline, read a book on child development or elicit advice from friends and extended family hoping that their do-it-yourself approaches will be successful.

At this point, the problem is still conceptualized as emotional but the parents have not yet developed a formal demand for the services of a mental health expert. As with the potential product consumer, the potential mental health consumer is highly influenced in his decision to seek mental health services by members of their social network, i.e. family members, extended family, friends, and peers. Specific effects of the'various agents have not been studied systematically, but some inferences for our purpose can be drawn from related research.

Studies show that there are sexual differences in help-seeking behaviors of adults with individual problems. Fisher and Turner (1970) found women consistently more positive than men about seeking help. Phillips and Segal (1969) show that, given similar physical and psychiatric symptoms, women are more likely than men to seek professional help. Jourand and Lasakow (1958) found women freer to reveal personal problems than men. Therefore, we could speculate that in the families with a problem child, there would exist a potential for parental disagreement over what actions needed to be taken.

In other cases, the decision to seek psychological help may be based on previous conflicts between the parents. For example, sending the child for help may express defiance, revenge, or criticism towards a spouse--the familiar challenge of "Look what you have done to your son!" It may also be a parent's last-ditch effort to show good faith and try to regain a spouse who is about to leave (Holzman and Schlesinger, 1972). Furthermore, parents who wish to find help for themselves may use the child as a face-saving means of gaining admission into a psychiatric center. This last example is similar to the father who buys the child a train but ends up playing with it himself, perhaps even excluding the child.

A family's ethnic or cultural background may also play a role in the decision to accept help. Studying the utilization of medical services, Zola (1966) found that Irish families presented four times as many complaints about eye, ear, nose and throat symptoms than did Italian families. Perhaps ethnic group correlations exist for specific psychiatric symptoms. Or, perhaps different ethnic groups have varying tolerences for similar sets of symptoms. Clinically, black ghetto families apparently tend to overlook bedwetting problems (Drew, 1974). Ethnic correlations for psychiatric symptoms, however, have not been studied. In another medical utilization study, McKinlay, (1970) found that "sophisticated" individuals seek care earlier in the stage of illness than "unsophisticated" individuals, and that the less sophisticated depend more on advice and suggestions from their family and friends. It is also known that most people are more willing to use medical services than they are to seek psychiatric help. Blackwell (1967) found that this was particularly the case for upper middle class adults. These findings were interpreted as evidence that a medical illness is more socially acceptable than a psychiatric illness.

This leads us to emphasize the importance of social stigma which is frequently attached to the act of seeking psychological aid. Not only does the general public hold negative attitudes towards the mentally ill (Nunally, 1961), but also it has been demonstrated in laboratory experiments that normal subjects who were labeled as being emotionally disturbed were stigmatized by other subjects, in spite of the fact that their overt behavior in no way justified the stereotyped response (Farina and Ring, 1965). Thus, the decision to obtain psychiatric services can imply much more than simply the consumer's taste, preferences, and status. To one's reference group, it may imply that the consumer is inferior, disturbed, inadequate, weak, defective, or dangerous. Rather than reflecting the consumer's prosperity or success, the use of psychiatric services can carry strong negative connotations. Unfortunately, most consumers of psychiatric services themselves view this need in a negative light. My own research shows that parents applying to a child psychiatry clinic almost universally feel guilty and experience their need for assistance as a validation of their personal failure as parents (Woods, 1972, 1974).

Aside from the influence of social or cultural pressure, the parents, decision to utilize mental health services is also affected by the psychological meaning of accepting help. These factors can include anxiety over losing one's sense of pride or self-esteem, fears of being humiliated, shamed, blamed, or criticized, the inability to trust others, and early childhood experiences with adult authority figures.

It is important to note that some families are pressured by social institutions to use mental health services. For example, a school may require that a child who has been suspended be seen by a psychiatrist before re-enrollment. Since the family is forced to seek help, they usually skip the earlier decision stages. These families may not have been warned of the problem; instead, they are confronted with it. As a result, they may be surprised and often are angry at the school, the child and themselves. They frequently interpret the institution's demand to be a personal attack. The parents' awareness of the problem has been so abrupt that they may suffer from a state of cognitive shock and disbelief. In coping with this emotional disturbance, a temporary shift in a family's decision rules can occur. A family's tradition of careful assessment and deliberation may be overridden by the need for immediate action. If the overall family system is not in concert with the decision, because the normal channels of demand, feedback, and revised feedback have been circumvented, the family may make arbitrary decisions which are contrary to the usual decision pattern. Many of these families then impulsively request help but end up underutilizing the available services. Consequently, they are often labeled as unmotivated or resistant by the delivery system. A more accurate assessment of this problem would encompass the conflicts over problem awareness between the family and the institution.

Despite variations in delay time, self-help attempts, social pressures, personal inhibitions, or institutional demands, the family must eventually acknowledge that the problem is out of their control before they can move to the next decision level, the determination of type of mental health service. At this decision level, the consumer manifests formal demand for mental health services. Unfortunately, the consumer can still be confused, since the notion of mental health service is usually vague and imprecise. Being uncertain of what the service entails, consumers are not clear about what they can expect from a psychiatric facility.

Unlike shopping for a new car which can be test-driven or searching for a pair of shoes which aan be-tried on for fit, a therapeutic relationship is something the consumer has to experience over a considerable time period before it can be understood. As Lennard and Bernstein (1960)have pointed out, "Psychotherapy is not a subject of public observation. One has to participate before one can completely grasp its requirements." The product consumer can compare different types of bicycles, for example, in terms of concrete measurable qualities such as weight and size. Psychiatric consumers, however, must rely on their own impressions and suggestions of others. Because the service is unclear, utility-maximizing rules break down and break-even points are difficult to determine; assessment variables are more often qualitative than quantitative. The consumer's knowledge is certainly less than Adam Smith's concept of "perfect." Fees can play a role in a family's specific choice of service, but the demand curve for psychological treatment is generally inelastic. Fee reductions rarely create new customers.

