Community Ment Health J (2016) 52:311–322 DOI 10.1007/s10597-016-9990-9

ORIGINAL PAPER

Mental Illness Discrimination in Mental Health Treatment Programs: Intersections of Race, Ethnicity, and Sexual Orientation Lynn C. Holley1 • Kyoko Y. Tavassoli1 • Layne K. Stromwall1

Received: 31 May 2015 / Accepted: 12 January 2016 / Published online: 21 January 2016  Springer Science+Business Media New York 2016

Abstract People with mental illnesses (PWMI) who are of color and/or lesbian, gay, or bisexual (LGB) experience mental health disparities, including within mental health treatment programs (MHTPs). Informed by a critical framework with attention to intersectionality and microaggressions, this qualitative study asked 20 PWMI and family members who also are of color and/or LGB whether they had experienced mental illness discrimination in MHTPs, a possible factor in disparities. We also asked participants about aspects of MHTPs that supported recovery. Participants reported that they were ignored/not listened to, not viewed as complex individuals, experienced condescension/lack of respect and violations of privacy or other rights, and were presumed to lack intelligence. In addition, identifying mental illness discrimination was complex due to intersections of identities. Despite these perceptions of discrimination, participants described supportive aspects of MHTPs. Implications for practice and research are offered. Keywords Mental illness discrimination
Heterosexism
Racism
Intersectionality
Microaggressions
Stigma

Introduction People with mental illnesses (PWMI) who are of color, compared to whites, experience more serious diagnoses, less effective and convenient treatments, and fewer & Lynn C. Holley [email protected] 1

Arizona State University, School of Social Work, 411 N. Central Ave., Ste. 800, Phoenix, AZ 85004-0689, USA

providers from the same identity groups (U.S. Department of Health and Human Services [DHHS] 2001). In addition, people who are lesbian, gay, bisexual, or transgender (LGBT), compared to cisgender heterosexuals, report less satisfaction with mental health services, particularly if they are of color (Avery et al. 2001). These disparities may be partially explained by experiencing discrimination based on oppressed social positions (Meyer 2003). For example, negative mental health outcomes are associated with experiencing discrimination based on race or ethnicity (DHHS, 2001; Williams and Mohammed 2009), sexual orientation (Mays and Cochran 2001), and intersecting racial/ethnic, sexual orientation, and gender identities (Balsam et al. 2011; Szymanski and Gupta 2009). These forms of discrimination occur in mental health treatment programs (MHTPs) as well as in the larger society. PWMI have reported that staff in MHTPs engage in racial (e.g., Delphin-Rittmon et al. 2013), sexual orientation (e.g., Kidd et al. 2011), and mental illness (e.g., Angell et al. 2005; Stromwall et al. 2011; Charles 2013) discrimination. Recent studies have explored the form of discrimination that Sue (2010) terms microaggressions: ‘‘brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership’’ (p. 24). Research indicates that microagressions such as stereotyping of Black clients by white supervisors (Constantine and Sue 2007) and assuming that PWMI lack intelligence (Gonzales et al. 2015) occur within MHTPs. To our knowledge researchers have not asked PWMI who are of color and/or LGBT about what staff behaviors or program characteristics they view as evidence of mental illness discrimination—including microaggressions—in MHTPs. In this exploratory study, we interviewed adults in one U.S. southwestern state who self-identified as PWMI or as

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family members of PWMI; all identified as of color or as lesbian, gay, or bisexual (LGB); or both of color and LGB. We asked participants whether they had experienced mental illness discrimination in MHTPs and about program aspects that supported recovery. Specifically, the study asked: (1) Do PWMI and family members who are of color and/or LGB perceive that they have experienced mental illness discrimination in MHTPs? If so, what experiences do they describe as discriminatory? (2) Are members of these identity communities aware of efforts of MHTPs or people within these programs to reduce mental illness discrimination? (3) What aspects of MHTPs are viewed as supporting recovery for PWMI who are of color and/or LGB?

Theoretical Framework A range of theoretical frameworks have been developed to understand the experiences of PWMI with mental illness discrimination. Ottati et al. (2005) described ‘‘stigma’’ mechanisms related to individuals’ cognitive-based stereotypes, prejudicial attitudes, and discriminatory behaviors. Link and Phelan (2001) recognized power differences between perpetrators and targets of stigma and the structural nature of stigma. Pescosolido et al. (2008) advocated considering micro-, messo-, and macro-level factors that contribute to stigma. As noted by Heflinger and Hinshaw (2010), however, most frameworks focus on attitudes of the general public or on internalization of negative attitudes by PWMI. They assert that researchers must examine discrimination by mental health professionals and organizations and that frameworks should include attention to ‘‘individual, community, and societal factors that… support professional and institutional stigma’’ (p. 68). Consistent with this call by Heflinger and Hinshaw (2010), this study used a critical framework that assumes that prejudice and discrimination are systemic and manifest at individual, institutional, and societal levels (Holley et al. 2012; also see Andersen and Collins 2004 and Young 1990). At any level, discrimination may be overt or covert and intentional or unintentional (Andersen and Collins 2004; Holley et al. 2012; Cole 2009). Discriminatory experiences are understood as the result of multiple forms of systemic inequality related to simultaneous, intersecting identities (Cole 2009; Warner and Shields 2013). Young (1990) presents five forms of oppression; experiencing any is sufficient to classify a social group as oppressed. We consider three of Young’s forms that PWMI and their families might experience: cultural imperialism, marginalization, and violence (Holley et al. 2015). Cultural

