Reflective Essay the Most Daunting Part of My Academic Career Had

Reflective Essay

The most daunting part of my academic career had arrived where I had to write a 30-page thesis for my political science degree. As someone who could not fathom writing a paper more than 15 pages, the idea of writing a thesis of original work scared me, luckily Cal Poly Pomona’s services helped any anxieties I had about my research project. My department mentor, Professor Neil Chaturvedi advised me to start reading peer-reviewed sources which closely aligned with my research project to help create my research question. As someone who took the course offered by Cal Poly Pomona Library titled “Lib 150”, I found this process relatively easy since I formerly had experiences navigating through the University Library search engine. I started my research with a broad lens by researching mental health service opinions from two sets of populations, those diagnosed with a mental illness and the general public. By doing overall research, it helped me weave in the common denominator of negative opinion about mental health services.

Having researched other classes before, I was all too familiar with the process of a search engine yielding so many results to the point that it could be overwhelming. And while the number of research results seemed promising to expand my research, as I scanned through the listed peer-reviewed articles, I kept finding myself in a position in which I didn't find any scholarly articles which paralleled my research point of interest. For example, since my research focused on mental health education and the effects of mental health services, I kept encountering research that examined attitudes about mental health perception in places like Cambodia, or Canada, although similar, it was not something I could use since I wanted to contribute to scholarship in the context of mental health attitudes in the United States. Having encountered the infamous ‘writer block,’ I decided to meet with my subject librarian, Donald Page, who was able to garner scholarly material which best fit my research. He helped me generate research terms such “mental health attitudes” “Mental health opinion United States” “public health opinion/attitudes United States” and “Mental health perspective.” What further help me garner relevant research was adjusting the dates publishes along with the subject. Because my paper aimed to contribute research in the realm of public administration, the option of narrowing subjects to "political science" and "public administration" helped me obtain better results. After adjusting these settings, I was able to locate multiple sources which included scholarly articles that were accessible online and some materials that I had to be ordered. I was also able to order two books via document delivery in time, and the most fun part of my research was using archived newspaper online to examine public attitudes about mental health which is provided through one of the library databases.

As I combed over more than forty peer-reviewed sources which concerned my research, I was able to create a literature review which would later motivate my research question. Since there was a common theme amongst my literature review which suggested that an individual’s lack of mental health education affected their mental health delivery, I was able to create the question of what role does mental health education play in mental health delivery. My research question later helped me create the hypothesis that argued that “an individual’s limited mental health education negatively affects their opinion of mental health services. After creating my data via survey, I was able to assess my data to determine that there is a stark difference between who received and did not receive mental health education and their reported attitudes of mental

health services. With these results, social scientists along with health care official can confirm what is usually assumed about mental health education and the effect of an individual’s attitudes about mental health delivery.

Despite my dread to write a thesis paper because I did not consider myself as a social science researcher, the tools provided through the University Library helped this process become easier and enjoyable. My success in contributing to political science scholarship is not to say that my research process itself was a breeze, I was often met with discouraging times such as believing that there was no scholarly material published in which I can’t discuss in my literature review. Knowing that there had to be existing research on my topic, I overcame the barrier of not finding well-suited research about my topic by consulting with my subject librarian who would help me have a new set of eyes in my approach to my research project. Upon learning new research strategies, I was able to gather peer-reviewed resource which helped motivate my scholarship contribution in the effects of mental health education on mental health services.

CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA

Public Opinion of Mental Health Post Deinstitutionalization

Marilyn Guzman

March 2018

ABSTRACT

One in five Americans have a mental health condition (U.S. Department of Mental Health), yet despite the increase of mental health insurance provided by the Affordable Care Act, the utilization of these services does not parallel the current number of people diagnosed. Although factors such as insurance cost and mental health clinic proximity play an influential role in the accessibility of these services, existing literature suggests that an individual’s multi-layer identity may impede their mental health delivery. Although deinstuilization was geared to foster a positive environment for the mentally ill in a community setting, current public attitudes suggest that they do not reflect the objectives of this movement. In order to assess the implications of public attitudes toward the mentally ill, this paper will utilize public opinions to examine the effects of mental health education and how respondents view issues pertaining to mental illness. By using public opinion, this thesis seeks to examine if limited mental health education negatively affects public opinion of these services.

