Perceptions of Mental Health Stigma and Discrimination in a Mexican American Sample

1. Perceptions of Mental Health Stigma and Discrimination in a Mexican American Sample Presented: 11/09/2011 Latino Behavioral Health Conference By Jeff D. Wright, Ph.D.

2. What is Stigma • Word originally referred to the mark or brand that was put on Greek slaves to separate them from free men • “An attribute that is deeply discrediting… A sign of disgrace or discredit which sets a person apart from others.” – Goffman, 1963

3. Examples of Stigma Stigma of Physical Handicaps Physical disabilities have been found to be highly stigmatized conditions. Saetermoeand colleagues (2001) found that the severity of a disability, especially physical disabilities, have a strong impact on how they are perceived by others. Murphy (1995) reported that individuals with physical disabilities experienced significant stigma in the form of discrimination(i.e. employment) and social rejection (i.e. limited social circle).

4. Examples of Stigma Stigma of Obesity The negative attitudes that reinforce the stigmatization of obese individuals are accepted, and even encouraged, in American society. Stigmatization of the obese is reinforced through the media, cultural beliefs, and societal perspectives on individuals who are obese (Wang, Brownwell, & Wadden, 2004). Research has consistently shown that stereotypes consistently view obese individuals as lazy, undisciplined and unhappy (Hebl and Turchin, 2005) . Obese individuals are discriminated against in professional and employment arenas (Hebl & Kleck, 2002; Roehling, 1999).

5. Background Link’s Theory of Stigma Stigma exists when the following interrelated components converge: People distinguish and label human differences. Dominant cultural beliefs link labeled persons to undesirable characteristics and negative stereotypes Labeled persons are placed in distinct categories so as to accomplish some degree of separation of “us” from “them” Labeled persons experience status loss and discrimination that lead to unequal outcomes. Thus, we apply the term stigma when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows them to unfold(Link and Phelan, 2006).

6. Background At any given time 20% of the population of the United States has a diagnosable mental disorder (DHHS, 1999). 66% of people with diagnosable mental disorders do not seek treatment Stigma was one of the foremost barriers to not seeking treatment (DHHS, 1999). Of treatment seekers, 74% prefer to receive treatment from their primary care physician, as opposed to a mental health professional (Ben-Porath, 2002; Regier, Hirschfeld, Goodwin, & Burke, 1988). Some evidence suggests that minorities are at increased risk for experiencing mental health problems due to stress associated with minority status. Minorities are underrepresented in mental health treatment. It is believed that this underutilization of services is, in part, due to the stigma of mental health. Paucity of research on minority groups, such as Mexican Americans and the stigma of mental health.

7. Brief Background Ethnic Differences and the Stigma of Mental Health Problems There is a lack of studies in the literature focusing on racial or ethnic differences In a study using college students it was found that African-Americans and Latinos held more negative views of mental health problems than their white counterparts (Silva de Crane & Spielberger, 1981). Saetermoeand colleagues (2001) found Asian American participants tended to be more stigmatizing toward physical and mental disabilities than African American, Latinos, or White non-Hispanic European Americans.

8. Brief Background Ethnic Differences and the Stigma of Mental Health Problems Not all ethnic minority groups stigmatize mental health to the same degree, such as some Native American cultures View an individual’s disability as being minor Tended to focus less on the disability and more on the contribution the person makes to the overall society (Groce & Zola, 1993). Other data regarding the stigma of mental health problems among ethnic groups has been found to be mixed. One study found Hispanics who have a disabled child, either physically or mentally, view themselves as chosen by God to raise that child because they would be able to care for that child (Mardiros, 1989). Others have found that Hispanics tended to stigmatize mental health more than severe physical disabilities, as compared to other ethnic groups (Saetermoe et al., 2001).

