How people get into mental health services: stories of choice, coercion and "muddling through" from "first-timers"

Soc Sci Med. 1998 Jan;46(2):275-86. doi: 10.1016/s0277-9536(97)00160-3.


Previous work examining how individuals enter mental health treatment comes either from the health services utilization tradition, which implicitly assumes that clients make decisions to seek care, or from the socio-legal perspective, which examines how clients are forced into care. This paper draws from the Network-Episode Model to systematically consider the different social processes through which people come to enter psychiatric treatment by exploring the "stories" told by individuals making their first major contact with the mental health system. We combine the use of qualitative and quantitative methods to examine data from the Indianapolis Network Mental Health Study, a longitudinal study of individuals in treatment at the largest public and voluntary facilities in the city. We analyze detailed self-reports of how they came to use mental health services, classifying these stories as "choice," "coercion," or "muddling through". Using multinomial logit analyses, we examine how factors such as gender, race and diagnosis shape the types of stories that individuals tell. The preliminary results indicate that fewer than half of the stories (45.9%) match the notion of choice underlying the dominant utilization theories. Almost a quarter of respondents (22.9%) report coercion and nearly one-third (31.2%) tell stories that lack a clear agent. Diagnosis and social networks tap differences in how individuals experience entry into care. Individuals diagnosed with bipolar disorder or who have larger, closer social networks are more likely to tell stories of coercion. We discuss the theoretical, methodological, and clinical implications of findings drawn from this examination of clients' stories.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Case-Control Studies
  • Coercion*
  • Decision Making*
  • Female
  • Health Services Accessibility*
  • Humans
  • Indiana
  • Logistic Models
  • Male
  • Mental Health Services / statistics & numerical data*
  • Middle Aged
  • Multivariate Analysis
  • Patient Acceptance of Health Care / psychology
  • Patient Acceptance of Health Care / statistics & numerical data
  • Social Support