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Conceptualizing Mental Health Care Utilization Using The Health Belief Model

Article Text The process of change in psychotherapy, regardless of the clinician's orientation, length of treatment, or outcome measure, begins with this: The client must attend a first session. However, several national surveys coach outlet canada in the past decade converge on a rate of approximately one-third of individuals diagnosed with a mental disorder receiving any professional treatment (Alegr, Bijl, Lin, Walters, & Kessler, 2000; Andrews, Issakidis, & Carter, 2001; Wang et al., 2005). A review of the literature surrounding mental health utilization reveals evidence that a complex array of psychological, social, and demographic factors influence a distressed individual's arrival to a mental health clinic. Thus, developing effective strategies for decreasing barriers to care is a critical task for clinicians and administrators. The aim of this article was to review current research focused on appropriate utilization of mental health services and to use the Health Belief Model (HBM; Becker, 1974) as a parsimonious model for conceptualizing the current knowledge base, as well as predicting and suggesting future research and implementation strategies in the field. First, it is important to address whether increasing mental health service use is an appropriate public health goal. A World Health Organization (WHO) survey comparing individuals with severe, moderate, or mild disorder symptoms indicated that approximately half of those surveyed went untreated in the past year (WHO World Mental Health Survey Consortium, 2004), with even less treatment among those with more severe symptoms. Many costs are associated with untreated mental disorders, including overuse of primary care services for a variety of reasons (Katon, 2003; White et al., 2008), lost productivity for businesses and lost wages for employees (Adler et al., 2006), as well as the negative impact of mental disorders on medical disorders, such as diabetes and hypertension (Katon & Ciechanowski, 2002). These com bined expenses have been calculated to rival some of the most common and costly physical disorders, such as heart disease, hypertension, and diabetes (Druss, Rosenheck, & Sledge, 2000; Katon et al., 2008). The consequences of providing additional services to address unmet need may vary by the cost-effectiveness of treatment, availability of providers, and the interaction of mental health symptoms with other illnesses. Medical cost offset and cost-effectiveness research address these questions (for further review, see Blount et al., 2007; Hunsley, 2003). Medical cost offset refers to the estimation of cost savings produced by reduced use of services for primary care as a result of providing psychological services. Reduced medical expenses could occur for several reasons: increased adherence to lifestyle recommendation changes such as diet, exercise, smoking, or taking medications; improved psychological and physical health; and reduction in unnecessary medical visits which serve a secondary purpose (e.g ., making appointments to fill social needs; Hunsley, 2003). In comparison with the indirect costs to society, the individual, and the health care system, costs for providing mental health treatment are quite low (Blount et al., 2007). However, debate continues regarding how to facilitate mental health care utilization. Identification of mental health need through primary care screening for depression is one research area that highlights the complexity of this issue. Palmer and Coyne (2003) point out several important issues in developing a strategy for addressing this goal: First, several studies suggest that identification of depression in primary care is not enough, as outcomes for depression are similar in primary care patients who have detected depression and those who have not (e.g., Coyne, Klinkman, Gallo, & Schwenk, 1997; Williams et al., 1999). This is supported by research indicating a large gap between the number of individuals who are identified through screening and referred to care, and those who actually receive care (Flynn, O'Mahen, Massey, & Marcus, 2006). Second, it is critical to evaluate attempts to increase utilization, rather than to assume they will be successful, cost-effective, and targeting the appropriate individuals. Therefore, a theoretical framework that addresses both psychological and practical factors associated with treatment utilization will be a beneficial addition to this literature. Little systematic research has been conducted on the specific topic of psychological factors related to seeking mental health services. However, extensive work has been conducted within two broad, related areas of research: help-seeking behavior and health psychology. Many models have been proposed to explain help-seeking and health-protecting behaviors, none of which has been accepted as wholly superior to the rest. The HBM (Becker, 1974; Janz & Becker, 1984; Rosenstock, 1966) is one of several commonly used social-cognitive theories of health behavior. This model will be reviewed, followed by a brief discussion of several other models. A discussion of the strengths of the HBM and its applicability to mental health treatment utilization research will follow. Health Belief Model The HBM (Rosenstock, 1966, 1974), based in a socio-cognitive perspective, was originally developed in the 1950s by social psychologists to explain the failure of some individuals to use preventative health behaviors for early detection of diseases, patient response to symptoms, and medical compliance (Janz & Becker, 1984 ; Kirscht, 1972; Rosenstock, 1974). The theory hypothesizes that people are likely to engage in a given health-related behavior to the extent that they (a) perceive that they could contract the illness or be susceptible to the problem (perceived susceptibility); (b) believe that the problem has serious consequences or will interfere with their daily functioning (perceived severity); (c) believe that the intervention or preventative action will be effective in reducing symptoms (perceived benefits); and (d) perceive few barriers to taking action (perceived barriers). All four variables are thought to be influenced by demographic variables such as race, age, and socioeconomic status. A fifth original factor, cues to action, is frequently neglected in studies of the HBM, but nevertheless provides an important social factor related to mental health care utilization. Cues to action are incidents serving as a reminder of the severity or threat of an illness. These may include personal experiences of symptoms, such as noticing the changing shape of a mole that triggers an individual to consider his or her risk of skin cancer, or external cues, such as a conversation initiated by a physician about smoking cessation. In addition, Rosenstock, Strecher, and Becker (1988) added components of social cognitive theory (Ba ndura, 1977a, 1977b) to the HBM. They proposed that one's expectation about the ability to influence outcomes (self-efficacy) is an important component in understanding health behavior outcomes. Thus, believing one is capable of quitting smoking (efficacy expectation) is as crucial in determining whether the person will actually quit as knowing the individual's perceived susceptibility, severity, benefits, and barriers. Other health care utilization theories Other models for health care utilization have been proposed and used as a guide for research. In general, these theories pull from a number of learning theories (e.g., Bandura, 1977a, 1977b; Lewin, 1936; Watson, 1925). Two such models, the Theory of Planned Behavior (TPB; Ajzen, 1991) and the Self-Regulation Model (SRM; Leventhal, Nerenz, & Steele, 1984), share many commonalities with the HBM. Ajzen's TPB proposes that intentions to engage in a behavior predict an individual's likelihood of actually engaging in the