Word count: 165

I. Introduction

Current data indicate that 1 in 5 adults have a mental health condition, and youth mental health continues to decline from 5.9% in 2012 to 18.2% in 2015 (Mental Health America 2017).

While there is increased availability of mental health services provided by the Affordable Care

Act, there is not a proportional use of service to the number of people who are diagnosed with a mental health condition. Americans tend only revisit the issue of mental health once another mass shooting has occurred. However, as seen with the 2017 Las Vegas shooting or the

Sutherland Springs, Texas church shooting, after an allotted amount of time subsides, the public continue with their lives without creating a dialogue past gun control. Although mental health treatment garners bipartisan support, Americans are not as willing to use mental health services as they would with any other social service program. Part of the underutilization of these services is rooted in public attitudes leading up to deinstitutionalization. As medical professionals treated mentally ill patients by housing them in state institutions, Americans became inundated with images and stories of under-resourced and inhumane facilities. With the combination of the development of chlorpromazine and the advocacy to shift from state mental institutions to community-based treatment, deinstitutionalization began to take root. This paper will specifically examine attitudes post deinstitutionalization to examine if current attitudes contribute to an individual’s unfavorable view about mental health services.

Due to the recurrent theme that individuals are not aware of current mental health services that are available (Saechao et al. 2011), or the several types of mental health treatments and how they can effectively treat mental illnesses (Marna et al. 2008). The lack of mental health education leads me to create the research question of: how does mental health education affect attitudes of respondents view on mental health treatments? My thesis will explore if an

1 individual’s absence of mental health education will affect their opinion of these service. In the field of Political Science, the use of public opinion has historically influence decisions on public policy. Public opinion has also made government officials to reassess their political decisions as seen in the case of the Vietnam War where public opinion increasingly grew to the opposition of

U.S. lead involvement which eventually guided the United States to disengage from the war. By highlighting current public attitudes regarding mental illness, policies which advocate for an increase of mental health services can be set in motion should attitudes reflect these needs. In an age where mental illness is discussed in the context of mass shooting, public opinion can pave the way to increase current funds for mental health services. The use of public attitudes and its potential influence public policy is especially prevalent during a time where presidents Trump

2019 budget proposal indicated that administrations such as the Substance Abuse and Mental

Health Services Administration would have its budget slashed by $665 million. Alternatively, by creating dialogue surrounding mental illness past mass shootings and gun control we can increase our current progress in our mental health reform by continuing to increase access to healthcare which includes mental health service plans. By improving our mental health reform, the United States can address its long overdue high number of inmates who have a mental health condition. By increasing mental health awareness while simultaneously expanding the accessibility of these services, we can reduce the number of inmates which continues to be a pressing problem in the United States by providing individuals with mental health care. Other consequences that can be reduced by increasing mental health reform includes decreasing the use of illicit drugs as a coping mechanism to deal with mental health issues. In an economic perspective, by contributing to the current mental health infrastructure, the United States can

2 increase its economic productivity by investing in treatments which can allow an individual to remain employed.

In order to provide context to the current problems surrounding mental illness and how these shared attitudes affect mental health service opinions, I will provide a literature review which discusses current scholarship about public views on mental health treatment. Upon presenting different scholars discussion of public attitudes of mental health treatments, the hypothesis will be presented which is motivated by the literature review. To examine current attitudes of mental health treatment, this quantitative study will utilize a random sample of Cal

Poly Pomona students whose data and its implications will be discussed in the section titled as results.

II. Literature Review

Despite the increase of coverage for mental health services, Americans continue to not use mental health treatments proportionally to the number of people diagnosed. The following literature review includes scholars discourse in attempting to understand why mental health underutilization continues to persist by identifying obstacles across several ethnicities and socioeconomic backgrounds. While previous works of literature concluded the limited number of mental health providers drove underutilization of these services, current studies articulate that an individual’s lack of mental health education about treatments tailored to their needs may funnel the decrease of utilizing these services thus creating an unfavorable opinion of these services.

