by Monica A. Ross, LPC
This first semester of classes is over. I’ve narrowed down even further what I want my capstone project to focus on. I started out writing about wanting to address the issue of achieving equal opportunity and justice. I wrote about how this particular grand challenge underlies all of the other grand challenges. My new focus is on health disparities related to mental health and closing the health gap.
This semester we went through the basics of innovation dynamics: actors, limits, history, future, configuration, and parthood. We traced social norms and thought about ways of both deviating from them and then diffusing the deviation. I traced the social norm of 1) The idea that people are "crazy" and 2) That the mentally ill cannot function or participate in regular society fully because they are mentally ill.
The state of mental health care in the United States has declined steadily. According to the Center for Mental Health Services (CMHS) as part of the process of deinstitutionalization the number of patients in state and county psychiatric hospitals has decreased from 512,501 beds in 1950 to 49,947 beds in 2005 (Eckart, 2010). That is a 90% decrease, so that today there are about 14 beds per 100,000 people.
That same ratio was approximately the ratio of beds to persons treated in 1850 (Torrey, Fuller, Geller, Jacobs, & Ragosta, 2012). With all of these individuals released from state and county psychiatric hospitals the question becomes where are these individuals now being treated?
Today there are 3.9 million people with severe mental illness who are not receiving any form of treatment (Mondics, 2014).. The dismantling of the scaffolding by which the mentally ill were formerly treated did nothing to eradicate the issue of mental illness itself. Individuals have continued to go on needing treatment.
Instead one third of the homeless population suffers from mental illness (Mondics, 2014). Jails and prisons in the United States are holding three times the amount of seriously mentally ill individuals than hospitals (Torrey et al., 2012). In other words, because individuals are going untreated they often end up either living on the streets or in prison.
The Adverse Childhood Experience (ACEs) study that took place in the 1990s was a study conducted by a major health insurance provider Kaiser Permanente in California. It sought to connect the linkages between adverse experiences and later health crises (Lanius, Vermetten, & Pain, 2010). This study points to the relationship between body and mind—between mental and physical health.
The relationship, however, is not straightforwardly biomedical but caused by coping mechanisms induced by the psychological distress that mental health issues bring (Lanius et al., 2010). We know that living with depression and chronic health conditions decrease one’s quality of life. Psychological distress and physical illness, in turn, contribute to shortened life expectancy rates.
Globally, the average life expectancy has doubled since 1900 with the average life expectancy today nearing 70 years. In the year 2000 the world’s population was around 6.1 billion and by 2050 it is projected to be 9.4 billion (United Nations, 2003). There is no country in the world so dispossessed that it has a life expectancy at its highest that reaches what the highest life expectancy was in 1800 (Roser, 2013).
Yet, while life expectancy rates have improved overall, people with severe mental illness have a 13 to 30 year shortened life expectancy rate than the average person (De Hert et al., 2010). There are societal shifts and changes taking place within the health care field in other ways.
The top 10 big pharmaceutical companies known as “Big Pharma” make more money every year than the other 490 companies on the Fortune 500 list combined (Malagutti, 2007). This excessive profit is indicative that the business of medication is big business. In 2015 there were 67, 753 pharmacies nationwide.
The United States has a reputation of aggressive forms of medical treatment not the least of which is the over prescription of pharmaceutical drugs. And yet, due the to the extreme proliferation of pharmacies, if pharmacies like Walgreens alone were to open a health clinic in each of its stores about three fourths of the population of the United States would have access to health care (Singhal, 2017). In other words, the United States has the delivery and distribution methods to think of creative ways of providing better treatment at the ground level.
There are different theoretical frameworks that tie into the crisis we see in health care. One of those frameworks was developed here at The University of Texas at Austin by Steele and Aronson. Steele and Aronson (1995) define stereotype threat as “being at risk of confirming, as self-characteristic, a negative stereotype about one’s group.”
The fear is that an individual will be judged by his actions or treated in a stereotypical fashion whether the individual believes in the stereotype or not. The authors pointed out that African-American students at the time may also have been loaded with what the researchers called “self-threat” or a hyperawareness or self-consciousness about their abilities which interfered with performance.
A similar thing may be at play for individuals experiencing mental illness and in both a stigmatized and power down position. Whether an individual believes in the stereotype placed or not is an important point. Cognitive dissonance theory which was developed by Leon Festinger (1962) describes the situation in which an individual might hold attitudes and beliefs that are different from her behaviors.
So conceivably a person might be born into unfortunate circumstances and find themselves marginalized and with the mark of stigma and feel the effects of prejudice and discrimination in society yet believe themselves to be worthy despite social norms. But their behaviors nonetheless may put them into situations in which they would reinforce social norms and perpetuate the stigma and discrimination that follows even though their attitudes and beliefs differ.
As an example, an individual with mental illness may have some sense that she is capable of holding down work, yet because her caseworker reinforces the social norm that claiming disability may be the more appropriate option the individual with mental illness may go ahead and file. The disharmony creates cognitive dissonance or turmoil within the individual.
For the individual in this example it is a message both of “I’m capable and I’m incapable.” The mentally ill who find themselves in cognitive dissonance are forced into a situation then where something has to change in order to create harmony. They therefore either change their attitudes and beliefs to be in greater alignment with their behaviors and buy into the idea that they are in fact incapable.