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imperialism leads to stereotyping and may result in dominant group members indicating aversion or condescension, such as avoiding eye contact (Young 1990). This concept helps understand discrimination in MHTPs, as such behaviors occur even among those who ‘‘are quite consciously committed to equality and respect’’ (Young, p. 134). Marginalization leads to ignoring rights to privacy, individual choice, and respect. Violence includes physical and verbal attacks designed to ridicule, degrade, or stigmatize (Young 1990). An intersectionality lens suggests that experiences with discrimination will vary by different intersecting identities (e.g., LGB PWMI may experience mental illness discrimination differently from heterosexual PWMI). Young’s conceptualizations overlap with the more recent microaggressions construct. Microaggressions might take the form of microassaults, which are explicit and often conscious derogatory comments; microinsults, generally unconscious remarks or behaviors that are demeaning or rude; and microinvalidations, which also are unconscious and negate ideas and experiences of the targeted groups (Sue 2010).

Literature Review This section provides an overview of research about discrimination reported by PWMI, people of color, and LGBT individuals. Although perceptions of discrimination do not mean that discrimination definitely has occurred, perceived discrimination is important to study because it is associated with negative physical and mental health outcomes (e.g., Pascoe and Richman 2009; Schmitt et al. 2014). This area is of particular significance when considering PWMI, who may find recovery more difficult if their symptoms worsen due to experiences with discrimination. Intersectionality studies have found that LGBT people of color experience heterosexism within their racial/ethnic communities and racism within their sexual orientation communities (e.g., Balsam et al. 2011). The discrimination may take the form of microaggressions (Balsam et al. 2011) and is associated with negative psychological outcomes (Balsam et al. 2011; Szymanski and Gupta 2009). While these researchers have considered mental health status as an outcome of heterosexism, racism, and other forms of discrimination, we are aware of no studies that examine the intersections of race/ethnicity, sexual orientation, and having a mental health condition when examining discrimination experiences, including within MHTPs. In the absence of such literature, we present findings from research about discrimination in MHTPs related to sexual orientation, race/ethnicity, or mental illness.

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Sexual Orientation and Racial/Ethnic Discrimination in MHTPs

choice’’ (p. 373). Finally, family members report ‘‘stigma by association’’ (Quinn and Chaudoir 2009; Schulze and Angermeyer 2003; van der Sanden et al. 2014), including being socially excluded and treated negatively by providers (Schulze and Angermeyer 2003; van der Sanden et al. 2014).

A few studies have explored heterosexist discrimination within MHTPs. Kidd et al. (2011) found that providers discriminated against lesbian and gay PWMI by ignoring or questioning their sexual orientation; assuming that mental illnesses were in some way related to their sexual orientation; or not allowing mild displays of affection that were accepted for heterosexual patients. Studies focusing on race- or ethnicity-based discrimination in MHTPs have found that lack of understanding of culture, stereotyping (Delphin-Rittmon et al. 2013), and communication with providers (Newhill and Harris 2007) were barriers to effective services. Studies of racial microaggressions have found that white supervisors stereotype Black clients (Constantine and Sue 2007) and that African American clients with white therapists report experiencing 12 categories of racial microaggressions, including minimization of racial-cultural issues, stereotypic assumptions, colorblindness, and patronization (Constantine 2007). Mental Illness Discrimination in MHTPs In their discussion of services for children and youth with mental illnesses and their families, Heflinger and Hinshaw (2010) assert that professionals might engage in mental illness discrimination consciously or unconsciously. Behaviors evidencing discrimination might include referring to service participants by their diagnoses rather than using person-first language, having low expectations, focusing on deficits and illness rather than strengths and the whole person, and placing PWMI in passive roles. They encourage researchers to examine whether MHTPs engage in institutional-level mental illness discrimination, whether intentionally or unintentionally. Studies of mental health providers show they may hold prejudicial attitudes toward PWMI (e.g., Peris et al. 2008; Schulze 2007; Stuber et al. 2014). One study of PWMI found that mental health providers were the most commonly reported source of mental illness discrimination, with 20 % of the sample reporting ‘‘a lot’’ of such discrimination by providers (Hansson et al. 2014). PWMI have reported experiencing lowered expectations and negative prognoses (Angell et al. 2005; Schulze and Angermeyer 2003) and infantilization by providers (Angell et al. 2005). A study of microaggressions toward PWMI found that providers minimized their experiences and assumed they were not intelligent (Gonzales et al. 2015). Charles (2013) identified five dimensions of provider stigma: ‘‘shame and blame; disinterest, annoyance and/or irritation; degradation and dehumanization; poor prognosis/fostering dependence; and coercion and lack of ‘real’