given behavior. Ajzen hypothesizes that intentions are influenced by attitudes toward the usefulness of engaging in a behavior, perceived expectations of important others such as family or friends, and perceived ability to engage in the behavior if desired (Ajzen, 1991). This theory has been applied to a variety of health behaviors and has receiv ed support for its utility in predicting health behaviors (Ajzen, 1991; Armitage & Conner, 2001; Godin & Kok, 1996). However, its relevance in predicting mental health care utilization has received relatively little attention (for two exceptions, see Angermeyer, Matschinger, & Riedel-Heller, 1999; Skogstad, Deane, & Spicer, 2006). Similarly, the SRM (Leventhal et al., 1984) focuses on an individual's personal representation of his or her illness as a predictor of mental health treatment use. The SRM proposes that individuals' representation of their illness is comprised of how the individual labels the symptoms he or she is experiencing, the perceived consequences and causes of the symptoms for the individual, the expected time in which the individual would expect to be relieved of symptoms, and the perceived control or cure of the illness (Lau & Hartman, 1983). The HBM, TPB, and SRM are well-estab lished socio-cognitive models with similar strengths and weaknesses. The models assume a rational decision-making process in determining behavior, which has been criticized for not addressing the emotional components of some health behaviors, such as using condoms or seeking psychotherapy (Sheeran & Abraham, 1994). There is substantial overlap in the constructs of these three models. For example, an individual's perception of the normative beliefs of others can be seen more generally as a benefit of treatment (e.g., if I seek treatment my friends will support my decision) or as a barrier (e.g., my family will think I am crazy if they know I am seeking professional help). The SRM lacks a full description of the benefit and barrier aspects of decision making identified in the HBM. However, the illness perceptions about timeline, identity, and consequences do provide a more complete conceptualization of aspects of perceived severity, and in this way the SRM can inform the HBM with these factors. Andersen's Sociobehavioral Model (Andersen, 1995) and Pescosolido's Network Episode Model (Pescosolido, 1992; Pescosolido, Brooks Gardner, & Lubell, 1998) emphasize the role of the health care and social network system in influencing patterns of health care use, while Cramer's (1999) Help Seeking Model highlights the role of self-concealment and social support in decisions to seek counseling. In particular, the Network Episode Model hypothesizes that clear, independent choice is only one of seve ral ways that clients enter treatment, along with coercion and passive, indirect pathways to care. According to Cramer's model, individuals who habitually conceal personally distressing information tend to have lower social support, higher personal distress, and more negative attitudes toward seeking psychological help. Thus, according to this model, self-concealment creates high distress, which pushes an individual toward seeking treatment, but also creates negative attitudes toward treatment, pushing an individual away from treatment. The HBM includes system-level benefits and barriers to utilization, but these three models more fully emphasize the social-emotional context of decision making. Critiques and limitations of the HBM The HBM has received some criticism regarding its utility for predicting health behaviors. Ogden (2003), in a review of articles from 1997 to 2001 using social cognition models, questions whether the theory is disconfirmable. She found that two-thirds of the studies reviewed found one or more variables within the model to b e insignificant, and explained variance accounted for by the model ranged from 1% to 65% when predicting actual behavior. Yet, Ogden writes, rather than rejecting the model, the majority of authors offer alternative explanations for their weak findings and claim that the theory is supported. While authors' conclusions about their findings may be overstated in many cases, some explanations of insignificant findings are valid limitations of the model. For example, some (e.g., Castle, Skinner, & Hampson, 1999) point out that construct operationalization could be improved for the particular health behavior being studied. However, insignificant results should not be explained away without considering alternative models as well. Certainly, the HBM has received strong support in predicting some health behaviors http://sd62onlinelibrary.ca/ (Aiken, West, Woodward, & Reno, 1994; Gillibrand & Stevenson, 2006), but questions remain as to its ability to predict all preventative health situations. The usefulnes s of the HBM in predicting mental health utilization has not adequately been tested to our knowledge. The HBM may be limited further by its ability to predict more long-term health-related behaviors. For example, from an early review of preventive health behavior models including the HBM by Kirscht (1983), we can anticipate that the factors associated with initiating treatment, as discussed here, may differ from the factors that predict mental health treatment adherence and engagement. Thus, these outcomesttending one therapy appointment versus completing a full course of psychotherapy treatmenthould be clearly distinguished from each other. Strengths of the HBM Researchers have not explicitly investigated mental health utilization patterns using the HBM framework; however, much of the existing literature can be conceptualized as dimensions of severity, benefits, and barriers, indicating that the model may be a useful framework for guiding research in this area. For example, cultural researchers often examine barriers to treatment and perceived severity of symptoms and benefits of treatment in various ethnic populations (e.g., Constantine, Myers, Kindaichi, & Moore, 2004; Zhang, Snowden, & Sue, 1998). In general, the focus of these studies has been to examine cultural differences in beliefs about symptom causes (Chadda, Agarwal, Singh, & Raheja, 2001), changing perceptions of mental health stigma among various ethnic groups (Schnittker, Freese, & Powell, 2000), and cultural mistrust or perceived cultural insensitivity of mental health providers as a barrier to effective treatment (Poston, Craine, & Atkinson, 1991). These studies lay the groundwork for using the HBM as a framework for understanding mental health care utilization for all populations. Parsimonious and Clear The model's use of benefits and barriers opposing each other provides a dynamic representation of the decision-making process. In this "common sense" presentation, the impact of each positive aspect is considered in the context of the negative aspects. The model in this way provides a parsimonious explanation of a variety of constructs within one clear framework. Useful and Applicable One strength of focusing on attitudes and perceptions related to treatment seeking is the clinical utility of such models. By identifying attitudes that may inhibit appropriate help seeking, psychologists can then use research findings to develop interventions for addressing maladaptive attitudes or inaccurate beliefs about mental health and its treatment. Therefore, socio-cognitive theory provides a useful focus for research that ultimately may result in programmatic changes to benefit clients. Once developed, perception-change interventions can be evaluated through changes in observed treatment utilization. Within the HBM framework, three general approaches can be used to increase appropriate utilization: increasing perceptions of individual susceptibility to illness and severity of symptoms, decreasing the psychological or physical barriers to treatment, or increasing the perceived benefits of treatment. The following discussion will highlight how each perception can be