9. To what extent are mental health problems stigmatized in Mexican American culture and what factors are associated with the stigma of mental health problems? Statement of the Problem

10. What is the need for this research? • Hispanics are the largest minority group in the U.S. and Mexican Americans constituted 63% of the Hispanic category. • Empirical data on Mexican Americans and their stigmatizing attitudes toward individuals with mental health problems are limited. • Limited research has been conducted on gender differences among minorities and the stigma of mental health. • Lack of research examining Mexican American acculturation level and the stigma of mental health. • Lack of research targeting Spanish speaking Mexican Americans. • Understanding stigma aids in the quality and provision of care to ethnic minorities, especially in the mental health arena. Justification of the Study

11. Research Questions Research Question #1: Do Mexican Americans and White non-Hispanic European Americans differ in the stigma of mental health. Research Question #2: Do Mexican American and White non-Hispanic European American males and females differ in the stigma of mental health. Research Question #3: Is Mexican American acculturation level related to the stigma of mental health. Research Question #4: Is Mexican American age, years of education, participation in counseling and/or mental health services, and level of perceived ethnic discrimination related to the stigma of mental health.

12. Methodology

13. Participants A total of 550 individuals completed the survey. 507 met the original criteria for the study: 18 years of age and older self-identified as Mexican\Mexican American male or female or self-identified as White non-Hispanic European American male or female Recruited from two cities in the southern part Idaho

14. Number of Participants by Ethnicity, Language and Gender English Spanish Total Participants Ethnicity/Race Female Male Female Male N % Asian American 4 2 - - 6 1.1 African American 2 2 - - 4 .8 Mexican American 84 39 57 46 226 41 White non-Hispanic European American 171 89 - - 260 47 Native American 6 1 - - 7 1.2 Total 267 133 57 46 503 91

15. Number of Participants by Ethnicity and Generation Level Generation Level Participants Total Ethnicity/Generation 1st 2nd 3rd 4th 5th Unknown 6 Asian American 1 - 3 1 - 1 4 African American - - - - 4 - 222 Mexican American 107 51 16 21 8 19 252 White non-Hispanic European American 7 5 25 48 151 16 7 Native American - - 3 1 2 1 Total 115 56 47 71 165 37 491

16. Number of Participants who have had Counseling and/or Mental Health Services (MHS) by Ethnicity and Gender Counseling MHS Participants Ethnicity/Race Female Male Total Female Male Total Asian American 4 2 6 1 1 2 African American 2 1 3 - - 0 Mexican American 42 23 65 17 8 18 White non-Hispanic European American 105 52 157 46 22 68 Native American 4 - 4 3 - 3 Total 157 78 235 67 31 93

17. Mean and Median for Age and Years of Education by Ethnic Group Age Education Participants Ethnicity/Race Mean Median Mean Median Asian American 41.2 35.5 13.6 13 African American 27.8 22.5 11.5 11.5 Mexican American 36.1 34 11.2 12 White non-Hispanic European American 41.6 40 15 16 Native American 31.9 30 13.3 12 Total 39 37 13.2 13

18. Measure # Items Scale Internal Consistency Reliability Self-Stigma of Seeking Help scale (SSOSH) 10 5-point Likert scale 1(strongly disagree) to 5 strongly agree) 0.86 – 0.90 Measures Social Distance scale (SDS) 8 4-point Likert scale 0(definitely willing) to 3(definitely unwilling) 0.92 Multigroup Ethnic Identity Measure – Revised (MEIM-R) 6 5-point Likert scale 1(strongly disagree) to 5 (strongly agree) .83 Brief Perceived Ethnic Discrimination Questionnaire – Community Version (Brief-PEDQ-CV) 17 5-point Likert scale 1(never) to 5(very often) 0.70 – 0.87 Language Proficiency Subscale (LPS) 12 4-point Likert scale 1(very poorly) to 4(very well) .97

19. Reliability Coefficients and Descriptive Statistics for Survey Measures with Mexican Americans Participants Measures # of Items Cronbach’s Alpha M (SD) Min. – Max. Self-Stigma of Seeking Help scale a 10 .63 2.55(.26) 2.15 – 2.97 Social Distance Scale b 8 .82 1.28(.28) .962 – 1.69 Brief Perceived Ethnic Discrimination Questionnaire – Community Version c 17 .90 1.99(.38) 1.42 – 2.74 Language Proficiency Subscale d 12 .85 3.10(.25) 2.75 – 3.45 Multigroup Ethnic Identity Measure – Revised e 6 .91 3.50(.18) 3.19 – 3.69

