The psychological treatments available for anxiety disorders are well known to work in reducing the symptoms that individuals with these disorders experience on a daily basis. Why, then, do people with these disorders ever stay away from psychotherapy? Perhaps you have a friend who has a diagnosis of social anxiety disorder, with symptoms ranging from fear of being embarrassed in public to extreme anxiety about having to speak in front of strangers. You know full well that this individual suffers tremendously and has experienced negative repercussions both at work and in daily interactions with family and friends. However, no matter how hard you try to convince this person to see a therapist, this individual insists that the problems aren’t “that bad.”
According to new research by Massachusetts General Hospital’s (MGH) Elizabeth Goetter and colleagues (2020), it’s not uncommon at all for people with both social anxiety (SAD) and generalized anxiety disorder (GAD) to stay out of a therapist’s office and therefore fail to benefit from the treatments that can help them. As the MGH authors note, despite the high prevalence (nearly 30 percent of U.S. adults) of these disorders and the price they exact on people’s quality of life, three-quarters of those with these disorders don’t utilize mental health services. In the words of the Boston-based authors, “These low health care utilization rates are troubling, especially given that safe, effective, evidence-based psychotherapy and pharmacotherapy treatments for SAD and GAD exist” (p. 5). Even more troubling is the fact that, left untreated, people with these disorders are at risk for such negative consequences as substance use, medical problems, impaired social functioning, and suicidality.
Ironically, as Goetter and her colleagues note, the very symptoms that characterize these anxiety disorders, particularly SAD, may pose the greatest barriers to keep individuals with these disorders from receiving the treatments that could help them. Therapy, for these individuals, is perceived as amounting to another source of embarrassment. Your friend’s reluctance to seek intervention may be due in large part to concern over what other people might think. No matter how much you provide reassurance not only that therapy can work but that it’s perfectly acceptable to seek intervention, your friend worries about being labeled by others as mentally unstable.
The MGH-led research team sought to discover the systematic barriers that can cause people like your friend, and those with the more generalized form of anxiety, to stay away from treatment. Such barriers, they theorized, could include demographic factors such as race and ethnicity, gender, marital status, income level, education, and the existence of other diagnoses such as major depressive disorder, specific phobia, and obsessive-compulsive disorder. As the authors note, although fear of embarrassment might characterize people with SAD, less is known about why people with GAD similarly resist becoming involved in treatment.
The 229 participants in the Goetter et al. study ranged from 18 to 65 years of age, with an average of 28 years; the majority were female (78 percent with GAD; 57 percent with SAD). Most were White, single, and college graduates or higher. Members of the clinical research team conducted diagnostic interviews and provided ratings of the participants on clinician-administered measures to assess the severity of symptoms of social anxiety and general anxiety. Additional measures assessed the presence of depressive symptoms as well as life satisfaction and the degree of the individual’s functional impairment.
Using a Barriers to Treatment Questionnaire (BTQ), participants also indicated the reasons that they had not sought treatment. Items on the 23-item BTQ asked participants to rate the extent to which they delayed or avoided treatment in the past 12 months on such stigma-related items as “I felt embarrassed about my problems” and “I was worried about being judged or criticized by my friends if I sought treatment.” Taking into account the roles of race and ethnicity, several items asked participants whether they felt that such culturally-defined barriers between themselves and a mental health professional would exist (e.g. “I was afraid of being treated badly in treatment because of my race or ethnicity”). Items involving logistics and finances tapped whether participants believed they had no time in their schedule for treatment and that health insurance would not cover the costs.
Out of a maximum score of 92 on the BTQ scale, the scores for the two anxiety groups averaged at 22, with most scoring between 8 and 38. Within the BTQ items, participants were most likely to endorse items tapping shame and stigma, with over 80 percent stating that they wanted to “handle my problems on my own.” Logistic problems and financial limitations were the second most likely barriers to be endorsed by participants, with approximately 60 percent agreement rates. Interestingly enough, although therapy may seem to be more acceptable to younger generations, it was the older individuals in the sample who perceived fewer barriers. There was also greater reluctance to seek therapy among individuals from ethnic minority backgrounds, those who were single, and individuals with incomes below the poverty level. However, there were no relationships between BTQ scores and gender or educational level.
Symptom severity also played a role in predicting who would perceive more barriers to treatment, but not in the direction you might expect. It was those individuals with higher, not lower, symptom scores who enumerated more reasons not to seek therapy. As the authors note, “This is unsettling because the findings suggest that those with more severe symptoms, who may benefit most from treatment, are precisely those who perceive the most barriers and fail to recognize their need for treatment” (p. 10). Almost as concerning, because the study was conducted in a major urban setting with ample mental health clinics, was the extent to which participants cited logistical problems as therapy barriers.
As the authors conclude, the findings provide important insights into the role of perceived costs and benefits of treatments known to work. In addition to educating the public about the advantages of treatment and its potential to be offered in nontraditional and more convenient formats (such as virtual therapy or self-help interventions), the findings support the need for greater cultural competence in mental health workers and the organizations for which they work.
Returning to the case of your socially anxious friend, the Goetter et al. findings suggest that you directly address the issue of stigma along with the related belief that people can treat these symptoms on their own. Although the MGH study didn’t examine the relationship among subscales of the BTQ with each other, it’s reasonable to expect that people who use financial and logistic problems as a reason not to seek therapy might also be focused on shame, embarrassment, and possible cultural barriers.
To sum up, the fact that there are effective treatments for anxiety disorders doesn’t guarantee that people will take advantage of them. Educating others, or perhaps yourself, may be the best way to give these treatments a chance to work.
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Goetter, E. M., Frumkin, M. R., Palitz, S. A., Swee, M. B., Baker, A. W., Bui, E., & Simon, N. M. (2020). Barriers to mental health treatment among individuals with social anxiety disorder and generalized anxiety disorder. Psychological Services, 17(1), 5–12. doi:10.1037/ser0000254.