Method Sample and Recruitment Procedures The sample population comprises adults from one U.S. southwestern state who self-identified as (1) PWMI or as family members of PWMI and also (2) of color and/or LGBT. We selected this broad range of identities for this exploratory study because no literature exists about the nature of mental illness discrimination experienced by people who are LGBT and/or of color; learning about the experiences of people with a range of identities can provide a foundation for research about people living at specific intersections. The study announcement was emailed to state MHTPs employing or run by peer or family staff; to professionals who serve as instructors for university student interns in organizations that provide social services for PWMI, people of color, and/or LGBT populations; and to local and state online newsletters whose recipients were likely to fit study parameters or to work with those who did (e.g., newsletters of MHTPs). The study was approved by a university Institutional Review Board, all authors certify responsibility for the manuscript, and there are no known conflicts of interest. Participants were offered reimbursement for transportation and a $15 gift card as a token of appreciation. Fliers directed potential participants to contact the Principal Investigator (PI). Thirty-five individuals did so, and 20 met the study parameters (i.e., at least 18 years old, a person with a mental illness or family member, and of color and/or LGBT) and completed the interview. The response rate cannot be known as we do not know how many people received forwarded emails or how many who read the announcement fit the study parameters. Interview Guide and Interviews We worked with PWMI and family members to develop the interview guide; the final guide was approved by these community members. We asked whether participants had experienced mental illness discrimination and recovery supports in MHTPs, larger society, LGB communities, and their respective racial/ethnic communities. Findings related to discrimination and supports in traditional MHTPs— those that are not peer- or family-run—are reported in this

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paper. Specifically, we asked, ‘‘Have you ever experienced or seen mental health-related prejudice or discrimination in the behavioral health system?’’ If they responded ‘‘yes’’ or ‘‘maybe,’’ they were asked to give examples. Participants also were asked about ways in which the system had supported their or their family members’ recovery and if they knew about anti-stigma or anti-discrimination efforts of the behavioral health system. The 18 face-to-face and two telephone in-depth interviews were conducted in English from September 2012 through July 2013 and ranged from 25 to 80 min in length; on average, 20–30 % of interview time addressed questions considered in the current analysis. The PI conducted 18 interviews one-on-one; one interviewee had a service provider with her for support, and one was conducted by an undergraduate student with the PI present. Participants selected the sites of the face-to-face interviews, which included a university office (n = 13), participants’ workplaces (n = 2) and homes (n = 2), and a social service agency (n = 1). No differences in interview length, content, or willingness to describe discriminatory or supportive experiences arose due to these differences and no one declined participation after the interviews began. Interviews were audiotaped and transcribed verbatim. Participants selected pseudonyms, but four were replaced with the pseudonym’s first initial to protect confidentiality. Data Analysis and Interpretation

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Data Interpretation We acknowledge that our perspectives affected all stages of research (Creswell and Miller 2000). We thus constantly returned to the data to ensure that our findings reflect participants’ experiences, include quotes to allow readers to assess our interpretations (Drisko 1997), provide disconfirming evidence (see Miles and Huberman 1994), and offer explanations for our interpretations. Our theoretical framework led us to look for multiple forms of discrimination related to intersections of identities during data analysis. In interpreting our findings, we consider ways in which societal-level discrimination might create the conditions for individual- and organization-level discrimination reported by participants.

Findings The sample includes 13 PWMI and seven family members; two family members have children with mental illnesses, two have siblings, one has both a sibling and a parent, and one each has a partner or a cousin with a mental illness. Participants were 21–60 years old and 12 are LGB and 15 are of color; seven identified as LGB people of color. See Table 1 for additional information. All had participated in public MHTPs. Because no participants were transgender, our findings and discussion use the term LGB rather than LGBT as appropriate.

Data Analysis Discrimination Related to Mental Health Conditions Each transcribed interview was formatted into a table with pseudonyms, paragraph numbers, and columns for codes and memos (La Pelle 2004). Using a constant comparative method (Tracy 2013), researchers read each transcript to identify passages related to the research questions; identified first-level codes that emerged (Tracy 2013) and entered them into the code column; categorized the firstlevel codes to develop second-level codes (Tracy 2013); and created tables for each second-level code that included the speaker and context of the passage. When members of the research team coded content differently we discussed our perspectives until we reached agreement. In reporting findings related to mental illness discrimination, a secondlevel code is considered a theme if discussed by one-third of the participants, though three of the five themes were discussed by at least half of the participants. Finally, we searched for patterns, focusing on whether there were differences in theme content related to participants’ race, ethnicity, sexual orientation, and PWMI versus family member status. Unless we preface a participant name with ‘‘family member,’’ we refer to a person with a mental illness when we cite participants below.

