Fear of Adverse Mental Health Treatment Experiences: Initial Psychometric Properties of a Brief Self-Report Measure

Background:

Many are apprehensive about mental health care, which can affect engagement in recovery processes as well as health outcomes. This paper introduces a tool to assess fear of adverse mental health treatment experiences from the client’s perspective.  In a sample of adults receiving mental health services at community agencies in California, this study is an initial exploration into the validity of the Fear of Adverse Treatment Experiences Scale (FATES), which assesses fears associated with commonly-experienced coercive or disorganized interventions.  The FATES is a 10-item Likert-type scale originally developed in preparation for a randomized controlled trial investigating outcomes of consumer-led services.  Items were generated using a deductive approach, drawing from the expertise of researchers and leaders of mental health consumer groups in northern California.    

Method:

Following an analysis of missing data, two factor analytic approaches were employed and compared.  First, principal components analysis was conducted based on the polychoric correlation matrix. Principal axis factoring, based on the Pearson’s covariance matrix, was then used as a comparison with Quartimax rotation.  Eigenvalues were assessed in both procedures, with values greater than one suggesting the dimensionality of the scale.  Internal consistency was evaluated using ordinal reliability theta as well as the traditional Cronbach’s alpha.  Finally, nonparametric tests of proportion equality were used to evaluate score patterns among groups with characteristics theoretically linked to fear of treatment.

Results:

In this sample of 656 participants, the mean age was 39 years, 54% of the sample identified as male, and 54% identified as Causcasian.  The most frequent pattern of missing data (n =52) involved fears of staff restricting freedom and staff calling police; significant associations were found between this skip pattern and reported ethnicity.  Factor analyses supported the construct validity of the 10-item FATES.  The two methods utilized in this study produced similar results, with no approach visibly yielding two separate strong factors.

The FATES significantly discriminates based upon service characteristics, gender, history of victimization, and past experiences with coercive or disorganized interventions, with higher levels of fear reported by users of traditional mental health services, former inpatients who had their voluntary admission status changed, males, people with history of childhood abuse, and people with certain forms of criminal justice involvement.

Implications:

Factor analyses support the construct validity of the 10-item FATES in this sample.  In comparing median scores between groups, there were many expected findings as well as some that challenged initial hypotheses.  All are worthy of further investigation as fear of adverse treatment is not well-documented in scientific literature.  Opportunities for further validation may be found in studies of treatment adherence and termination, therapeutic rapport, or the characteristics of people who have chosen not to engage in conventional mental health care. Given previous use of these scale items to predict patterns of help-seeking, future exploration of self-perceived need for services in tandem with fear of services may be useful in clinical or research applications.