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Barriers to Care: Fiction’s Potential Influence on Inhibiting Help-Seeking

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Although estimates vary, it is generally agreed that at least 40% of people who suffer mental health issues do not receive mental health care.  Barriers to care include concrete barriers like limited access to providers and financial constraints; other barriers are attitudinal and may center on societal stigma or negative personal beliefs about treatment’s effectiveness.

In fact, beliefs and attitudes may pose more substantial barriers to care than do economic obstacles (Mojtabai et al., 2011).  Stigma is a well-known deterrent to seeking help for mental health problems.  But some research has shown that negative attitudes towards mental health care and its likely effectiveness have a more deleterious effect on pursuing needed care than even stigma does (Sudom, Zamorski, & Garber, 2012).

Novels that depict therapists and the therapeutic process have the power to influence public opinions in subtle ways.  When these books show ethical breaches and unconventional interventions as routine business, they do harm to a reader population for whom these negative expectations might interfere with help-seeking.

One of the pleasures of reading fiction is the opportunity to explore unexpected situations and meet unusual characters. Tallying treacherous therapists and psychopathic psychologists is of little utility; such depictions are unlikely to impact on opinion as they are so clearly devices to drive the plot.   To argue that all fictional therapists should be neat and ideal is unrealistic and, frankly, unappealing.  But there is still room to protect the integrity of mental health endeavors while writing engaging works.

For example, fewer than 24 hours after an anonymous sexual encounter in a parking garage, Dr. Grace Blades is confronted by the man with whom she had the encounter; he’s on her schedule as a new patient.  Flustered and embarrassed, Grace still manages to collect herself professionally, informing the patient that she obviously cannot handle his care but emphasizing that she will gladly get him a referral to another provider.  Perhaps not surprisingly, this balancing act of ethics and entertainment is pulled off by Jonathan Kellerman, a clinical psychologist turned author (Grace’s story is told in The Murderer’s Daughter, 2015).

In contrast, Blue Monday (2011) by Nicci French has numerous examples of boundary-breaking, ethical violations, and generally questionable practices.  Upon learning of a woman’s sexual exploitation by her psychiatrist, Dr. Frieda Klein goes to a restaurant and physically assaults the offending psychiatrist. She later asks the victimized woman for a favor, although the woman has become Frieda’s own patient. The favor itself is a sufficient violation, of course; the fact that it put the patient at odds with her own professional standards only makes it worse.  Then, in her unofficial role as consultant to the police, Frieda turns therapy sessions with one man into a hunt for his criminal brother. And there are other ethical issues.  After a workman falls through her ceiling from the floor above, Frieda agrees to have him partition the office while he works to repair the hole. She takes no steps to ensure patient confidentiality behind that partition and, in fact, the workman overhears nearly an entire session. Learning of this and confronting him, Frieda feels appropriately horrified at the breach. However, she then goes on to have a discussion with the workman about the session he has just overheard, a discussion in which Frieda reveals the patient’s first name.  The book is generally reviewed positively on Amazon.  However, tellingly, among the negative reviews is a near-consensus that Frieda is an unlikeable character.

The Night Bird (2017) by Brian Freeman is located somewhere between these two books in terms of its negative portrayals of therapy and therapists.  Dr. Francesca Stein inexplicably goes by the nickname “Frankie,” giving her the near-monstrous moniker of Frankie Stein.  She practices a form of trauma treatment in which she replaces traumatic memories with sanitized ones while her patients are under hypnosis.  Following the treatment, patients can remember seeking help but cannot remember the implantation of the false memories.  The treatment is given a great deal of attention in the novel, but controversy is acknowledged (e.g., “Many of her peers disagreed bitterly with the ethics of her treatments, and they’d waged an academic war to discredit her”).  As the plot unfolds, Frankie herself is given reasons to question the desirability and acceptability of such treatment practices.

Negative attitudes towards mental health treatment can interfere with seeking needed help.  It is therefore crucial to monitor potential influencers of those negative attitudes, including fictional books, in order to counteract inaccurate and disparaging impressions.



Mojtabai, R., Olfson, M., Sampson, N., Jin, R., Druss, B., Wang, P.,…Kessler, R. (2011). Barriers to mental health treatment: Results from the National Comorbidity Survey Replication.  Psychological Medicine, 41(8), 1751-1761.

Sudom, K., Zamorski, M., & Garber, B. (2012). Stigma and barriers to mental health care in deployed Canadian forces personnel. Military Psychology, 24(4), 414-431.





Barriers to Care: Fiction’s Potential Influence on Inhibiting Help-Seeking

Kathryn Lawson

Kathryn Lawson, PhD is a clinical psychologist in Peachtree City, Georgia, specializing in the treatment of trauma/PTSD, grief, anxiety and depression among older adolescents and adults. Before transitioning to private practice, she worked for the Bureau of Prisons for 10 years. During that time, she also worked as an adjunct faculty member at a small college, teaching diverse groups of nontraditional students. Her private practice, teaching, and government service have all been guided by a commitment to reaching underserved populations. Dr. Lawson is passionate about issues of stigma and inclusion and how these impact individuals affected by mental illness.

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APA Reference
Lawson, K. (2018). Barriers to Care: Fiction’s Potential Influence on Inhibiting Help-Seeking. Psych Central. Retrieved on March 23, 2019, from


Last updated: 9 Feb 2018
Last reviewed: By John M. Grohol, Psy.D. on 9 Feb 2018
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