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All but one participant described incidents that appear to be mental illness discrimination, with 16 describing incidents in traditional MHTPs (the focus of this analysis). Five themes emerged: ignoring/not listening, not viewed as complex individuals, condescension/lack of respect, violations of privacy or other rights, and presumed lack of intelligence. Ignoring/Not Listening Participants reported many experiences in which they or their family members were ignored. A subtheme in this category is that staff ignored the perspectives or needs of PWMI. For example, family member Ann described a psychiatrist’s attitude during an appointment with her partner as: I just want to ask the questions and you’re going to answer [them] and that’s it. I don’t want you to talk, there should be no narrative. It’s just a ‘‘Yes’’ or ‘‘No’’ so that I can go check, check, check [on my form].

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Table 1 Sample description (N = 20) Identities and demographics

Table 1 continued n

Identities and demographics

PWMI

13

a

Family

7

PWMI or family member

No

White

5

Mexican American

3

African American

2

Native American

2

Asian American

1

Mexican American and Native American

3

Native American and African American African American and White

2 1

African American and White and Native American

1

Sexual orientation Heterosexual

8

Lesbian

5

Gay

5

Bisexual

2

Of color versus white 9 sexual orientation 7

Of color and heterosexual

8

White and LGB

5

Diagnoses of PWMIa Bipolar disorder

8

Anxiety disorders

6

Paranoid schizophrenia

2

Major depression Multiple personality disorder

2 1

Diagnoses of family membersb Bipolar disorder

5

Anxiety disorder

3

Schizophrenia

3

Depression

1

ADHD

1

Emotional instability

1

Gender Women

12

Men

8

Transgender

0

Education Some high school

3

High school diploma or GED Some college

5 3

Associates degree

1

Bachelor’s degree

7

Master’s degree

1

Has been employed in MHTPs Yes

13

Diagnoses reported by participants; ns do not total 13 because two PWMI reported two diagnoses and two reported three diagnoses b

Race/ethnicity

Of color and LGB

n

7

Diagnoses reported by family members; ns do not total 7 because two family members had two or more relatives with mental illnesses and four family members with mental illnesses had more than one diagnosis

Reflecting this same subtheme, M requested a female therapist and non-medication supports. Yet she has been offered only medications—except for one appointment with a male therapist. Others told about recent positive encounters that contrasted with past experiences when they had been ignored. In Jesse’s words, ‘‘I finally have a case manager that hears me out.’’ A second subtheme is that participants reported that they or their family member with a mental health condition were physically ignored. For example, L said, ‘‘[The nurse practitioner] was sitting there banging on his keyboard and I’m trying to talk to him. He… didn’t focus on me or anything. He was just banging away, banging away.’’ Family member Chanel describes another way that a person was physically ignored: [My brother] has a particular counselor that makes a lot of empty promises…. ‘‘I’m gonna come visit you when you’re in the hospital.’’ ‘‘I’m gonna come to your court date and help.’’ And he, he never shows up. He, he’s just not there…. No intersections-related patterns emerged regarding experiences with ignoring/not listening. Not Viewed as Complex Individuals Stories within this second theme suggest that treatment providers did not see PWMI as complex individuals with unique needs. Some participants said that PWMI were seen as diagnoses rather than individuals, as when Gerard explained that staff ‘‘gear’’ PWMI to say ‘‘I am bipolar’’ rather than ‘‘I have bipolar disorder.’’ (Italics indicate participant’s emphasis.) A subtheme in this area was that not understanding individuals’ unique needs led to inappropriate or inadequate treatment. For example, Martin said, [W]hen I went to the adult center [after aging out of the children’s program] it was like, ‘‘Oh, you can deal with it now…. You don’t see a counselor so much. Here are some… medications. See you in 3 months.’’ It felt like they assumed… I am ready just to go off. A second subtheme in this area was that participants reported that staff did not recognize their feelings or

