Role of Affect and Cognition in Lay Judgments About the Need for Mental Health Treatment and Willingness to Help
ABSTRACT: Mental illness has become a major public health concern, but it is rarely studied from the point of view of laypeople. The current research used surveys to investigate ordinary people’s perceptions of the need for mental health treatment in a target individual and willingness to help the target. It also investigated the mediating role of affect and cognition in these evaluative processes. Four experiments found that affect mediated the relationship between mental illness and evaluations of the need for treatment, but that cognition mediated the relationship between mental illness and people’s willingness to provide help. We concluded that negative affective responses to the presence of mental illness result in increased perceptions of the need for treatment. When personal responsibility for helping was requested, people relied on cognitive processes likely associated with their own ability, knowledge, and willingness to help. This research provides a preliminary understanding of how to approach the treatment of mental illness from the point of view of the public. The perceived need for mental health treatment has traditionally been studied from the point of view of the person suffering from mental illness. An area that has been somewhat less studied is the lay public’s knowledge and motivation to help those in need of mental health treatment. Mental health issues do not affect the individual alone, but also affect society at large. Research has shown that mental illnesses 166 International Journal of Mental Health such as generalized anxiety disorder and major depressive disorder contribute to an increased number of missed work days, decreased work productivity, economic burden, and increased need for health care services [1, 2]. These data suggest a major public health concern. Therefore, addressing mental health treatment from the level of society, as well as the individual, is an important step in promoting prevention and treatment strategies in the broader community. Understanding how the general public can and does address treatment issues related to mental health is essential. Public Attitudes and Beliefs About Mental Illness and Treatment Needs Attitudes toward mental illness have evolved over the years. One study found that whereas lay conceptions of mental illness in the 1950s were associated with fear, negative stereotypes, and rejection, studies from the 1970s to the 1990s showed that people with mental illness were more willing to seek treatment and self-refer to treatment [3]. The increased rates of seeking help for mental illness demonstrate improvement in knowledge and awareness about mental health disorders within society. However, mental illness is still stigmatized [4–6], and knowledge about mental illness is still lacking among the general population [7]. Some noteworthy trends were identified in a review examining lay beliefs and attitudes toward people with mental illness since the 1990s [8]. Research using vignettes describing mental health disorders showed that the majority of lay respondents could not identify specific mental illnesses. Instead, they described psychological disorders as variants of stress. For example, a study from Australia found that when lay participants were shown a vignette about a person described as having depression or schizophrenia, most of them could recognize that a mental health problem was present, but were not able to apply the correct psychiatric label [9]. A lack of understanding that a specific set of symptoms is indicative of a disorder that may require treatment is likely to restrict treatment-seeking behavior. Of further importance to the current study are attitudes about the efficacy of treatment for mental health disorders. Attitudes undoubtedly influence willingness to help. Research has shown that lay beliefs about the efficacy of mental health treatment differ from the beliefs of licensed professionals. One study showed that laypeople were more likely than professionals to consider self-help books, vitamins, and minerals as effective treatments [10]. Further research found that nearly a third of participants believed that for people with serious emotional problems, receiving mental health treatment was either equal to or worse than receiving no care at all [11]. Additionally, it was found that the laypeople rated medications such as antidepressants as less effective treatments than did professionals [11]. Although we agree that certain self-help strategies can be beneficial, it is of concern that the efficacy of professional mental health treatment was questioned. If the public consensus is that mental health services do not help and might even summer/fall 2013 167 do harm, then no matter how effective treatment practices are, they will not be enough to motivate individuals to seek help. The low perceived effectiveness of professional treatment suggests that public interventions are necessary to change perceptions about mental health. For example, increasing knowledge and awareness about the effectiveness of certain treatments, such as cognitive behavioral therapy, may increase treatment-seeking behavior [12]. One place where change can begin is within families and communities [13]. Friends and Family Members Seeking Help The research examining ordinary people’s motivation to help those in need is fairly sparse. Though sparse, the literature provides several insights into how the lay public can become involved in improving mental health outcomes. A concept known as expressed emotion has been used to show the importance of family and community in mental health recovery. Expressed emotion is a measure of the family environment that determines how family members talk and relate to relatives with psychiatric illnesses [14]. High scores on the expressed emotion measure indicate that the family expresses high levels of hostility, is emotionally overinvolved, and makes critical comments. A meta-analysis showed that high levels of expressed emotion were a strong predictor of relapse of schizophrenia, eating disorders, and mood disorders [14]. These findings reveal that social environment can influence the prognosis of those with mental illnesses. Furthermore, they highlight the importance of paying attention to