increased or decreased, and the implic ations for such intensification of the perceptions. Examples of intervention strategies that can serve as individual or system-level "cues to action" will be reviewed within each domain of the model. In addition, where appropriate, the discussions will highlight how sociodemographic factors such as age, sex, and ethnicity impact the perceived threat from the disorder and the expectations for the benefits of therapy. The model we discuss assumes that the individual seeking therapy is autonomous in this decision making. That is, it is not directly applicable to those who are required to seek therapy by the judicial system, a spouse, or their place of employment, nor does it address children's mental health care utilization. We will address some of these issues briefly later in our discussion. Figure 1 is a visual representation of the model we propose for conceptualizing mental health care utilization using the HBM as a framework. The studies reviewed in each section below were designed primarily without use of the HBM framework. However, the model is a useful heuristic tool to organize and draw in research from a variety of disciplinesarketing, public health, psychology, medicine, etc. Sociodemographic variables in the HBM Several demographic variables consistently predict utilization of mental health services. Despite similar levels of distress, some groups are less likely to seek professional treatment than others, creating a gap between need and actual use of outpatient mental health services. Groups identified as consistently underutilizing services include men, adults aged 65 and older, and ethnic minority groups in the United States (Wang et al., 2005). Within the HBM framework, these demographic variables are hypothesized to influence clients' perceptions of severity, benefits, and barriers to seeking professional mental health services. Studies exploring the relationship between demographic variables and HBM constructs will be highlighted throughout this article. Systems approaches to addressing perceived susceptibility and severity According to the HBM, individuals vary in how vulnerable they believe they are to contracting a disorder (susceptibility). Once diagnosed with the disorder, this dimension of the HBM has been reformulated to include acceptance of the diagnosis (Becker & Maiman, 1980). In addition, increasing an individual's perception of the severity of his or her symptoms increases the likelihood that he or she will seek treatment. In relation to mental health, perceived susceptibility goes hand in hand with perceived severity (i.e., Do I have the disorder and how bad is it?), and so they will be discussed together. In health-related decisions, the majority of consumers are dependent upon the expertise and referral of the medical professional, usually the trusted general practitioner (Lipscomb, Root, & Shelley, 2004; Thompson, Hunt, & Issakidis, 2004). Unlike decisions about the need for a new vehicle or a firmer mattress, determining whether or not feelings of sadness should be interpreted as normal emotional fluctuation or as indicators of depression is a decision often left to an expert in the area of mental health or a primary care physician. This places a great responsibility on practitioners, psychiatrists, psychologists, and other mental health service providers when discussing the severity of a client's symptoms and options for treatment. Ethical Considerations in Increasing Perceived Severity and Symptom Awareness The American Psychological Association (APA) provides ethical guidelines for clinicians about how to inform the public appropriately about mental health services. According to the 2002 Ethics Code (American Psychological Association, 2002), psychologists are prohibited from soliciting testimonials from current therapy clients for the purpose of advertising, as individuals in such circumstances may be influenced by the therapistlient relationship they experience. Additionally, psychologists are prohibited from soliciting business from those who are not seeking care, whether a current or potential client. This may include a psychologist suggesting treatment services to a person who has just experienced a car accident or handing out business cards to individuals at a funeral home. However, disaster or community outreach services are not prohibited, as these are coach outlet online canada services to the community. Psychologists are prohibited from making false statements knowingly about their training, credentials, services, and fees, and are also prohibited from making knowingly deceptive or exaggerated statements about the success or scientific evidence for their services. In this way, limits are placed on the influence of practitioners on those in vulnerable situations. Identification of Symptoms What, then, does an ethical symptom awareness intervention look like? It would involve clearly differentiating between clinical and nonclinical levels of distress, with an indication of what types of intervention strategies may be most effective for each. For example, in cases of mild symptomatology, individuals may be encouraged to use a stepped care approach beginning with bibliotherapy, psychoeducation, and increases in social support. Also important is the provision of accurate, research-based information regarding symptoms of psychological disorders and treatment options. This may call for challenging our assumptions that psychotherapy is helpful for all psychological distress. Recent studies of grief counseling and postdisaster crisis counseling, for example, suggest there may be an iatrogenic effect of therapy for some individuals (Bonanno & Lilienfeld, 2008). On the other hand, some research indicates that individuals with subclinical levels of distress who receive treatment early may avoid developing more severe pathology (e.g., prodromal psychosis; Killackey & Yung, 2007). In programming for all components of health beliefs, not just severity, the credibility of psychotherapy is dependent upon ethical, appropriate public health statements and service marketing. Many examples of mental health education campaigns have been discussed in the literature, often focusing simultaneously on increasing awareness of mental illness, destigmatizing individuals with mental illness, and increasing awareness of mental health resources. The Defeat Depression Campaign of the UK was designed with these goals in mind, and results of nationally representative polls before, during, and after the campaign indicated positive changes in public attitude toward depression and recognition of personal experiences of symptoms (Paykel, Tylee, & Wright, 1997). Similarly, more recent national campaigns in Australia have provided some evidence that education increases public accuracy in identifying mental illness (Jorm & Kelly, 2007). National screening day initiatives for depression, substance abuse, and other psychological disorders also aim to increase awareness of illness severity for individuals who may not recognize symptoms as signs of illness warranting treatment. Approximately 71% (Lipscomb et al., 2004; Thompson et al., 2004) of individuals report looking to their primary care physician for mental health information, treatment, and referrals. However, many physicians lack the appropriate knowledge to identify mental health problems (Hodges, Inch, & Silver, 2001). After examining five decades (1950?000) of articles evaluating the adequacy of physician training in detecting, diagnosing, and treating mental health, Hodges et al. (2001) offer several suggestions for improving primary care physicians' training to effectively identify patients with mental health issues. Beyond learning the diagnostic criteria for the major disorders and providing appropriate medications when needed, however, physicians also need to be aware that they can act as a "cue to action" in the patient seeking psychotherapy. Such cues would alert the