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emotions. After describing staff who disregarded his opinions, Jesse said, ‘‘We have thoughts, feelings, and emotions just like everyone else does.’’ Family members whose responses fell into this second subtheme told about incidents when their family members should have received apologies from staff but did not. No other intersectionsrelated patterns emerged regarding experiences with this theme. Condescension/Lack of Respect Participants reported treatment conveying condescension or lack of respect. Sometimes condescension was evident through the subtheme manner of speech. For example, family member Josh said that staff ‘‘talk to me sarcastically, then act like they don’t have to talk to me like a normal person because I’m there with someone [who has a mental illness].’’ Illustrating manner of speech and the second subtheme treated like children, family member Sally described her treatment when staff assumed she had a mental illness: I noticed the difference in the tones; I noticed the difference in the way they spoke to me. The one that thought I was SMI used very small words; the other used regular words, talked to me [at an] adult level. Thomas said, ‘‘They often try to intercede on my behalf and do things for me, rather than empower me to do things for myself,’’ and Mike and Jesse both said they were ‘‘yelled at’’ like they were ‘‘children.’’ A few participants reported use of disrespectful language (e.g., ‘‘crazy’’ to refer to PWMI) that indicated condescension and lack of respect. Two patterns emerged regarding the theme of condescension/lack of respect. Almost all of the participants who had worked in MHTPs described condescension/ lack of respect, and all of the men in the sample but no woman with a mental illness discussed this theme. Violations of Privacy or Other Rights Participants expressed concerns with violations of rights, including HIPAA violations. For example, Gerard told of overhearing staff talking in the hallway about a fellow inpatient. Family member Ann described a situation her partner experiences: Additionally, when she goes in for the blood draw, you’re in a communal room! And they’re [discussing her medications]…. [S]he… tells me how uncomfortable she is with that…. [E]ven if I don’t have an anxiety disorder, I’m not gonna like it. No intersections-related patterns emerged regarding rightsrelated discrimination.

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Presumed Lack of Intelligence Finally, participants described incidents that they perceived as indicating that staff assumed they were not intelligent. As Thomas said, ‘‘[P]eople would often explain things very… elementary when I was able to grasp complex concepts quite easily.’’ Lynn told about her psychiatrist refusing to consider her opinion when the psychiatrist wanted to make a drastic change in her medications. She said that her thoughts were ‘‘Look, I’m not stupid…. I may have this diagnosis and all that… but I’m also smart enough to know what’s going on and how [the medications are] working.’’ Analysis of patterns revealed that content in this theme emerged primarily from narratives of participants who had at least a bachelor’s degree or were men. Discrimination Related to Race/Ethnicity When asked whether they had experienced mental illness discrimination, the majority of the participants of color also reported racist discrimination. For example, in describing the lack of race- or ethnic-specific services, family member Chanel said it ‘‘may not be a blatant prejudice’’ but gives the appearance that the system may not ‘‘really be as concerned with’’ communities of color. Some participants found the lack of staff of color problematic. For example, Gerard said that Mexican American women would be less likely to seek services because there are few such women in professional positions. L’s discussion indicated that she assumes that only a Native American psychiatrist can treat Native Americans: Native American people have no one to turn to and there is only one [Native American psychiatrist at the program I attend] trying to take care of everybody…. One. And he is trying to take on the whole thing and I know he can’t. Conversely, family member Sally said individual staff can be a good ‘‘fit’’ for families of color regardless of their race or ethnicity. Some participants asserted that they are not treated as well as whites. For example, Native American Martin described his efforts to determine whether his negative treatment by receptionists was due to his mental illness, his weight, or his race: You know you can just feel… the aura as of like, ‘‘Aye, you’re here’’ [using a ‘‘Who cares?’’ tone]. At first I thought maybe it’s because… ‘‘Well, I’m here at the loony doctor.’’… But like a few minutes later… she greets someone else that… could be the same body structure, but the difference was that he was white. She just kept talking up a storm [with him]….

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And this has happened… not only in one setting, but… over time. Some participants said staff engaged in racial stereotyping. For example, as described above, some staff insisted that family member Sally had depression. When she asked a provider why he had that inaccurate assumption, he said, ‘‘… because you’re a single mom. You’re a single Mexican mom.’’ Although M described examples of racism and mental illness discrimination, she also described a positive racespecific aspect of a facility, saying that posting flyers about this study and other information focusing on people of color ‘‘shows that they care.’’ She explained that these posts make her feel that being a Native American with a mental illness ‘‘is not a bad thing.’’ Discrimination Related to Sexual Orientation LGB participants reported experiences with heterosexist discrimination in MHTPs. Among comments were that LGB PWMI experience a ‘‘double stigma and prejudice’’ (Gerard), staff and clients did not want lesbian partners ‘‘hanging out’’ together (L), and that ‘‘being gay’’ was an ‘‘issue’’ with some Native American staff at one facility (Martin). In addition, Martin told about being suspected of sexual misconduct at a facility for adolescent males, saying that ‘‘they still have that stigma [that] you’re gay so you’re a pervert or you’re going to prey on people.’’ Robert, who is gay, discussed the consequences of ignoring sexual orientation: I call it discrimination because they don’t take into mind your sexuality…. I think there should be some counseling involved to prepare [gay clients] to be themselves [as gay] and to accept their [diagnosis], because it’s kind of like a double whammy. In contrast, Bernadette said that her lesbian identity helps her feel welcome in her workplace despite being the only employee who identifies as having a mental health condition: ‘‘I am the first [peer mentor] they have had…. I don’t feel like I am a guinea pig or anything, because… there’s other lesbians.’’ Family member John, who identifies as gay, said that the system no longer discriminates against LGBT individuals. He described multiple efforts to counter heterosexism and transgender discrimination, including workshops for staff. Intersecting Identities: Mental Health Condition, Race/Ethnicity, and Sexual Orientation Demonstrating the complexities of attributing discrimination to only one of their simultaneous identities, some