20. Reliability Coefficients and Descriptive Statistics for Survey Measures on the White non-Hispanic European Americans Participants Measures # of Items Cronbach’s Alpha M (SD) Min. – Max. Self-Stigma of Seeking Help scale a 10 .87 2.45(.25) 1.99 – 2.82 Social Distance Scale b 8 .85 1.22(.51) .686 – 2.04 Brief Perceived Ethnic Discrimination Questionnaire – Community Version c 17 .94 1.62(.28) 1.20 – 2.36 Language Proficiency Subscale d 12 .82 2.65(1.31) 1.32 – 3.93 Multigroup Ethnic Identity Measure – Revised e 6 .90 3.20(.15) 3.07 – 3.48

21. Results

22. SSOSH Factor Analysis – White non-Hispanic

23. SSOSH Factor Analysis – Mexican Americans

24. Research Question #1: Do Mexican Americans and White non-Hispanic European Americans differ in the stigma of mental health, as measured by the SDS? Hypothesized that Mexican Americans and White non-Hispanic European Americans would differ on SDS. Results for the main effect of ethnicity did not support the hypothesis. Mexican Americans (M = 10.06, SD = 4.80) White non-Hispanic European Americans (M = 9.72, SD = 4.06) F (1,476) = .158, p = .692.

25. Research Question #2: Do Mexican American and White non-Hispanic European American males and females differ in the stigma of mental health, as measured by the SDS? Hypothesized that males and females would differ on the SDS. Results for the main effect of gender did not support the hypothesis. males (M = 9.87, SD = 4.73) - females (M = 9.88, SD = 4.42) F (1,476) = .017, p = .896. Hypothesized a significant interaction between gender and ethnicity with Mexican American males desiring significantly more social distance than Mexican American females and White non-Hispanic European American males and females. Results did not support the hypothesis. Mexican American males (M = 9.62, SD = 4.73) - Mexican American females (M = 10.34, SD = 4.84), White non-Hispanic European American females (M = 9.51, SD = 4.03) - White non-Hispanic European American males (M = 10.11, SD = 4.09). F (1,476) = 2.44, p = .119.

26. Research Question #2: Tested for gender differences on SSOSH within the White non-Hispanic European American group. Results of the statistical analysis supported the prediction that there would be a gender difference. White non-Hispanic European males (M = 26.00, SD = 6.89) - females (M = 23.44, SD = 7.32) t (256) = 2.72, p = .007.

27. Research Question #3: Is Mexican American acculturation level related to the stigma of mental health; as measured the SDS? Hypothesized that Mexican Americans’ language proficiency would be associated with the SDS. Results did not support the hypothesis. r (234) = -.04, p = .56. Hypothesized that Mexican Americans’ level of ethnic identity would be related to the SDS. Results did not support the hypothesis. r (182) = .07, p = .35. Hypothesized that Mexican Americans’ generation level would be associated with the SDS. Results did not support the hypothesis. tau-b (218) = -.06, p = .22.

28. Research Question #4: Is Mexican American age, years of education, participation in counseling and/or mental health services, and level of perceived ethnic discrimination related to the stigma of mental health, as measured by help-seeking attitudes and the amount of social distance from individuals with mental health problems? There was a statistically significant correlation between age and the amount of social distance desired from individuals with mental health problems for Mexican Americans, r (219) = .17, p = .01. No statistically significant relationship between level of education and the amount of social distance desired from individuals with mental health problems for Mexican Americans, r (216) = -.04, p = .52. No statistically significant correlation between participation in counseling and the amount of social distance from individuals with mental health problems for Mexican Americans, rpb (232) = .03, p = .60. No statistically significant correlation between participation in mental health services and the amount of social distance from individuals with mental health problems for Mexican Americans, rpb (232) = .07, p = .32. No statistically significant correlation between perceived ethnic discrimination and the amount of social distance desired from individuals with mental health problems for Mexican Americans, r(219) = -.05, p = .55.