patient that his or her symptoms of distress or depression had reached severe levels and that the trusted family physician believes additional treatment is needed. Influence of Demographic Variables on Perceived Severity An individual's personal label of the symptoms and illness are thought to contribute to perceived severity. In a study of four large-scale surveys of psychiatric help seeking, Kessler, Brown, and Broman (1981) found that women more often labeled feelings of distress as emotional problems than men did, a factor thought to help explain the consistent finding that men seek mental health services less often than women even when experiencing similar emotional problems. Similarly, Nykvist, Kjellberg, and Bildt (2002) found that among men and women reporting neck and stomach pains, women were more likely to attribute pains to psychological distress, while men were more likely to indicate no significant cause and little concern regarding the somatic symptoms. Relatively little research has been conducted regarding how individuals of diverse backgrounds perceive the severity of their mental illness symptoms. However, some evidence suggests that individuals of different ethnic backgrounds appraise the severity of their illness symptoms differently, such that individuals from minority cultures are more influenced by their own culture's norms about mental illness symptoms than White Americans (Dinges & Cherry, 1995; Okazaki & Kallivayalil, 2002). Cues to action from providers may be more effective if they are framed in a way that is congruent with individuals' attributions about symptoms. In other cases, education about symptoms, provided in a culturally sensitive manner, may be necessary. This is an area where additional research is needed to determine practice. Older adults are more likely to seek treatment when they perceive a strong need for treatment (Coulton & Frost, 1982). However, some aspects of aging may influence whether or not older adults perceive ambiguous symptoms as psychological in nature or due to physical ailments. For example, among older adults, particularly those experiencing chronic pain or illness, somatic symptoms of mental illness may be interpreted as symptoms of physical illness or part of a natural aging process, rather than as symptoms of depression or anxiety (Smallbrugge, Pot, Jongenelis, Beekman, & Eefsting, 2005). In this way, some depression symptoms may be overlooked by older individuals and the physicians who see them (Gatz & Smyer, 1992). Systems approaches to addressing perceived benefits Even if clients do view their symptoms as warranting attention, they are unlikely to seek treatment if they do not believe they will benefit from professional services. Thus, increasing perceived benefits of treatment is a second approach to increasing appropriate utilization. Public Perceptions of Psychotherapy In response to changing health care markets, the 1996 APA Council of Representatives called for the creation of a public education campaign to inform consumers about psychological care, research, services, and the value of psychological interventions (Farberman, 1997). Results of preprogram focus group assessments indicated that participants were frustrated with changes in health care service delivery in the United States and many participants did not know whether their health insurance policy included mental health benefits. Participants indicated that they did not know when it was appropriate to seek professional help, and often cited lack of confidence in mental health outcomes, lack of coverage, and shame associated with help seeking as main reasons for not seeking treatment. Participants reported that the best way to educate the public about the value of psychological services was to show life stories of how they helped real people with real-life issues. Informed by the focus groups and telephone interviews, APA launched a pilot campaign in two states using television, radio, and print advertisements depicting individuals who have benefited from psychotherapy, as well as an 800 telephone number, a consumer brochure, and a consumer information website. During the first six months of the campaign, over 4,000 callers contacted the campaign service bureau for a referral to the state psychological association to request campaign literature, with over 3,000 people visiting the Internet site weekly (Farberman, 1997). In sum, addressing perceived benefits of treatment means answering the question, "What good would it do?" When individuals are made aware of how treatment could improve their daily functioning, they may be more motivated to overcome the perceived barriers to treatment. Especially for individuals who have not previously sought mental health treatment, describing realistic expectations for treatment may be an essential first step in orienting individuals to make informed treatment decisions. Public Preference for Providers of Care Many different types of professionals serve as mental health service providers, and individuals' beliefs about the relative benefit of seeking help from various lay and professional sources likely impact decisions to seek help. Roles have shifted in treatment over time, with the introduction of managed care and the increased role of the PsyD, master's-level psychologist or counselor, and MSW as treatment providers. Counseling has been considered a primary role of clergy for many decades; however, specificity of counseling training has changed over time, with some clergy receiving specific training as counselors within seminary education. Primary care physicians have been relied upon for treatment through pharmacotherapy with the development of improved medications for depression, anxiety, and attention deficit hyperactivity disorder, among others. While few primary care physicians conduct traditional therapy sessions, many individuals report that they first share mental health concerns with their primary care physician, making this profession an important potential gateway for psychotherapy (Mickus, Colenda, & Hogan, 2000). Level of distress may also influence where individuals seek help: Consumer Reports' popular survey of over 4,000 participants found that individuals tend to see a primary care physician for less severe emotional distress and seek a mental health professional for more severe distress (Consumer Reports, 1995), while Jorm, Griffiths, and Christensen (2004) found that individuals with depressive symptoms were most likely to use self-help strategies in mild to moderate levels of severity and to seek professional help at high levels of severity. Some support has been found for the importance of a match between individuals' perceptions of the cause of symptoms and the type of treatment they seek. In a German national survey, perceptions of the cause of depression and schizophrenia significantly predicted preferences for professional or lay help. Those who endorsed a biological cause of illness reported they would be more likely to advise an ailing friend to seek help from a psychiatrist, family physician, or psychotherapist, and less likely to advise seeking help from a confidant. Perceptions of social-psychological causes of illness, such as family conflict, isolation, or alcohol abuse, were related to advising a confidant, self-help group, or psychotherapist rather than a psychiatrist or physician (Angermeyer et al., 1999). Demographic Variables and Perceived Benefits Perceptions of mental health treatment as beneficial are likely shaped by cultural influences as well as an individual's personal experience. In a subset of randomly selected individuals from a nationally representative survey, Schnittker et al. (2000) compared Black and White respondents' beliefs about the etiology of mental illnesses and their attitudes toward using professional mental health services. Black respondents were more likely than White respondents to endorse views of mental illness as God's will or due to bad