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participants focused on their intersecting identities when describing discrimination within MHTPs. For example, when asked if they had observed or experienced mental illness discrimination, many participants first described incidents related to race, ethnicity, sexual orientation, or gender in addition to, or rather than mental health conditions. For example, Gerard, a gay Mexican American, told about feeling a connection with a Mexican American provider, then feeling ‘‘dissonance’’ when she overtly ridiculed a lesbian client; he deemed her behaviors as reflecting both heterosexism and mental illness discrimination. He described his reactions to this experience: It was like ‘‘Wow!’’… Because… you identify with both of [them]…. and for myself, it’s all of who I am. I’ve always had to split myself into piecemeal, my true identity like that, that’s how I survived here [in the mental health service system], and like every day I still do that. Martin’s response to learning of this study suggests that he feels a sense of isolation in MHTPs: ‘‘I saw this [announcement]…. I’m like, ‘Hey this is interesting [sounds excited]!’ I was like, this is the first time I’ve seen something that… combines all three [identities].’’ Efforts to Decrease Mental Illness Discrimination When asked if they were aware of efforts of MHTPs to fight mental illness discrimination, only about one-third of the participants said yes. Individual-level efforts focused on supportive behaviors of individual staff. Organizationlevel examples included the existence of training about respectful language and that national and local peer- and family-led organizations are working for change. Family member John explained, ‘‘I think the system looks to the peer and family organizations to… champion that cause.’’ Gerard’s perception was that peer-runs have focused on this problem, but that professionals have resisted supporting peer-led efforts. Lynn’s perspective was ‘‘I don’t necessarily [think MHTPs are] teaching other people to be less judgmental [disappointed-sounding laughter], but just teaching people who are mentally ill perhaps to deal better.’’ Helpful Aspects of Mental Health Treatment Programs Participants were asked to describe aspects of MHTPs that had been helpful in supporting their or their family members’ recovery. With the exception of one family member, all participants described at least one helpful aspect. (Peerand family-run programs were described as helpful, but are not the focus of this paper.) The most commonly

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mentioned helpful aspects were talk therapy, case managers, respectful medical staff, medication, a team approach, and support groups. No responses about case managers described provision of or referral to ‘‘hard’’ services. Instead, they described caring attitudes, such as ‘‘she wants to support me and be there for me when I go through my rough times’’ (Jasmine); ‘‘… even though he was keeping the boundaries he had that kind of like, ‘big brother’ feel, that I could talk to him’’ (Martin); and ‘‘They just told me that they’re proud of me, that’s all’’ (Q). In describing respectful medical staff, participants often contrasted respectful treatment by current providers with previous negative treatment. For example, family member Ann said, I want to hear ‘‘I understand you’re upset, I can understand why. I feel I’ve made a mistake.’’… I didn’t get that [from the previous psychiatrist. The current psychiatrist asks her partner,] ‘‘What do you think?’’…. There is some respect…. This is a partnership…. Similarly, Gerard was pleased that his current nurse practitioner ‘‘gave me a 5-page summary of the medications I was taking. She [said], ‘This is what I know. You go from there.’… [She asked me,] ‘Do you notice patterns?… I am asking you this because of this, this, and this.’’’ Participants who said that medications were helpful all were PWMI and those who said the team approach was helpful all were family members. For family member Chanel, attending team meetings helped her assess the quality of her brother’s team and learn how he was doing so she could support him. No other patterns emerged.

Discussion Consistent with previous research (e.g., Angell et al. 2005; Charles 2013; Schulze and Angermeyer 2003), this study found that PWMI perceive that they are targets of mental illness discrimination in MHTPs. It may seem illogical that mental health professionals and organizations whose purpose is to serve PWMI might exhibit mental illness discrimination. Providers might be tempted to assume that the perceptions of participants in this and previous studies are inaccurate, reflect erroneous attributions of the causes of (mis)treatment, or occur only in isolated programs. But as Heflinger and Hinshaw (2010) state in considering services for children and youth, ‘‘… without acknowledgment of the strong possibility of professional and institutional stigma… it will be extremely difficult, if not impossible, to provide for optimal mental health care’’ (p. 67). Several important findings emerged from this study. It is encouraging that all PWMI and all but one family member

