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Stigma of Mental Illness Among Ethnic Minority Populations American Indians: 

Stigma of Mental Illness Among Ethnic Minority Populations American Indians Donna Grandbois, M.S., R.N. June 27, 2004 SAMHSA-MFP Fellow This research was supported by the Substance Abuse & Mental Health Services Administration (SAMHSA), the College of Nursing, University of North Dakota & The Otto Bremer Foundation

This research focuses on Northern Plains Indians in the upper Midwest. Four tribal nations in two states are included in this study.: 

This research focuses on Northern Plains Indians in the upper Midwest. Four tribal nations in two states are included in this study.

Research Objectives : 

Research Objectives Identify cultural responsiveness of mental health service providers for American Indians (AI) utilizing the Indian Health Service System (IHS) Briefly describe how federal funding impacts mental health care Identify how stigma of mental illness can function as a barrier to access to care

A Perspective on American Indians: 

A Perspective on American Indians Evidence indicates Indigenous Peoples, AIs, have inhabited North America for more 75,000 years Population consists of 2.4 million people or less than 1 % of the US population Approximately 558 sovereign tribes reside in the US, with over 1,000 distinct languages, many proud & unique traditions and cultures, various population sizes with people located throughout the US (Josephy, 1991, Walters, Simoni, Evans-Campbell, 2002.)

Distribution of American Indians among States : 

Distribution of American Indians among States Alaska 16.4% New Mexico 9.5% South Dakota 8.2% Oklahoma 7.8% Montana 6.5% Arizona 5.5% North Dakota 4.8% Wyoming 2.3% Washington 1.8% Nevada 1.8% (Population Estimates Program, Population Division, US Census Bureau, August 2000)

Too many health disparities exist Among American Indians : 

Too many health disparities exist Among American Indians Less access and availability to health services A poorer quality of all health services is evident Health service eligibility could include life or limb test Evidenced-based research is sparse Same disorders exist, with greater prevalence & severity among AIs when compared with any other American population group (Mental Health: Culture, Race and Ethnicity, Smedley, 2003)

Health Disparities are linked to: 

Health Disparities are linked to A history of trauma, marginalization, oppression, & cultural genocide AIs are the “poorest of the poor” Most AIs (98 %) served by IHS meet federal poverty guidelines More than half of AI Elders live in poverty AIs receive the lowest health care dollar allocated by the Department of Health & Human Services

A Glimpse at the Health Status of American Indians: 

A Glimpse at the Health Status of American Indians Alcoholism is 638 % higher than the general US population Tuberculosis is 400 % higher than the US population Diabetes mellitus is 291 % higher than the US population Accidents are 215 % higher than the US population Suicide is 81 % higher than the US population Homicide is 81 % higher than the US population (Ref at bottom) (Indian Health Service, Trends in Indian Health (2000)

American Indians have the lowest life expectancy in the Western hemisphere (Walker, R.D., 2003) : 

American Indians have the lowest life expectancy in the Western hemisphere (Walker, R.D., 2003) Courtesy of River Trading Post

Research was approved by the Indian Health Service & the University of North Dakota Board for the Protection of Human Subjects: 

Research was approved by the Indian Health Service & the University of North Dakota Board for the Protection of Human Subjects Opinions expressed in this presentation are those of the researchers and do not necessarily reflect the views of the Indian Health Service

Study was designed with Three Phases: 

Study was designed with Three Phases Phase I: Determine if AIs with chronic mental illness (CMI) are receiving culturally responsive mental health care as perceived by providers Phase II: Determine the perceptions of health & health seeking behaviors of AIs experiencing CMI in the community/reservations [In process] Phase III: Develop culturally competent, comprehensive mental health care programs for AI nations

Qualitative study with grounded theory: 

Qualitative study with grounded theory Qualitative Tools Audio-taped interviews Semi-structured interview guide Focus groups were used to validate our findings Quantitative approaches Descriptive statistics

In phase I the Following Health Care Providers were Interviewed: 

In phase I the Following Health Care Providers were Interviewed MLCSW n = 6 Mental Health Tech n = 4 Psychiatrist n = 2 Psychologist n = 5 Social service Rep n = 2 N = 29 Community health Rep (CHR) n = 2 Child development Specialist n = 1 Administrators, Unit Directors, Public Health Nurses) N = 7

Phase I: Findings Services Available : 