character, and less likely to attribute mental illness to genetic variation or poor family upbringing. These beliefs predicted less positive views of mental health services, and the authors found that more than 40% of the racial difference in attitudes toward treatment was attributable to differences in beliefs about the cause of mental illness. Older adults' reluctance to seek psychological services has been connected with more negative attitudes toward psychological services (Speer, Williams, West, & Dupree, 1991). Attitudes toward psychotherapy appear to improve by aging cohort, however. Currin, Hayslip, Schneider, and Kooken (1998) assessed dimensions of mental health attitudes among two different cohorts of older adults and found that younger cohorts of older adults hold more positive attitudes toward mental health services. Thus, attitudes among older adults may be less attributable to age than to changing cultural acceptance of mental illness over time. Older adults who have engaged in professional psychological treatment tend to see mental health treatment as more beneficial than their counterparts who have never sought treatment (Speer et al., 1991). Across diverse religious orientations, beliefs in a spiritual cause of mental illness have been associated with preference for treatment from a religious leader rather than a mental health professional (Chadda et al., 2001; Cinnirella & Loewenthal, 1999). For individuals who interpret psychological distress symptoms as spiritually based, a religious leader may be viewed as a more beneficial provider than a traditional mental health professional. Some clients prefer to see clergy for mental health concerns. Some psychologists have formed relationships between religious organizations and mental health providers to foster collaboration and access to many care options for community members (McMinn, Chaddock, & Edwards, 1998). Benes, Walsh, McMinn, Dominguez, and Aikins (2000) describe a model of clergysychology collaboration. Using Catholic Social Services as a medium through which collaboration took place, psychologists, priests, religious school teachers, and parishioners collaborated through a continuum of care beginning with prevention (public speaking about mental health topics, parent training workshops) through intervention (1-800 access numbers, support groups, and counseling services). The authors note that bidirectional referralsot simply clergy referring to cliniciansnd a sharing of techniques and expertise are keys to the success of such programs. Providing care to individuals through the source that they consider most credible or accessible is an innovative strategy for increasing perceived treatment benefits and decreasing barriers Marketing Psychological Services While the idea of marketing psychological services may seem unappealing to some psychologists, marketing strategies designed to encourage appropriate utilization may serve as both a strategy for the field of psychology as well as an outreach service to improve public health. In order to benefit from psychotherapy, individuals must view it as a legitimate way to address their problems. Strategies may include marketing psychological services at a national level, such as the APA's 1996 public education campaign (Farberman, 1997); at a group level, such as a community mental health system providing rationale for increased funding; or at an individual level, such as an independent private practitioner seeking to increase referrals. Two theories, social marketing theory and problem-solution marketing, are useful models for developing effective mental health campaigns. Social Marketing Theory Rochlen and Hoyer (2005) identify social marketing theory as a framework for identifying strategies specifically aimed at changing social behaviors. Three principles define social marketing: negative demand, sensitive issues, and invisible preliminary benefits (Andreason, 2004). Negative demand describes the challenge of selling a product (psychotherapy, in this case) that the individual does not want to buy. In the case of individuals who see therapy as unhelpful or a frightening experience, addressing negative demand would include considering the viewpoint of a reluctant audience and perhaps utilizing the Stages of Change model (Prochaska & DiClemente, 1984), in which the goal of the marketing campaign would be to move an individual from the precontemplation stage to the contemplation stage of change. Social marketing theory also takes into account the degree of sensitivity in the task being encouraged; that is, seeking psychotherapy requires a greater amount of mental energy and vulnerability than less sensitive purchases, such as a new motorcycle. The principle of invisible preliminary benefit reminds those marketing psychological services that the benefits of choosing to seek psychological help are often not seen immediately, as they are when receiving a pain medication. Therefore, marketing strategies for mental health must make consumers aware of psychotherapy's benefits and the long-term prospect of improving quality of life. It is composed by zhanhong1 2015-12-02 coach outlet canada.
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Obtaining Affordable Medical Health Insurance Coupled With the Problems Involved

In thinking of our health, we always make sure that we get the best service that our money can afford and, with that, most, if not everyone, would look for affordable medical health insurance that can cover future medical needs such as hospitalization, check-ups and the like. However, with the proliferation of health insurance companies at present, so does the danger in buying a substandard and pretentious insurance plan that would be more of a liability than an advantage. With the way things are, it is important for people to be more cautious in choosing and purchasing health insurance plans. Affordable medical health insurance, as it is, should be economically beneficial to those purchasing the plan without having to sacrifice the wide range of services that should be able to accommodate a person's health needs. A comprehensive health insurance plan should be able to cover regular operations up to moderate health cases. Of course, hospital check-ups with health specialists should also be included in the package. So what makes purchasing a medical health insurance risky? With all honesty, the promise http://cloudbyte.com.au/ of buying a good priced and all-inclusive health insurance at present time is relatively slim. What with the increasing number of health insurance companies, almost all of them offer affordable medical health insurance plans that fit just about anyone's budget. The question is: Will the plan they sell be able to cover all of your health needs the moment you require such services? One more risk in buying health insurance plans is that a good and fairly useful insurance in one state may just be useless in another. Two states may or may not have the same health insurance michael kors outlet australia policies and, thus, may or may not recognize a health insurance that was availed from another state. The coverage of a medical health insurance plan in one state may have to be paid for when in a different state. Now, although this holds true for a lot of insurance plans, there are those that might cost you a bit more but are universally recognized, no matter which hospital you visit or which state you're in. Regardless of whether or not you michael kors bags australia are getting health insurance for yourself and/or for others, remember that it is important that you check for things that could otherwise make your purchase useless and uneconomical. Although there are affordable medical health insurance plans that might look light on the budget, it may not be a bad idea to get something that might cost a bit more, as long as you're sure that it'll benefit you in the long run. It is composed by zhanhong1 2015-12-02 michael kors australia.