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identified recovery supports in MHTPs. Based on many statements that current providers are more respectful than previous staff, it appears that improvements have been made. We learned that team meetings were important for families, though PWMI did not mention this aspect as helpful. Many of our findings about mental illness discrimination in MHTPs are consistent with those of previous studies (Angell et al. 2005; Charles 2013; Gonzales et al. 2015; Schulze and Angermeyer 2003). New findings include reports that staff discriminate against PWMI by physically ignoring them and violating privacy or other rights; both of these behaviors appear to be microinsults [i.e., unconscious behaviors that are demeaning or rude (Sue 2010)]. These microaggressions may be related to participants’ intersecting identities—providers may be more likely to engage in these behaviors toward PWMI of color, or LGB PWMI, or LGB PWMI of color, for example—though research with samples that include white heterosexual PWMI is needed to consider this interpretation. Our focus on multiple identities yielded significant information. Because participants were alert to discrimination related to multiple identities, identifying discrimination related to mental health status was complicated. The complexities were apparent when the first responses of some participants to a question about mental illness discrimination were descriptions of racist, heterosexist, or sexist discrimination, though with clarification that the interviewer wanted to hear if they had experienced mental illness discrimination all but one participant described experiences with or observations of this type of discrimination. Martin’s narrative describing his attempt to discern the cause of his mistreatment further demonstrates these complexities and illustrates Sue’s (2010) description of the energy expended in trying to assign attribution when microagressions occur in ambiguous situations; this experience likely is common among other PWMI who are of color and/or LGB and may reduce their willingness to engage with the system. Looking at identity intersections, we found that LGB PWMI may experience a ‘‘double stigma’’ (Gerard) or ‘‘double whammy’’ (Robert) that is ignored by MHTP providers. This finding requires further examination, in that Gerard and Robert are gay PWMI of color, but they did not refer to a ‘‘triple stigma.’’ It is possible that the continued overtness of heterosexist and mental illness discrimination leads to a stronger need to support positive identity development for LGB PWMI of color, particularly if they experience heterosexism within their racial/ethnic communities (Balsam et al. 2011). Further, consistent with the microinvalidation construct (Sue 2010), participants perceived that ignoring their race, ethnicity, or sexual orientation was a form of discrimination. Some people of color

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cited the lack of staff of color and racial/ethnic-specific programming as forms of discrimination; LGB participants explained the importance of offering counseling to assist LGB PWMI in affirming multiple identities. Contrary to expectations, no differences emerged in experiences with mental illness discrimination within MHTPs related to participants’ racial, ethnic, and sexual orientation identities. This finding may be related to participants’ reports that providers ignored the importance of these identities in their lives. If providers view PWMI as ‘‘all the same,’’ they may engage in similar mental illness discrimination regardless of other identities. If future studies find that PWMI who are of color and/or LGB are more likely than white heterosexuals to be physically ignored and to experience rights violations (see above), then this interpretation will need to be reconsidered. Three patterns related to gender, education, employment experience, and PWMI versus family status emerged. First, participants who had worked in MHTPs talked about condescension as a form of mental illness discrimination and those with at least a bachelor’s degree were more likely to report presumed lack of intelligence. We assume that earning a college degree or being an employee leads one to expect better treatment and thus to notice these behaviors. Second, most of the narrative content indicating presumed lack of intelligence and condescension/lack of respect was from men. It is possible that women experience less of these forms of discrimination in MHTPs. Consistent with our framework, however, we posit that systemic oppression exposes women to condescension in various arenas in their lives (Frye 1983), thus rendering such treatment within MHTPs unremarkable and unnoticed. Finally, family members said that providers did not apologize for disrespectful treatment. The fact that no PWMI mentioned deserving apologies—despite reporting multiple experiences with discrimination—may suggest that because they experience mental illness discrimination in multiple areas of their lives, they have come to expect it in all settings. This interpretation is supported by Martin’s initial assumption that he was being mistreated because he was at ‘‘the loony doctor.’’ Our critical framework is useful in understanding the themes that emerged from the data. Four of the themes related to mental illness discrimination—condescension/ lack of respect, presumed intellectual inferiority, ignoring/ not listening, and not treating PWMI as complex individuals—appear to be microaggressions due to cultural imperialism, in which staff accept society’s social construction of PWMI as inferior and engage in stereotyping and degrading treatment (Young 1990). Being yelled at by staff may be evidence of violence (Young 1990) and rights violations appear to be evidence of marginalization (Young 1990). Our framework suggests that these instances of