community and familial efforts when addressing public health concerns related to mental illness. A more recent study of people with depression investigated the efficacy of seeking help from family and friends [15]. This study found that family and friends could provide a supportive environment to people with mental illnesses that might act as a bridge to seeking professional mental health treatment. However, when family and friends made judgmental comments and stigmatized attitudes, then informal health seeking was found to be disadvantageous [15]. Based on this research, positive and nonjudgmental support from social networks seems to promote behaviors seeking mental illness treatment . In other words, people who suffer from a mental illness but have supportive social networks are more likely than those without such networks to seek professional help. This knowledge is an important first step in addressing the public health issues facing mental illness treatment today. Role of Affect and Cognition in Mental Health Evaluations Based on the literature, limited knowledge and negative public views of the efficacy of mental health treatment seem to be predominant. An important area of study, therefore, is gaining an understanding of how social perceptions of mental illness influence treatment-seeking behavior. Gaining insight into public perceptions of mental illness requires several considerations. First of all, laypeople’s perceptions 168 International Journal of Mental Health and knowledge about the need for mental health treatment need to be assessed. Second, we need to discern the factors that influence their willingness to help those with mental illnesses seek appropriate treatment. Each of these considerations requires decision-making and evaluative processes related to social perception. Researchers who study the social perception of stigmatized groups have suggested a dual-process model [16]. The dual model includes a reflexive system that reacts impulsively or spontaneously to a stimulus, and a reflective system that uses thoughtful or deliberative processes to evaluate and adjust initial reactions. These systems are not opposed to each other, but rather unfold over time, with the reflexive reactions happening immediately, and the reflective reactions developing later. Two studies support this dual-process model [16]. Using a sliding scale, participants were asked to rate their feelings toward a target described as having a stigmatized condition. Results revealed that initial responses were based on reflexive negative affective reactions related to stigmatized beliefs. Over time, however, as cognitive processes were used to make adjustments to the initial evaluations, more positive ratings resulted [16]. This study suggests that separate processes are used when making social judgments. Specifically, it suggests that an affective system is utilized to make initial evaluative judgments, whereas cognitive processes are used for further evaluation. It is also possible that separate processes are used when making judgments about the need for mental health treatment versus deciding to help someone in need of treatment. For example, when making evaluative judgments about the need for treatment, it is likely that individuals rely on their immediate affective reactions. However, when they reflect on the decision to help, cognitive processes are likely to be used. The following research supports these conjectures. First of all, it is important to note that the existence of affect and cognition as separate components has been empirically demonstrated [17–19]. Furthermore, it is well established that emotions are an integral part of evaluative judgments [20–24]. Specifically, when individuals attempt to make conclusions about social situations, they often consult their emotions as a clue to their opinions. For example, mood-congruency models suggest that affect tends to bias thought content toward the affective state being experienced [25–30]. Specifically, negative affect results in mood-congruent negative thoughts that color decision-making and evaluative processes. We can apply this idea to judgments about mental health treatment. Negative moods elicited by stigma or symptomatology may serve to color a layperson’s thoughts surrounding mental illness in a negative way. In other words, negative emotional evaluations may result from erroneous beliefs related to the stigmatized views of mental illness. Therefore, affect is integral to the evaluative processes associated with perceptions about mental illness and mental illness treatment. It is important to note that mood-congruency models suggest that greater levels of negative affect would result in evaluations recognizing a greater need for mental health treatment. Although increased public awareness about the need for mental health treatment is the desired result, it becomes a matter of concern if the impetus summer/fall 2013 169 for increased evaluations of treatment needs is fear and stigma. Instead, it is important that correct knowledge rather than fear should prompt evaluation of mental health treatment needs. This idea will be discussed in more detail later. Next, we must consider the difference between an evaluation of the need for treatment and the willingness to provide help. Although negative affect might influence initial judgments about the need for treatment, when personal responsibility is considered, cognitive processes are likely to be more heavily relied upon. For example, research has demonstrated that when an individual makes a decision about what to do in a given situation, a process of reasoning about what is right and wrong is usually employed [31]. Therefore, cognitive considerations about social and moral issues (e.g., what ought to be done) are necessary in order to make certain decisions about helping. Research has shown that more mature forms of sociomoral reasoning processes are associated with concern about the well-being and needs of others and knowledge of the impact of one’s behavior on others [32]. Sociomoral reasoning is also associated with conflict resolution [33] and prosocial behaviors such as helping [34]. Therefore, cognitive reasoning processes, especially sociomoral reasoning, seem to be integral to the decision-making processes related to helping behavior.
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