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The Marketing Campaigns Of Ipod And Ipod Video

The ipod presents, besides an fascinating technical evolution, an unique and modern way of selling and marketing, which differs in fashion and slogans from your 1st advertisements from the initial era of iPods, towards the most current iPod video marketing campaigns. The very first campaigns concentrated upon the new item promoted each the iPod and iTunes brands. These promoting campaigns were leaded by the slogan A thousand songs, in your pocket, which was launched in November 2001. The colors which had been chosen for your initial iPod campaigns had been brisk and filled with live: turquoise, cyclamen, bright grass green and other joyful nuances had been selected to symbolize the thought of both music and video clip, which means both visible and auditory sensations. The wrap advertising was used, in the identical time with the other and far more conventional types of BTL marketing: there had been various mild rail wraps in busy centers or midtowns, making use of the identical visual message because the banners. Large banners and billboards were displayed in numerous active centers, with substantial visibility. The promotion was intense, ahead and dynamic, with only extreme and optimum high quality for all cheap toms canada of the components: the colors had been vivid, the real advertisements were significant as well as the represented pictures were dynamic. The Television advertisements had been concentrated upon the thought of music, dancing and mobility and the text of these was just limited to the slogan in the product and of the Apple model (Think clear). In 2003, the new marketing campaign that Apple launched was on account of the conjunction with the start http://tomsshoescanada.shabkar.net/ with the iTunes music store. The campaign concentrated largely on the interpretation of well-liked songs by distinct individuals wearing iPods. This campaign was a massive hit, on account of the reality that it was depending on well-known pop, rock and hip hop songs, belonging to artists like Eminem or Pink. Later that yr, in October 2003, iPod launched a brand new series of advertisements, based on the silhouette campaign, which was the base for most with the print ads, like banners, billboards and wraps, even through the appearance with the very first technology of iPods: the pictures basically confirmed black silhouettes of folks dancing whilst carrying iPods. This new campaign was realized determined by the identical extreme colours and dynamic pictures like the very first marketing campaign. Even more, the good results from the marketing campaign was owed to the recognition with the carried out music, like The Vines' Trip, The Caesars' Jerk it Out, Gorillaz' Really feel Great Inc., Steriogram's Walkie-Talkie Guy, Jet's Are you currently Gonna Be My Lady, Propellerheads' Take California, Ozomatli's Saturday Evening, N*E*R*D's Rock Star (Jason Nevin's Blend), Franz Ferdinand's Get Me Out or Daft Punk's Technologic. With the launch with the new iPod video, the picture in the item and its promotion started to change. The slogan from the new item was 1 more factor..., meaning the brand new and expected video clip characteristic, which was a huge plus comparing with the newest design of 2005. The ads for this new item were focused on the video taking part in capabilities with the device. Actually, the ad featured U2's Authentic from the Species through the Vertigo: Live From Chicago DVD. Determined by the identical concept, there were 2 far more movies which featured Eminem and Wynton Marsalis. Nonetheless, with the identical time, the advert which was presenting the dancing silhouettes continued, but it was modified into some thing more representative for your new video system: the backgrounds had been not basic vivid colours anymore, they had been textured and had numerous patterns, symbolizing the evolution regarding the picture as well as the video properties in the new design of iPod. The two variants of the movies featuring the two common artists ranged from an orange urban theme in the hip hop music to a cool blue one with the jazz appear. The latest iPod advert, launched in March 2006 isn't based on the silhouette model toms canada any longer; as an alternative, the producers opted for a video clip showing a variety of CD covers, integrating in an iPod nano, beneath the exact same older slogan A thousand songs, in your pocket. It is composed by zhanhong1 2015-12-02 toms outlet canada.
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Use Your Mental Game To Overcome Self-intimidation

Intimidation is a massive mental barrier for many athletes. It often happens when you compare yourself to your opponent's skills before competition. Many athletes worry about the skill level of their opponents and then feel inferior, for example. What do you think about when you see the word intimidation? Do you think about feeling intimidated by an opponent or do you see yourself as the intimidator? Most intimidation in sports comes from your own thought process, which I call *self-intimidation*. Some athletes try to intimidate others intentionally because they think it gives them a mental edge, or feel they need to do this to win. However, most intimidation comes from athletes who psych themselves out - all on their own. They psych themselves out because of negative thoughts or fears, which then turn into mental gremlins. Self-intimidation is what you bring on yourself because you worry too much about your competition or the team you are about to play. One student I coach, for example, gets intimidated by the ranking of his opponent. If his competitor has a high ranking, he begins to doubt his ability to win the match. And then he plays tight and is afraid he will lose the match. Self-intimidation is the most common type of intimidation in sports and the hardest intimidation to overcome. You can easily ignore what others might say to you to yank you out of the zone, but you cannot ignore your own doubts or feelings of inferiority! Self-intimidation can come in many forms such as: -Feeling pressure to perform your best or win. -Worry about performing against other athletes who are just as skilled. -Comparing yourself to coach factory outlet canada other athletes who you think are better. -Worry about competing against a *ranked* or well-known coach outlet canada athlete. -Getting caught up in the hoopla or importance of a game. Confident and composed athletes do not intimidate themselves. Confident athletes, who are in control of their emotions, love the challenge of testing their skills against others athletes. The bigger and better the challenge, the more enjoyment they gain from the competition. Many athletes are not even aware that they intimidate themselves because doubt can be very subtle such as, "Can I beat this athlete who has more wins than me? " Your first task in overcoming intimidation is to be very honest with yourself, and recognize those times when coach canada outlet you are psyching yourself out of the competition before you even start! Look for signs such as: -You give too much energy to your competition during pregame. -You have doubts about playing well against a certain competitor or team. -You are in awe of the situation or hoopla of the competitive environment. -You feel inferior to the competition and make comparisons to others. Once you are aware that you are psyching yourself out with self-intimidation, you can move forward to improve your self-composure and poise. ---------------------------------- Want to learn simple, proven mental toughness skills that you can apply to competition? Grab my free online mental training newsletter, Sports Insights Magazine - for athletes, coaches, and sports parents Dr. Patrick Cohn is a master mental game coach who work with professional and amateur athletes, sports parents, and teams of all levels. It is composed by zhanhong1 2015-12-02 coach outlet canada.