Patient Mistrust in Health Care

To examine why individuals may have a negative opinion of mental health services, it is essential to review the treatment of specific populations in health care. Historically, there has

been a level of mistrust in health care amongst minorities. As the early years of medical practices

developed in the United States, minorities were often the first to be subjected to inhumane

testing. James Marion, who is dubbed as the father of gynecology was the first to successfully

develop the surgical technique in repairing the vesicovaginal fistula at the expense of performing

multiple surgeries on three enslaved African American women. While many people have

highlighted the successes of Marion’s surgical advancements, this pattern of using minorities to

advance medical practices continued throughout history. As seen with the legacy of the Tuskegee

study of Syphilis, this 1932 U.S. Public Health Service investigation received a public outcry once it was revealed that the six hundred black men chosen in this study were misled about the intentions of the research and were deliberately denied treatment to observe the effects of

Syphilis being untreated. Years after the investigation was concluded, (Emily et al. 2001)

articulates that for many African Americans the Tuskegee Trail became the epitome of the

mistreatment of black people in medicine. While no patients were purposely injected with

syphilis, (Brandon, Lydia, and Thomas 2005) argues that most of the respondents in their study who had limited accurate knowledge of this study remained under the impression that the patients were given Syphilis by research investigators. When questioned if another unethical research like Tuskegee could be carried out in modern times, mostly blacks from this study reported that such a situation was more likely to happen again. To understand why a high percentage of mental health services remain underutilized, (Randolph and Reginald 2017) argues that medical mistrust is a crucial component to understanding why African Americans are hesitant in seeking mental and physical health care. To understand why minorities, have a higher distrust of physicians in comparison to whites, (Katrina et al. 2007) roots minority mistrust to current and historical inequitable treatment, disparities in patient-provider communication and

low insurance coverage. One limitation in the concentration of studies amongst minorities and

healthcare mistrust is that there are relatively few studies that examine mistrust amongst other

races. Although Hispanics are considered minorities, (Katrina et al. 2007) suggests that

Hispanics report a higher level of trust in comparison to other racial/ ethnic groups. Future

studies on this topic should examine other ethnic groups independently to understand why some

group exhibit distrust in healthcare and how factors such as their racial medical history may

contribute to their current mistrust in the medical field.

An additional factor that contributes to the mistrust in healthcare is the several forms of

discrimination patients have faced. It has been a frequent occurrence for patients to receive

unfair treatment because of their type of insurance or the lack of insurance. While not having

health insurance does pose a barrier to accessing health care, (Han et al. 2015) argues that some

physicians are reluctant to accept Medicaid patients because of their low reimbursement rate. In the several case studies (Han et al. 2015) examined, one contributing factor to health insurance discrimination is the ranking of patients based on their insurance which would influence the quality of service they received. In conjunction with the type of coverage a patient has, a patient's race may influence them to believe that their quality of service would increase had they belong to a different race. In (Marcus et al. 2006) qualitative research, this investigation revealed that of the 248 respondents, those with public insurance were more inclined to feel that the combination of their race and public insurance leads to lower quality of health care. One motivating question examined in (Marcus et al. 2006) study was if patients believed that they would receive better medical treatment if they belonged to a different race/ ethnic group. This study revealed that

13.3% of individuals thought that they would receive better treatment if they were of another race. (Marcus et al. 2006) attributes this discrimination to the notion that ethnic and minority

groups are more likely to utilize public insurance, therefore, explaining why people who use

public insurance would report a lower quality of healthcare in compared to those privately

insured. (Irena and Gabriella 2017) highlights that people with little education, well-educated

blacks, and Native Americans report a higher rate of perceived discrimination in health

treatment. After adjusting sociodemographic and health-related factors (Iren and Gabriella 2017)

expressed that discrimination against Blacks quadrupled and for Native Americans more than

tripled. Since an individual’s race or their form of insurance plays an influential role in their

satisfaction of health care, individuals who report a negative experience may refrain from

returning to use these services. Although these studies did not specifically examine the

discrimination of patients who used mental health services, the findings of discrimination shared

in health care as whole can be a starting point in the underutilization of health care programs as

specific as mental health services. While the number of people insured has increased with the

expansion of the Affordable Care Act, the quality of publicly funded services suggests that some

individuals remain discouraged from using these services because some individuals believe that

their quality of care would not match those who are privately insured. These two scholarships

suggest the combination of an individual's type of insurance (public vs. private) and their race

can contribute to their over dissatisfaction of health care which in turns explains negative

attitudes of health care.

