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HOW TO MAKE PSYCHOTHERAPY MORE ACCESSIBLE: The GATE Equation
The fact that only 1 in 5 Americans with a mental disorder seeks out help (Flynn, 1998) shows that there are legions of potential clients out there who for one reason or another will not access therapeutic services. These people will often turn to a shaman, a faith healer, and even a fortune teller before facing the "shame" of contacting a psychotherapist. The concerns and misconceptions surrounding psychotherapy have become so entrenched in our society that "going to a shrink" can seem harder than a trip to the dentist. The barriers surrounding psychotherapy must be examined closely because behind those barriers are legions of suffering people who are afraid to ask for help. The strongest influence on the decision to see a professional usually comes from family and friends who recommend courses of action. This uninformed advice, doled out by the lay public, can become informed advice with our help. For instance, the stigma around psychotherapy has begun to come under attack from such organizations as the National Stigma Clearinghouse and the National Depressive and Manic Depressive Association. Also awareness about mental disorders is slowly increasing through such programs as the national Mental Illness Awareness Week. But these efforts are not enough to transform psychotherapy into an option as easily accessible to the public as a medical check-up. For this to occur, we must carefully consider all of the factors that contribute to the act of reaching out to mental health professionals. The following formula, the GATE equation, provides the road map from which we can direct our efforts.
Grold Access to Therapy Equation (GATE)
D=P[(C+R)-F]
D=Desire to enter therapy P=Problem or stress level C=Confidence in the benefits of psychotherapy R=Resource availability F=Fears and misconceptions
DEFINITIONS
D=Desire to enter therapy This is a measure of the client's overall motivation to begin the therapy process. It determines how likely an individual is to take the first step toward receiving therapeutic help. This is the measure of psychotherapy's accessibility.
P=Problem or stress level P is the psychological level of distress experienced by the client. The word experienced is emphasized because if the client is not aware of his or her own dysfunction--which is often the case, then it is unlikely that any positive action will be taken. Many disorders can occur with the client having little or no recognition that something is psychologically wrong.
C=Confidence in the abilities of psychotherapists Does the public understand all of the benefits that therapy can provide? If someone is experiencing impotence, frequent nightmares, or a fear of flying, will he or she realize that therapy can help? Even if afflicted individuals are aware that therapists attempt to cure their problem, they may not have faith and confidence in the healing ability of the mental health profession. If a mentally ill person believes that his or her situation can actually improve as a result of psychotherapy, then the C variable is high.
R=Resource availability Resource availability includes the knowledge of the available resources. This variable also includes how easily an individual will be able to access and afford the resources needed to assist with his or her particular problem. The factors associated with knowing how to locate the appropriate resource or therapist who can be of the most assistance are a part of the R variable.
F=Fears and misconceptions This includes the misconceptions and stigma surrounding psychotherapy--also the shame often experienced of admitting one has a problem, and the concerns of discrimination.
THE GATE EQUATION
D=P[(C+R)-F]
First this equation specifies the important varibles involved in creating the motivation to enter therapy. It then establishes that once a person realizes that he or she has a mental health problem, then the motivation to begin therapy is mediated by the confidence and knowledge of the benefits plus the available resources, minus the associated fears. Each one of the variables in the GATE equation includes two sub-parts. First, recognition: where an afflicted individual must acknowledge the topic area covered by the variable. And second, action: where the realization can lead to changes in the motivation level for therapy (D).
WHAT CAN BE DONE
As therapists, we have an obligation to "participate in activities which contribute to an improved community" (The principles of medical ethics with annotations especially applicable to psychiatry. 1993 ed. Section 7). What better way to do this than to make psychotherapy more accessible to the general public? Each varible in the GATE equation helps to guide our energies in this endeavor.
P=Problem or stress level Most often, clinicians attempt to increase access to therapy by focusing their public awareness efforts on increasing knowledge about specific problem areas such as manic depression or bulimia. These awareness campaigns are specialized to a particular disorder such as an eating disorder or alcohol issues. The important thing about these awareness campaigns is that they need to go beyond the information stage so that when the public learns about a disorder, the question "Does this problem apply to me?" can clearly be answered. Simple self-scoring questionnaires will fulfill this purpose.
C=Confidence in the benefits of psychotherapy We as therapists also need to increase awareness about the general process and benefits of therapy. Such as the idea that therapy can be a positive, self-explorative, meaningful experience where a person can learn more about themselves and how to live more effectively. This can be done by informing the public through lectures, pamphlets, and instructional articles in the local media. Our public relations efforts must focus on all of the situations where therapy can be helpful. The National Alliance for the Mentally Ill points out that treatment success rates are at 60% for schizophrenia, 65% for major depression, and 80% for bipolar disorder compared to roughly 50% success rate for heart disease (Flynn, 1998). Treatment success rates such as these need to become public knowledge in order to increase confidence in therapy. A meta analysis of over 400 outcome studies by Smith, Glass and Miller showed that at the end of therapy the average client is "better off than 80 percent of those who need therapy but remain untreated". Even though this was a controversial study, our successes need to be publically celebrated even as the media tries to highlight our failures. Good and upstanding therapists can and should be recognized as often as those who behave unethically.
R=Resource availability Since this aspect of the GATE equation involves educating the public about how to feel comfortable and knowledgeable about choosing a therapist, we as clinicians must model positive, healthy, mental health behavior. This doesn't mean that we should act problem-free. To the contrary, it just means that we should act appropriately when we do have difficulties and openly and proudly admit that WE are seeing a therapist. Unfortunately many therapists choose to be stoic and perpetuate the attitude of "the helper never needs help." We as clinicians can also take a socially active role in promoting mental health as part of health insurance. We can educate the public about the local resources available in our communities. Many people do not even know if therapy is covered by their insurance. The public needs to be informed.
F=Fears and misconceptions The fears and misconceptions surrounding mental illnesses have created a significant barrier to therapy which has been largely ignored by the therapeutic community. This may stem from such influences as the negative portrayal of therapy by the media or from early childhood messages such as "Be strong...you don't need help from anyone," or from such messages as, "Don't expose the family secrets." A person may not clearly recognize why they think therapy feels wrong, only that it must be avoided at all costs. Once we help them to recognize and face the reasons, then these issues can be confronted. Research has begun in this area with the creation of a self-inventory that covers the fears associated with beginning therapy--the Openness to Therapy Assessment (OTA) (http://www.1-800-therapist.com/ota.html). The OTA helps to pinpoint and clarify all of the causes that make beginning therapy feel difficult (see the web page listed below for a copy). This is only a start and more awareness needs to be focused on the fear of therapy and what can be done about it.
We as clinicians must work to open the gate to therapy. Because if it remains closed, then psychological disorders will continue untreated.
Dr. Kevin Grold is President of the international, 1-800-THERAPIST NETWORK. He has helped thousands of people begin the process of therapy and he has been recognized by the US Congress for his commitment to community service. http://www.1-800-therapist.com
References
Smith, M., Glass., & Miller, I. The benefits of psychotherapy. Baltimore: Johns Hopkins University Press, 1980 (p.124)
The principles of medical ethics with annotations especially applicable to psychiatry. 1993 ed. Section 7
National Alliance for the Mentally Ill (Feb 4, 1998) Director Laurie Flynn PR Newswire
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