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apparent discrimination may well be unintentional and unconscious on the part of providers. Consistent with a critical framework, findings suggest that organization-level discrimination also is present within MHTPs. Descriptions of providers focusing on filling out forms rather than listening to PWMI, offering only medications when other services were desired, discussing medications in a communal room, leaving anti-discrimination efforts to peer- and family-led programs or focusing on helping PWMI deal with discrimination rather than on decreasing its prevalence, and lacking race/ethnic-specific services and staff of color all suggest organization-level issues. That is, it appears that some organizations that are created to serve PWMI and their families may not be responsive to the priorities of these constituents, evidence of organization-level microinvalidation. These microinvalidations likely are unintentional and may be due in part to societal-level discrimination that leads to underfunding for programs that serve PWMI and their families. Still, underfunding alone would not explain these findings. For example, an organization’s acceptance of the medical model with its focus on expert provider/passive patient as suggested by some of our findings (e.g., not listening to PWMI) could suggest that its ideology accepts that PWMI are not competent experts about their own experiences, thus inevitably contributing to the maintenance of oppression where mental illness discrimination is justified and/or accepted. Several limitations of this study are important to consider. No transgender individuals participated and the convenience sample was drawn from one U.S. southwestern state. The sample was diverse in race, ethnicity, gender, sexual orientation, PWMI/family member status, and age, but future studies are needed to examine experiences of PWMI and family members at particular intersections of identities (e.g., Mexican American lesbians, Mexican American heterosexual women) and to consider additional identities (e.g., social class, gender identity/expression, physical disability status) and their intersections. All participants were out to providers as LGB and/or members of their racial/ethnic groups and all were participating in public MHTPs; their experiences likely are different from those who conceal these identities and/or do not participate in public MHTPs. Participants discussed racism, heterosexism, and mental illness discrimination even though the interviewer appears to be white and did not disclose her identities related to groups that were the focus of this study. Participants may have underreported experiences with discrimination if they assumed she is white, heterosexual, and not a person with a mental illness or family member. No member checking was conducted and the sample did not include MHTP professional staff. In addition, rather than asking participants whether they perceived that their racial, ethnic, sexual orientation, or other identities affected

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their experiences with mental illness discrimination, we looked for themes that emerged from the data; future studies might directly pose this question. Further, each participant was interviewed only once; it is possible they would have reported additional instances of discrimination, supports, and anti-discrimination efforts had they been interviewed multiple times with the opportunity to consider these topics between interviews. Finally, those who are more concerned with issues related to multiple identities and discrimination may have been more likely to participate; their perspectives, however, are critical for informing system change. Implications for Practice It appears that MHTPs include providers who are respectfully serving PWMI and family members who are of color and/or LGB. Our findings, however, suggest the need for improvement in several areas. First, training is needed to educate staff about behaviors, such as those described in this study, that are perceived as discriminatory. Professionals with mental illnesses might be particularly effective in leading training, though we are aware of the risks involved in disclosure of mental health conditions by professionals (Hyman 2008). Training might focus on concepts from a critical framework, including that discrimination can be intentional or unintentional; may take the form of microaggressions; can be present at individual, organization, and societal levels; and may be present even among providers who are ‘‘committed to equality and respect’’ (Young 1990, p. 134). Without organization-level initiatives, however, it is unlikely that staff training will lead to lasting change. MHTPs need to consider additional aspects of their organizations. For example, does the organization prioritize the views of ‘‘experts’’ over those of service participants? Does it actively recruit, mentor, and promote PWMI—including those who are LGBT and/or of color—to serve in leadership roles? Has it developed alliances with peer- and family-led organizations with aims of integrating their expertise and partnering in social change efforts? Findings also suggest that MHTPs need to feature staff of color and race/ethnicity-specific programs. Until these are available, all staff need to learn about cultures and issues affecting the communities they serve and develop skills in working across racial and ethnic difference. Information about avoiding microinvalidations and microinsults are of critical importance. LGB participants specified that providers need to recognize the importance of their sexual orientation identities; not doing so is evidence of microinvalidation by providers. Staff thus need to learn about issues confronting LGB PWMI and consider these identities when developing programs and service plans. Further, this study points out

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the importance of considering multiple intersecting identities when working with PWMI. For example, programs focusing on people of color must recognize that people of color may be LGB, and programs centering LGB individuals need to consider the effects of being members of particular communities of color. Finally, our critical framework stresses that micro-level discrimination reflects macro-level oppression (Cole 2009) and thus requires macro-level change. Actors within MHTPs need to work with PWMI and their families to advocate for social justice by addressing oppressive structures. These foci for change need to include cultural (e.g., stereotypes) and institutional (e.g., media, workplace, legal system) practices that contribute to the system of inequality that leads to and supports discrimination against PWMI within MHTPs. Implications for Research Studies are needed to build on and address the limitations of this study. Studies also are needed to assess the effectiveness of efforts to reduce discrimination within MHTPs. What content, staffing, and format are most effective in educating providers so they recognize and change what may be unconscious, unintentional microaggressions directed toward PWMI who are of color and/or LGB? What practices and policies have been implemented that members of these identity groups consider effective in improving MHTPs? Finally, research is needed to learn what components of racial/ethnic- and sexual orientationspecific programs are considered most helpful by PWMI and their families—including those who are both of color and LGB. Which elements can be used in programs that serve communities that are too small to warrant development of identity-specific programs?

Conclusion Mental health treatment disparities for PWMI who are of color and/or LGB make it critical to understand factors that may decrease their participation in or satisfaction with MHTPs. Unfortunately, little research is available to inform efforts to effectively engage and serve members of these identity groups. We hope that findings and implications from this study are helpful in addressing this critical issue.

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