Immigration Status

Using a sample deriving from California, (Elizabeth et al. 2006) also suggests that an individual’s immigration status may impede their healthcare delivery. In this study, (Elizabeth et al. 2006) argues that being foreign-born is not as significant amongst Blacks, Native Americans, and Whites, however for Asians and Latinos the foreign-born factor increases their rate of

dissatisfaction with their medical visitations. One explanation (Elizabeth et al. 2006) provides is

that fewer noncitizen immigrants have Medicaid or job-based insurance, therefore, explaining why there may be a high level of dissatisfaction in this population in comparison to other groups.

In conjunction with the factor that an individual’s immigration status may hinder their health care delivery, (Jie and Arturo 2011) examination of immigration status on mental health care utilization demonstrates that there are disparities in mental health care among immigrants and native-born Americans. Using data from the Medical Expenditure Panel Survey and National

Health Interview survey from 2002 to 2006 this study revealed that an immigrant's inferior access to health care services was a driving force in funneling disparities in mental health utilization for non-U.S. citizens. Because most immigrants are three times more likely not to be uninsured than U.S. citizens, when using mental health services, the first barrier in accessing these services can be rooted in not being insured for general doctor visits. For immigrants, the first year of living in a different country does take a toll on their mental health, so it is imperative that these services be able should the individual find the need to use these services. Between these two scholarships, (Elizabeth et al. 2006) argues that the lack of general health care insurance for immigrants impedes in their access to general care. But when examining mental health services and the effects immigration status (Jie and Arturo 2011) highlights that individuals negative opinion of mental health services can be contributed to the lack of access to these services.

Sexual Orientation

Existing literature articulates that people who identify as LGBT or who are gender nonconforming are at an elevated risk for mental health disorders. (Diana et al. 2008) confirms previous research that perceived discrimination remains an influential factor in the disparity of

utilization of mental health services between heterosexual and LGBT people. In this qualitative

study (Diana et al. 2008) examined the effects of an individual’s sexual orientation and their

underutilization of mental health care. While this study reported that most LGBT members

would report a higher need of mental health services than heterosexual people, they were also

inclined to report that their mental health needs were not met, or that such services were delayed.

(Deirdre and Kim 2015) highlights that some of the reasons why LGBT members cannot access

mental health services are due to their outward representation that does not reflect the

name/gender of documents such as their insurance card or identification documents. (Deirdre and

Kim 2015) asserts that the reason why mental health care may be delayed toward this subgroup

includes the lack of knowledge of counselors who have an established history with LGBT or

gender non-performing issues. Part of the reason why a high number of counselors have a lack of

understanding of these issues tailored to LGBT members is due to the lack of appropriate

training. If an LGBT patient asks questions with transgender-specific health care, (Deirde and

Kim 2015) repeatedly found that a provider may have limited dialogue between them and their patient because they do not know how to respond to the needs of their patients. Similarly, the same provider may have trouble finding outside resource which will meet the needs of their patients in which they could be referred too. One limitation of this study is that current data indicates that LGBT members rank as one of the most uninsured members; therefore, it can be challenging to examine the frequency of experiencing discrimination. Other reports also indicate

that LGBT discrimination is often committed in hospitals by other patients in doctor’s offices

rather than physicians discriminating their patients themselves. Studies regarding LGBT

discrimination in hospital settings should examine the discrimination amongst this group

independently from discrimination caused by patients from discrimination reported caused by

doctors. While most studies suggest that current mental health treatment for these groups are