29. Discussion

30. Implications of the Study This study suggested that Mexican Americans do not stigmatize mental health problems any more or less than White non-Hispanic European Americans. This argues against the stereotyped idea and some previous research that Mexican Americans tend to be more reluctant to accept mental health problems or interact with individuals with mental health issues. Furthermore, the assumption was that Mexican American males, in particular, were the likeliest group to want the most distance between themselves and individuals with mental health problems. Previous research had indicated that Mexican American males tended to seek mental health treatment at a significantly lower rate than Mexican American females and indicated greater distance from issues involving mental health (Vega, Kolody, Aguilar-Gaxiola & Catalano, 1999). This study does not support that research; rather it indicated that Mexican American males stigmatize mental health problems the same as White non-Hispanic European American males and females as well as Mexican American females.

31. Implications of the Study This study found a significant difference between White non-Hispanic European American males and females in their attitudes toward seeking help. Results indicated that females had significantly less self-stigma and were more likely to seek help for psychological problems than males. Mexican Americans’ age was significantly correlated with the amount of social distance from individuals with mental health problems. As age increased the desired amount of social distance increased. Reflect more of a generational shift in attitudes and beliefs regarding mental health problems. Conversely, younger Mexican Americans appeared to be more tolerant and may have different beliefs. This finding was consistent with Parra (1983) which found that younger Mexican Americans tended to be more reluctant to label individuals’ behaviors as representing a mental health problem.

32. Implications of the Study Additionally, this study supported previous studies regarding Mexican Americans underutilization of mental health and counseling services. A recent study by Vega et al., (1999) found that Mexican Americans, in general, underutilize healthcare across the board. Furthermore, Mexican American females were more likely to access mental healthcare significantly more than Mexican American males, but both genders utilized mental healthcare significantly less than White non-Hispanic European American males and females (Vega et al., 1999). Results of this study indicated that the Mexican American sample accessed counseling and mental health services at approximately half the rate of White non-Hispanic European Americans. This study utilized existing stigma measures and found that some measures (SSOSH) may not be appropriate for studying stigma with Mexican Americans in its current form.

33. StigmaStrategies for Change

34. Interventions • Protest Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

35. Interventions • Protest • Education Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

36. Interventions • Protest • Education • Contact Corrigan, River et al., 2001 Corrigan & Gelb, B, 2006 Rűsch et al., 2005

37. Anti-stigma Intervention Results • Protest→ • No measurable effect on attitudes

38. Anti-stigma Intervention Results • Protest → no effect • Education → • Positive effect on knowledge • Minimal effect on attitudes, perhaps greater in school children • Less effect on social distance • Longer interventions → more effective

39. Anti-stigma Intervention TrialsResults • Protest → no effect • Education → modest, limited effects • Contact → Greater impact on social distance than education alone. Impact still very small.

40. Contact→ Significant changes in some attitudes: • The depressed patient was held less responsible for being depressed. • Depression can improve with treatment. • Psychosis can improve with treatment. __________________________________ But not others: • The psychotic patient was held no less responsible for having psychosis. Corrigan, River, et al., 2001

41. Protest Revisited • Grassroots efforts directed at the media • Reduce the presentation of negative images about mental illness in the media • Increase the presentation of positive images about mental illness in the media

42. NZ National Plan 2007 - 2013 www.likeminds.org.nz Ministry of Health. 2007. Like Minds, Like Mine National Plan 2007-2013: Program to Counter Stigma and Discrimination Associated with Mental Illness. Wellington: Ministry of Health.

43. Sponsors of U.S. Anti-Stigma Efforts • National Alliance on Mental Illness (www.nami.org) • SAMHSA: (www.adscenter.org) • Address Discrimination & Stigma (ADS) Center • Elimination of Barriers Initiative (EBI) • Active Minds on Campus (www.activeminds.org) • National Mental Health Awareness Campaign • (www.nostigma.org) • Mental Health America • Chicago Consortium for Stigma Research • (www.stigmaresearch.org) • Open the Doors World Psychiatric Association • (www.openthedoors.com/english)