A mixed methods systematic review of factors impacting help-seeking in OCD, and an empirical study of psychological flexibility and resilience in care seeking and non-care seeking voice hearers exposed to trauma

Mental health difficulties are estimated to impact a quarter of people within the United Kingdom every year, however, only 1 in 8 of those people receive support for their mental health. Research has demonstrated that therapeutic interventions are effective at treating mental health difficulties and improving quality of life. This suggests that there are other factors which influence the care seeking patterns of people with mental health difficulties. Developing a better understanding of why people do or do not seek care is imperative to ensure that people are getting the support they need for any mental health difficulties that may be present. 
\nThe systematic review investigated the barriers and facilitators to care seeking for those with obsessive compulsive disorder (OCD). This is a highly relevant issue as OCD affects up to 3% of population but less than 40% of those with OCD in the UK actually seek support. Additionally, OCD has been recognised to be one of the most debilitating health conditions and rates of diagnosis have been increasing over recent years. It has been suggested that people may not seek support for OCD due to stigma; the process of labelling, stereotyping, and judging people. This review searched databases and reference lists, finding a total of 22 studies conducted across 12 countries. These studies were a mixture of qualitative and quantitative allowing for the development of rich findings that reflect the wide OCD population. Six integrated findings were produced that encapsulated both barriers and facilitators to help-seeking. These were treatment beliefs, stigma, making sense of own experiences, I am responsible, helplessness, and external support. Treatment beliefs referred to the negative or positive past experiences with support seeking and ideas about treatment effectiveness, alongside fears of cost and time implications. Stigma focused on the internal, external, and structural judgements that can be made about mental health and OCD, and that these can both motivate or prevent people from seeking support. A common theme related to people making sense of their own experience often stemmed from difficulties recognising OCD symptoms which are made more difficult by complex pathways to seeking support. Personal responsibility is a frequently held belief within OCD which was identified to be associated with people’s identity and values. Helplessness referred to the belief that OCD was either too severe or not severe enough to seek help, and that another mental health condition was required to be able to access support. Finally, external support outlined the role of family, friends, professionals, and religion in the process of seeking help. These findings appeared to present on a continuum with factors acting as facilitators or barriers dependent on the strength of the factor. Furthermore, the findings align with models of therapy and highlight areas for broader intervention to encourage help seeking for those with OCD. 
\nThe empirical study recognised that some people who experience traumatic events may go on to hear voices, some of whom seek support while others do not. This study investigated the differences between these groups in relation to psychological flexibility and resilience. It is estimated that up to 15% of people will hear something, such as a voice, that is not there, with those who have been exposed to trauma reporting much higher rates of voice hearing. However, not all of these people will go on to seek mental health support, suggesting that there are other factors that need to be considered in relation to hearing voices. One theory, called psychological flexibility, is that an individual’s ability to adapt to situations while balancing one’s own needs. Another relates to resilience which is the ability to use personal and social resources to respond to challenging situations. This study used a range of questionnaires in an online study with adults who hear voices and have sought care alongside those who have not to investigate these factors. The results showed that there was a difference between the groups based on the repeated exposure to the same trauma alongside the distress caused by voices and traumas. Additionally, those who sought care reported much lower levels of resilience and psychological flexibility. These results support the use of a range of interventions including cognitive behavioural therapy, family therapy, social prescribing, and open dialogue to foster skills in resilience, alongside acceptance and commitment therapy to develop the ability to respond in a psychologically flexible manner. The study identified possible avenues for future research and highlighted that voice hearing may be more frequent than expected in university populations, with additional support required. 
\nBoth the empirical study and systematic review furthers our understanding of help seeking across OCD and voice hearing populations. The combination of these results with the wider literature and future research, could allow services to provide effective interventions to those in need to a wider proportion of the population.

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