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Psychic IM Readings - How to Chat With a Psychic Without Leaving Your Home

Are you interested in talking to a psychic...yet nervous about picking up the phone, or having a reading face to face? If you are...you are NOT alone! The simple truth is that lots of people are a bit apprehensive, or intimidated at the thought of speaking to a psychic live and in person, and find the phone equally as overwhelming for their first experience. Psychic Chat MAY be Your Answer Why? Because it's not confrontational. It's easy. It adds a layer of comfort...and connection that you may NOT get right away on the phone. And if you are someone who is super skeptical...it COMPLETELY removes the possibility of cold reading, or giving away information by accident due to your voice inflections, your body language, your verbal communication cues or other subtle insights some psychic "scam" artists are well known to use. (believe me....it's happened to all michael kors australia of us at one time or another..:-) Psychic Chat is CONVENIENT...and often has NO waiting time to get started. (and if you know where to look....is often FAR less expensive michael kors australia than other options) michael kors bags australia What is required? Very little. A broadband Internet connection is optimal. A good IM chat client...or, even better, a built in IM "client" on the psychic network you've decided to use. (most have a dedicated IM chat feature that works very well) And of course...being a good typer is a plus as well....especially if you are paying by the minute! The downside of using IM when talking to a clairvoyant, medium or intuitive? Honestly? I've tested multiple services...and have had multiple chat readings, and I really enjoyed the experience. But for me...as someone who has had close to 20 years of psychic experience both personally AND professionally alike, I really prefer the intimacy, and real RAPPORT you develop with a reader on the phone. (or even in person) While a few of the IM experiences I've had have been amazingly good (and really powerful) the truth is, my FAVORITE readings have almost always been on the phone. Could that just be me? Of course! You may prefer IM, chat or even readings by email instead. The good news is that we live in an age where genuine, quality and AUTHENTIC psychics are available when we need them most, in a whole bunch of convenient and INSTANTLY accessible ways. (and whichever one works BEST for your needs, is the type of reading you should get!) Warning! Don't get scammed by another "fake" Psychic EVER Again! Skeptical? Good! Get a Genuine Psychic Reading Here! (the ONLY Online Psychic Reading That's GUARANTEED to be Great......or You DON'T have to Pay!) It is composed by zhanhong1 2015-12-02 michael kors australia.
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Itinerary For A Perfect Day At The Spa.

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Best Way to Recover Deleted Pictures from a Memory Card

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Generally speaking, your camera will locate the picture files on the memory card when you delete pictures from your camera, and then delete them,which means that the camera doesn't delete the picture file body thoroughly but leaves them as is. Therefore, it is possible for us to find our deleted photos back. Now, you must can't wait to get your photos back, alright? Ok, the first thing that you need to do is to connect your camera to your computer via USB, but please notice whether there is a drive letter in "My Computer" at at this moment, if not, you should get an external USB card reader to help you. When inserting the card into the car reader and connect it to your computer, you will find a drive letter in "My Computer", which will allow a software tool to access the data on the memory card. Here we recommend you Photo recovery software for Windows, which is very popular within the users in the global world. It just takes not less than minute to to download and install the software on your computer. It is very easy to use if you follow the instructions step by step. Click "Next" on the welcome window, and install it step by step. Then coach handbags canada Choose a destination for the recovered photos and click "Next" to start the scanning. It takes just several minutes to fully scan your memory card. After scanning, you can preview the detected pictures and choose which pictures you want to recover, and then click "nex" and AppleXsoft Photo Recovery for Windows will save the selected pictures to the location that you have chosen Best Wishes Phrases The Best coach outlet canada Ways Of Wishing The Best In every season or occasion of celebration, it is of course customary to offer greetings of good will to each other. We now offer this collection of best wishes phrases that can be used for a variety of festive events. Celebrate Christmas and ring in coach outlet online the New Year with the following best wishes phrases for the coming holiday season. "A wish that every day for you will be happy from the start and may you always have good luck and a song within your heart." "At the close of another year, we pause to wish you a warm and happy holiday season." "Our wishes for a Happy Holiday Season and a New Year of health, happiness and prosperity." "Holiday Greetings and Best Wishes for a New Year of Happiness in a world of peace." "Our wish this Holiday Season - A world to grow in where children will be safe and free. Peace!" "There is no time more fitting to say "Thank You" and to wish you a Happy Holiday Season and a New Year of health, happiness and prosperity." Wish the bride and groom a lifetime of wedded bliss with the following wedding greetings. "Congratulations! Wishing you a wonderful beginning, and love to last a lifetime!" "On your Wedding Day, a wish for a lifetime of beautiful tomorrows." "Wishing you every happiness as you begin your life together. Best Wishes on Your Wedding Day." These next miscellaneous best wishes phrases can be applied to any occasion. "Climb every mountain in your life. You will reach the top. Best Wishes to You." "If dishes were wishes, then I wish you many." "Today, tomorrow, and always you are loved and wished the best the future brings." "Best wishes to coach outlet online canada you in whatever you do." "If things are not as you wish, wish them as they are." "For each petal on the shamrock. This brings a wish your way good health, good luck, and happiness. For today and every day." "May you get all your wishes but one, so you always have something to strive for." And for compliments of a profound sort, here are a few best wishes quoted from some noted personalities. "And we all have the power to make wishes come true, as long as we keep believing." -Louisa May Alcott "The best friend is the man who in wishing me well wishes it for my sake." -Aristotle "Fly free and happy beyond birthdays and across forever, and we'll meet now and then when we wish, in the midst of the one celebration that never can end." -Richard Bach "Great minds have purposes; others have wishes." -Washington Irving "Some people want it to happen, some wish it would happen, others make it happen." -Michael Jordan "If I could wish a wish for you, it would be for peace and happiness not only now, but for the whole year through." -Catherine Pulsifer As it has often been said, it's the thought that counts. And while simple greetings of "Happy Birthday" or "Merry Christmas" may be enough to show one's thoughtfulness, well-thought out best wishes phrases can show just how much one has thought of someone on that particular special occasion. Bible Book Order - How Bile Help Improve coach outlet canada Teen Personality There were a lot of surveys taken to figure out the information of methods numerous teenagers be in religious organization by simply decision after they cost nothing to generate their own choices. 