To the average person, psychiatry is shrouded with mystery, magic and the esoteric. A family's expectation can be determined by what they have heard, read or previously experienced. For example, families who have had experiences solely with medical doctors base their expectation of mental health services on these medical relationships. Sobel (1964) has discussed the role confusion of the new psychiatric patient who must shift from the medical patient role. He showed that the role of a medical patient and a psychiatric patient demands completely opposite kinds of behavior. The medical patient is expected to be passive, dependent, and essentially follow the doctor's orders. In contrast, psychiatrists expect the patient to be active, self-directed, and more independent in the treatment relationship, Hollingshead and Redlich (1958) have observed that socio-economic factors have a bearing on adult patient expectations. Compared to middle class patients, the lower class patients view psychotherapy in more medical than psychological terms. They tend to see their problems as physical in origin, expect medication, and seek direct support and advice from a psychiatrist. Moreover, the lower class patient is more apt to tetminate treatment prematurely. In my work on parental attitudes toward child psychiatry treatment, I found that both lower and middle class parents expect concrete advice, and shy away from a treatment relationship which requires active or mutual participation. (Woods, 1972,1974).

Complicating a consumer's expectations is the fact that different therapists may subscribe to different approaches or schools of thought. In a large urban area, a family could seek help from the following: psychoanalytically oriented therapists, group therapists, behavior modification therapists., existential therapists, Adlerian therapists, orthodox Freudian analysts, neo-Freudian analysts, Jungian analysts, etc., etc., etc. Furthermore, in addition to the choice of orientations, there are different types of mental health personnel who provide direct service. The core mental health professionals usually include psychoanalysts, psychiatric social work ers, clinical psychologists, and psychiatric nurses. In certain settings, however, these professionals may supervise para-professional psychiatric aides and subprofessionals who do the actual treatment. While some consumers consider all mental health professional to be equally qualified and competent, others are willing to be treated only by a medically traingd therapist. Why families select one type of professional over another is open for study. Again public education may have an important role in consumer behavior.

The facilities for mental health service are also nonhomogeneous and consequently can be found in public and private hospitals, mental health centers, public health centers, community agencies, family service agencies, crisis intervention centers, and the offices of private practitioners. Each sponsor of their respective mental health service may claim that their "product" is psychotherapy, therapy, treatment, or counseling.

The variety of alternatives usually complicate and confuse the average family's decision as to what and where they shall seek help. Therefore, most mental health consumers rely on their own intuition or the recommendations of friends, ministers, or family physicians in the latter stages of decision.

Clearly, much more research is needed as to the specific selection processes a family goes through in making these final decisions. In terms of what different delivery systems may represent to potential consumers, an interesting study was conducted by Sieveking and Chappell (1970) which showed that the name "Psychological Center" was associated with the treatment of problems more serious than those treated at a "Counseling Center." The psychological center was also seen as more medical, expensive, personally embarrassing, and competent than the counseling center. Agency titles may have an effect upon service utilization and consumer expectation.

Besides reassessment for financial reasons,, families may have second thoughts because of the potential social-emotional repercussions in using this service. Most families recognize that therapy, even when only one family member is involved, can lead to changes in the over-all family relationships, alliances and power balances (Landy 1960). While many parents claim to be on the side of growth, openness and self-development, they cai quickly become insecure, uncomfortable, and threatened when a mental health interviewer begins to explore their life in detail.

While there has been an increasing amount of research relating to families who discontinue using psychiatric services after making an initial commitment, the findings have not been very enlightening. Discontinuers have been found not to differ form continuers with respect to symptoms and problems (Adams, Weinick, and Sherlock, 1971); clinicians judgment of the symptoms and the motivation for treatment (Levitt, 1958); diagnostic categories (Colen, Magnussen, 1967);or-father's occupational class (Ross and Lacey, 1961). McAdoo and Roeske (1971) found no significant difference between the parents of defectors and parents of continuers when compared on personality tests and clinical assessment. Levitt (1957) stated "so far as is known, the defector group is similar to the treated group in every respect except for the factor of treatment itself."

A major problem with the previous studies on discontinuance has been the repeated attempt to differentiate continuers from discontinuers according to descriptive differences such as social class measures., number of symptoms and types of problem. Perhaps a focus on the longitudinal decision making process that families must go through would yield more insights regarding the factors that distinguish those who continue treatment from those who do not. Also, the previous studies have been agency bound. They have not traced a family in its movements to substitute mental health service outlets or in a family's attempt to find alternate solutions to the problem, i.e. self help, education or medical assistance.

SUMMARY

In summary we have followed a family through a number of hypothetical levels of decision towards becoming a mental health consumer. We have noted the multiple forces which influence a family's decision making process and effect the eventual consumer choice. In light of our discussion it seems imperative that future research will again require a comprehensive, multi- disciplinary approach to understand the family as a consumer of mental health services.

Finally, it should be noted that while the stages of decision as outlined in this paper may exist theoretically, numbers of potential consumers of mental health service are not able to consummate their demand request because services simply do not exist at any price. A prominent example is the drastic shortage of in-patient services for disturbed children. Perhaps with a closer alliance between professionals in business and professionals in mental health, such gaps in service will be narrowed.

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