Phase I: Findings Services Available Outpatient Crisis management (crisis call, walk-in, emergency department) Acute care & stabilization (2 of 5 sites) Limited case management Long term care at state institutions

Phase I Findings: Four Most Common Diagnoses Treated: 

Phase I Findings: Four Most Common Diagnoses Treated Depression Anxiety Post Traumatic Stress Disorder Suicide Management

Phase II Focused on Individuals with Chronic Mental Illness : 

Phase II Focused on Individuals with Chronic Mental Illness Population N = 44 American Indians with CMI were interviewed We were interested in determining the perceptions about mental health management from clients who received their mental health care through the IHS System

Preliminary findings from Phase II: 

Preliminary findings from Phase II Political & bureaucratic structures profoundly impact the delivery of health care, including Bureau of Indian Affairs States Indian Health Service Tribal Nations

IHS Does not Adequately Address Mental Health Needs of Indian people as Reported by Clients with Mental Illnesses : 

IHS Does not Adequately Address Mental Health Needs of Indian people as Reported by Clients with Mental Illnesses Reported Concerns Issues around access to services Crisis management; Urgent care Delay in treatment seeking Integration of traditional & Western models for mental health care Lack of family involvement in client care

Treatment Delivered Could Re-Traumatize AIs & Provoke Negative Outcomes Based on Their: 

Treatment Delivered Could Re-Traumatize AIs & Provoke Negative Outcomes Based on Their Boarding School Experiences Previous History of Trauma Fear & Insecurity Daily Struggles Related to Poverty, Disenfranchisement & Alienation

Cultural Perceptions Support Stigma: 

Cultural Perceptions Support Stigma Belief that the person has “bad spirits” or that “bad medicine” was used If a person is crazy he or she should go live in the state hospital Mental illness puts a bad name on the family: illness in genes or family bloodline Family members are embarrassed by their ill member’s behavior

Stigma is a Major Barrier to Mental Health Care Among AIs: 

Stigma is a Major Barrier to Mental Health Care Among AIs Lack of socialization among clients: Creates isolation and loneliness Eliminates peer support Disturbs self-esteem Perpetuates Stigma

Stigma on the Reservation is Expressed in Various Ways: 

Stigma on the Reservation is Expressed in Various Ways Stigma is maintained & perpetuated through close tribal communities & connectedness Privacy is protected by denying the presence of mental illness, thereby maintaining the unspoken rule about not talking about mental illness The ill person needing services will “try to handle problems alone”, so not to be a burden AIs are socialized to handle their problems & avoid becoming a burden to their families

Stigma is demonstrated by : 

Stigma is demonstrated by Silence & discomfort that permeates council meetings when issues about mental illness are presented Example: A tribal leader commented, “Do we have that here?”. . . meaning mental illness Tribal leaders prefer to talk about alcoholism or imprisonment rather than mental illness

Implications for clinical practice: 

Implications for clinical practice Health education should focus on overcoming stigma, & include family centered approaches Employment should be a component of treatment Traditional healing ought be integrated into individual health plans as AIs rate healers’ advise higher (61.4%) than that of other providers (Mental Health: Culture, Race, and Ethnicity, 1999 ).

Implications for public policy: 

Implications for public policy Programs that link community need to budget allocations are necessary to eliminate mental health disparities Mutual Goal Setting among Agents and Agencies should be developed, and include Bureau of Indian Affairs Indian Health Service Tribal Leaders State Public Health Authority Support a Comprehensive Plan of Care Require Cultural Competence Among Providers Support and Educate Stakeholders for Mental Health, Employment Opportunities, Enhanced Academic Achievement

Implications for future research: 

Implications for future research Co-Occurrence of PTSD, Anxiety & Alcoholism Should be Explored from the Perspective of AIs as Trauma Survivors American Indian Resilience and Adaptive Coping Ought be Extensively Researched Determine the Efficacy of AI Healing Practices & their Potential for Practical Implementation with this Population

Thank You: 

Thank You Eleanor Yurkovich, PI, EdD, RN; Donna Grandbois, Co-Investigator, MS, RN; Izetta Hopkins-Lattergrass, B.A. Jessica Clairmont, BSN, RN Sara Roy, BSN, RN

As long as the moon shall rise, As long as the rivers flow, As long as the sun will shine, As long as the grass shall grow … : 

As long as the moon shall rise, As long as the rivers flow, As long as the sun will shine, As long as the grass shall grow …

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