Or they reduce the importance of their conflicting attitudes and beliefs, by perhaps believing on the one hand they are capable yet perhaps incapacitated by outside forces. Conversely, a person with mental illness might, in fact, believe in accordance with social norms that he is damaged, flawed, and crazy.
Yet he may engage in prosocial behaviors that would suggest the believes that he is capable of some level of functioning in society by for instance holding down a job, but still the inner disharmony and conflict. His inner belief in being flawed may later come into play when problems arise at work.
In order to bring his attitudes and beliefs in alignment with his behaviors again something needs to change. Instead of fighting to keep his job and work on whatever performance issues are at play he might instead take a defeatist attitude and give up on work to support his innermost belief that he is flawed and incapable.
It is possible that he may find treatment for his negative core belief that he is incapable and bring the new belief that he has the capability into alignment with more prosocial behaviors of seeking to find enjoyable work. Attitudes and beliefs must somehow come into alignment or they create psychic tension. Aronson’s stereotype threat and Festinger’s cognitive dissonance theory work in conjunction in terms of affecting health outcomes.
Those stigmatized with mental illness as in the example above may according to Aronson: 1. avoid treatment, 2. experience impaired communication during treatment, and 3. face poorer adherence to treatment plans by virtue of a type of learned helplessness. All of these behaviors may certainly be influenced by the inner disharmony felt. (Aronson, Burgess, Phelan, & Juarez, 2013).
The topic of empowerment is key when dealing with marginalized populations such as those with disabilities. Empowerment serves as a means of bringing into greater alignment one’s attitudes and beliefs and subsequent behaviors. A book published in 2018 by Oxford University Press reveals a mapping out of the role of stigma and discrimination.
It starts with an explanation of discrimination at all levels (cultural, institutional, and interpersonal) and then traces the role of discrimination in social cognitive processes, health behaviors, emotional and physiological reactivity, emotional and psychological recovery, and sustained psychophysiological dysregulation (Major, B., Dovidio, J. F., & Link, B. G. (2018).
The authors map the connections between stigma and discrimination and how they lead to choices in life at the individual level that in turn can contribute to adverse health outcomes. One example of this is stigma and discrimination leading to the unpredictable availability of needed resources which influences opportunistic risk-taking behaviors which may then lead to physical injury or drug use.
If the approach to the problem were to on one hand make health care easily accessible and easily affordable and empowering while on the other hand work to reduce stigma and discrimination, we may see progress on this issue. A model of empowerment for those marginalized with mental illness which seeks to into introduce the idea that people with mental health issues are normal and works against stigma and discrimination, stereotype threat, and cognitive dissonance may encourage those experiencing mental illness to bring their attitudes and beliefs into alignment with behaviors.
This could be done by providing greater education, tools, and resources to those suffering. This might assist with the reduction in both morbidity and mortality—improving both quality of life and life expectancy rates. This semester I began to flesh out a prototype for addressing the crisis in mental health care perhaps by the delivery of tools and services through a platform built on blockchain technology.
Aronson, J., Burgess, D., Phelan, S., & Juarez, L. (2013). Unhealthy interactions: The role of stereotype threat in health disparities. American Journal of Public Health, 103(1), 50-6.
De Hert, M., Correll, C. U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., Detraux, J., Gautam, S., Moller, H. J, Ndetei, D.M., Newcomer, J., Uwakwe, R., Leucht, S. (2011). Physical illness in patients with severe mental disorders. Prevalence, impact of medications and disparities in health care. World Psychiatry, 52-77.
Eckart, G. (2010, September 7). Division of Mental Health and Addiction Commission on Mental Health Presentation. Retrieved from http://www.iccmhc.org/sites/default/files/resources/State%20Psychiatric%20Hospitals- CMH%202010%20%282%29.pdf
Festinger, L. (1962). Cognitive Dissonance. Scientific American, 207(4), 93-106. Retrieved from http://www.jstor.org/stable/24936719
Lanius, R., Vermetten, E., & Pain, C. (2010). The impact of early life trauma on health and disease : The hidden epidemic / edited by Ruth A. Lanius, Eric Vermetten, Clare Pain. Cambridge, UK ; New York: Cambridge University Press.
Malagutti, I. & Mellara, M. (2007). Health for Sale. United States: California Newsreel.
Mondics, J. (2014, July 25). How Many People with Serious Mental Illness Are Homeless? – Treatment Advocacy Center. Retrieved from http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/2596-how-many-people-with-serious-mental-illness-are-homeless
Roser, Max (2013). Life Expectancy. Retrieved from https://ourworldindata.org/life-expectancy
Singhal, S. (2017, May). Distributed sites of care: At the tipping point? Retrieved from https://healthcare.mckinsey.com/distributed-sites-care-tipping-point
Steele C. M., Aronson J. (1995). Stereotype threat and the intellectual test performance of African Americans. Journal of Personality and Social Psychology. 69: 797–811. pmid:7473032
Torrey, E. F., Fuller, D. A., Geller, J., Jacobs, C., & Ragosta, K. (2012, July 19). No Room at the Inn Trends and Consequences of Closing Public Psychiatric Hospitals 2005 – 2010. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/no_room_at_the_inn-2 012.pdf
United Nations. World population projected to reach 9.6 billion by 2050. Department of Economic and Social Affairs. (2003, June). Retrieved from http://www.un.org/en/development/desa/news/population/un-report-world-population- projected-to-reach-9-6-billion-by-2050.html