Date of Award

January 2020

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Dr. Susan Busch

Second Advisor

Dr. Danya Keene



Objectives: This qualitative analysis explores how severity of need influences how patients perceive, experience and navigate mental health care.

Methods: Participants are English-speaking adults aged 18-64 with private insurance who have severe mental illness (SMI). After gauging interest in participating in telephone interviews, the principle investigators sampled those that used an out-of-network mental health provider (n=8), in-network mental health provider (n=8) and oversampled those that tried to use a mental health provider but ultimately didn’t (n=14). The 30 participants were interviewed for ~30 minutes each using semi-structured interview guides. All coding took place within Dedoose version 8.2.32.

Findings: “Severity” emerged and was perpetuated through individual interactions with providers and structural barriers. Participants expressed repeatedly advocating for treatment and having their symptoms normalized (mainly by their PCP). They not only internalized these minimizing consultations but also expressed seeking future care beyond the healthcare system, if at all. Scarcity of providers and burdensome costs of care also reinforced “Severity” by making treatment inaccessible through availability, affordability or both. Due to these barriers, participants identified the emergency room and hospitalization as crucial agents in expediting access to treatment. While these sites were successful in addressing immediate needs and sometimes even catalyzing long term care, it was clear that early opposed to emergent intervention was participants’ preference.

Recommendations: Based on participant narratives, the following actions are recommended.

(1) Mental health capacity should be built within primary care in order to increase PCP mental health competence and in turn, lessen patient self-advocacy burdens. This would also profoundly relieve scarcity issues.

(2) Insurance payers should increase reimbursements for in and out of network mental health providers in order to garner in network participation and mitigate out of network costs.

(3) The development of behavioral health specific emergent care options should be supported in order to provide more appropriate and timely care for high need patients.


This is an Open Access Thesis.

Open Access

This Article is Open Access