The cost of mental health care for victims of crime.

Mental health care use by crime victims is one of the least known aspects of victimization costs. Although the clinical literature clearly establishes that criminal victimization adversely affects victim mental health, little empirical analysis has assessed the magnitude of this problem. The National Crime Victims Survey, for example, asks victims about their physical injuries and medical expenses but not about mental health counseling or therapy.

A few studies have estimated the incidence of mental health care usage by victims of crime in special populations. For example, Golding, Stein, Siegel, Burnam, and Sorenson (1988) estimated a 17.8% mental health care usage rate among Los Angeles area women who had been sexually assaulted at some point in their lifetime, compared to 9.0% mental health care usage among those without any such history. Norris, Kaniasty, and Scheer (1990) surveyed households in Kentucky and estimated that 6.9% of property crime victims and 22.7% of violent crime victims used mental health care services. However, once these figures are adjusted for mental health care usage in the general (nonvictim) population, usage was no higher among property crime victims than the general population, whereas violent crime victims had a 14% to 18% higher usage rate.

A nationally representative survey of women (Kilpatrick, Edmunds, & Seymour, 1992) estimated that 31% of rape victims (compared to 5% in the nonvictim sample) ever had posttraumatic stress disorder (PTSD). Major depression was reported by 30% of rape victims, compared to 10% of the nonvictim sample. This was one of the first studies to document the extent of mental illness in a nationally representative victim population.(1) However, it did not ask respondents about mental health care usage.

Instead of directly surveying victims, this project surveyed 168 mental health professionals. This approach seemed to be a sound alternative to seeking sensitive information from victims. Victims are often reluctant to discuss mental health problems. Furthermore, because crime victims are not trained in diagnostic techniques, they may not be able to disentangle the mental health consequences of victimization from other underlying or preexisting conditions.

The survey respondents consisted of a nationally representative sample, stratified into eight different professional organizations -- including psychiatrists, psychologists, clinical social workers, mental health counselors, pastoral counselors, and marriage and family counselors. The main focus of the survey was to estimate (a) the number of crime victims receiving mental health counseling, by type of crime, and (b) the average annual cost of treatment for each type of crime victim. Multiplying these two figures yields an estimate of the annual cost of mental health care for victims of crime.

This survey estimated the actual use of mental health care services as opposed to mental health care needs of victims. Because many crime victims presumably do not receive mental health care services that would be beneficial, our estimates understate the true costs of mental illness caused by criminal victimization.

METHODS

Because no comprehensive registry lists all mental health care providers in the United States, we obtained our sample from membership lists provided by eight national professional organizations. These organizations represent approximately 80% of mental health care providers in the United States who are members of national professional organizations.(2)

No attempt was made to select respondents who specialize in victim services. Rather, random samples were drawn from the general pool of providers in each professional category. In some cases, a random sample was drawn directly from directories of the organization. In others, the organization supplied us a random sample of member names and phone numbers.(3) Initially, the goal was to complete telephone interviews with approximately 15 to 30 members of each group, depending on the size of the organization. Thus, a random sample of approximately 30 to 60 members was drawn from each group. In all, we identified a sample of 339 mental health care professionals from these eight different organizations. Because membership totals vary by organization, we did not use the sample means directly to estimate mental health care usage. Instead, each professional organization was considered as a separate sampling frame, with weights given according to the total number of members.

Table 1 lists each of these organizations with their estimated total membership in parentheses. Although the total estimated membership of the eight organizations is 221,184,(4) 22 of the 168 respondents indicated that they belong to one of the other organizations we surveyed. Eliminating this duplication, an estimated 207,874 mental health care professionals belong to these organizations. About 78% (131 of 168) of these members had some form of active clinical caseload as of 1991 -- approximately 158,000 individuals. Overall, we made direct telephone contact or received a mail survey from 189 of the 339 potential respondents (55.7%). Of these 189, we obtained usable data from 168 mental health professionals -- 49.8% of the original sample and 88.9% of those we were able to contact.

[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]

A survey instrument was drafted and pretested on several members of a local mental health care professional group.(5) …