1 information files which or higher of the young people around church who're typical potential clients go away and never give back once they are usually away from secondary school. What could be the reason for this kind of? And is generally there however for you to Bible Books Order it by happening? I do believe there are many reasons the key reason why young people tend to keep the actual cathedral, then one reason is specially notable: These types of teenagers have not, for the most part, been recently involved coach outlet in virtually any Bible Book Order, however possess simply already been likely to religious organization to sit by means of expertise and discover buddies. Due to this, they don't use a business understanding of The lord in addition to The Books Of The Bible In Order, and notice Him being private together. Several may have perhaps mentioned a involving confession along with involving crime, though the movements have also been merely so they really would not have to fear terrible, and they had missed the need for using a connection with their Beautiful Father. In case they are saved, why is it they do not perform Bible Book Order? If you inquire further, there's a excellent risk they will let you know it's mostly given that they merely don't have enough time. Some time they do have got is given to any or all types of fun, through time frame using close friends, time period by using technology, in order to other things they are able to consider for you to load his or her period. The effort it will take to believe factors via when it comes to attaining knowledge is often regarding little awareness. If they can undertake it swiftly in addition to with no a lot of additional effort, they may take the item. Numerous youngsters right now feel that the teenager decades are if it's time and energy to sit back along with do precisely what 1 wants. Of their close to , they presume that they can have enough time to obtain severe later. Shown last, although creating a enormous effect is this: Mom and dad store outstanding swing within the influence along with habits regarding young people by means of his or her individual suggestions along with help. Hence, if a person were to aid a teenager eliminate the defective imagining, and obtain your ex right into a Bible Books Order, will the style associated with Bible examine change lives inside their growth? Properly, consider the adhering to types of studies: Whenever you view the portions around book shops right now, you can find a massive supply of rapid for those young and old on the run along with chaotic life-style. These kind of brief, straightforward research is to help encourage people to look at a minimum of a few minutes of these morning to spend looking through plus meditation The Books Of The Bible In Order. The topics during these publications are intended to assist satisfy peoples' religious wants. Despite the fact that most of these studies are an improvement on nothing, if coach outlet anyone were to spend decades solely ingesting short, fundamental truths, there would always be no interesting depth associated with relationship with God. A lot of teenagers that have been challenged to keep up an everyday Bible Books Order study time choose most of these research because they are easy and quick looking through, as well as the request is very minimum picture this along the way concerning your day. Strong, existence fighting Bible Book Order are around intended for adolescents, and are intended as existence changing. Those are the the very least favorite Book Of The Bible In Order kind of study as a result of high intensity, mainly in your neighborhood connected with request. Your queries demand from customers responses which might be The Books Of The Bible In Order, in addition to point out the particular altered considering the particular mind. Merging textual content research in addition to app signifies that there has to be Order Of Books In The Bible added time needed, and yes it can be very difficult to remember to brush away or even ignore most of these potent studies. Black Radish - An Eventual coach outlet canada Solution for All Health Evils Ayurveda is the oldest scripture which basically belongs to Asians and it has a great relationship with health and medicinal world. In this scripture, there are all ailments related to small to big health coach outlet online disasters available and most of the ailments are commonly used vegetables, fruits or all the ingredients that can be found in your home kitchen. So, there is nothing wrong if we say that your kitchen is your real life protector. Among your daily used vegetables and food ingredients, perhaps black radish is one of them or maybe you don't really use it regularly but for sure you have seen it in your house kitchen once in your life if you are an Asian. If you have not yet recognized this ultimate vegetable black radish yet, then after reading on its description, may be you recognize it, I hope. Basically, black radish is having a black outer skin with snow white flesh and it is a vegetable like many other root vegetables such as radish, carrot, etc. This vegetable has a bitter flavor which is very hard as well. Sometimes, it causes bloating to some people and the oil of radish seeds is very famous and beneficial. Various Health Related Benefits Associated With Black Radish: Though, black radish is having a bitter flavor still it is quite nutritious and many nutritionists recommend it to people for good health. In addition to nutritional benefits, black radish is also having numerous medicinal coach outlet online canada qualities. Let's have a complete look on its medicinal benefits which are as below:- ?span style="font: 7pt "times new roman";"> Black radish is having Vitamin "C" and by consuming it, a person can get free from any sort of infections and radicals. In winter, it can work like a panacea. ?span style="font: 7pt "times new roman";"> It also contains Vitamin "B", so usually people who want to gain the quantum of Vitamin "B" in body, should necessarily use it regularly. ?span style="font: 7pt "times new roman";"> The vegetable has sufficient quantity of sulfur. ?span style="font: 7pt "times new roman";"> For peristaltic movements, it is very beneficial. ?span style="font: 7pt "times new roman";"> Black radish contains a great quantity of water and it has fiber, so both are required for a human body and for people who are having problem of constipation can benefit from eating this vegetable. Presence of chemicals is having a great significance as it keeps digestion process in control. Thus, in black radish a huge treasure for medical industry is present and with a proper consumption of it, everyone can be an owner of healthy life which would surely free from all health issues. 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Damas unveils musical legacy's musical on akshaya tritiya

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TCL has launched Pad 16 which is both a smartphone and a tablet

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http://catertown.com/profiles/blogs/give-a-spa-gift-basket-for-a-relaxing-and-calm-holiday-season
http://www.thrillbook.com/member/blog_post_view.php?postId=38383
http://likelook.ru/member/blog_post_view.php?postId=2542