ineffective, (Anna, Ronald, and Lori 2001) explains that LGBT patients would increase their utilization if counseling catered to sensitive LGBT issues such as discussing treatments of transitioning such as hormone therapy or sex reassignment surgery. While direct discrimination influences LGBT patient’s unlikelihood to consistently seek care, (Taylor 2014) addresses the need to highlight the issue of visibility. Most matters pertaining to LGBT patients may be difficult to identify which may lead them to believe that their problems are not as significant, which consequently may discourage them to seek out care. (Taylor 2014) identifies this as a postponement, due to the lack of representation of LGBT patients in research and health care providers, (Taylor 2014) suggest that LGBT patients do not utilize mental health service because of the lack of representation rather than affordability. Although only 4.1% of Americans identify as LGBT, it worth exploring why the same group who has a high need for mental health services equally report a high level of mental health service dissatisfaction. Some limitations surrounding this study include that LGBT mental health utilization is that sampling of this group has an increased likelihood of being nonrandom because researchers cannot guess an individual sexual orientation accurately. Another disadvantage in studying LGBT members is that this population does experience a high rate of homelessness; therefore, researchers are put in a difficult position to seek people who falls under the LGBT umbrella.

Effectiveness of Mental Health Treatment

A theme that prevails in the underutilization of mental health services is the low

credibility of the effectiveness of mental health services. One influential factor in the skepticism

of using these services is the patient disconnect in understanding how their treatment works and their expected commitment to their program. To understand the underlying question of why

9 some patient’s withdrawal before completing their mental health treatment, (Marna et al. 2008) suggest that some patients view their treatment as ineffective if they do not see immediate progress. Other patients may not understand how their treatment would help them as in the case in enrolling in counseling therapy. For someone who has never been in a setting where they are expected to talk about their emotions, they may have a tough time understanding the benefits of talking about their problems to improve their mental health. When patients believe that their treatment is ineffective, they may stop attending future sessions because they assume that other meetings would not be helpful. Typically, for a client to be considered as recovered, they must at least attend 11-13 sessions. For some individuals (Marna et al. 2008) argues that 11-13 sessions may get in the way of family or work obligations so completing all required meetings may not be realistic, therefore hindering the effectiveness of their treatment program. When doctors and patients do not set goals, (Marna et al. 2008) asserts that a client would more likely end their treatment prematurely. To lower the perception that mental health treatment is ineffective, (Mark et al. 2002) claims clinicians should spend the time to educate their patients of their mental health condition so that their patients could understand why their mental health treatment is needed to recover. Individuals may often underestimate the severity of their illness, so by recognizing how severe their illness is, patients are more inclined to remain in their programs despite not seeing immediate results.

Stigma Toward Mental Illness

The driving force behind the underutilization of mental health services continues to be the stigma in seeking professional help. Unfortunately, despite our generations efforts to reduce mental illness stigma, the media continues to influence most of our depiction of mental illnesses.

Typically, when new stories cover the topic of someone who has a mental illness, these

individuals are conveyed negatively. The adverse representation of people with mental illnesses

can be engrained as early in childhood. In comics or in cartoon characters, characters who have a

mental illness are always seen as dangerous, unattractive, and usually play the role of villains,

rarely do characters who have a mental illness appear in a favorable depiction. To assess the

trends of how mentally ill people are viewed in the media, (Emma et al. 2016) used a random

sample of 400 news stories concerning mental illness between 1995-2014. The objective of the

study was to examine if psychological illness news coverage improved by the decade. According

to (Emma et al. 2016), the second decade had a higher reporting of mental illness under the

context of mass shootings. Amongst the sample of 400 new stories, (Emma et al. 2016) reported

that these stories covered 55% interpersonal violence, 47% treatment for mental illness, and only

14% described successful mental illness treatment. From this report, we can conclude that most

news coverage of mentally ill people continues to be dominated of interpersonal violence which

(Emma et al. 2016) argues is disproportionate to the actual rates of violence that is carried out by the mentally ill. Because the media actively conditions the image of the mentally ill through stigmatization, public stigma also contributes to the underutilization of mental health services. In a study conducted to examine the effects of a population’s view of a person labeled as mentally ill, (Angermeyer and Matshinger 2003) investigation revealed that respondents who labeled an individual as mentally ill were more likely to believe that they are dangerous which consequently lead them to fear them. Since the use of labeling someone as mentally ill still conjures a negative image, most patients with a mental health condition choose to keep their illness anonymous as a method to cope with the stigma associated with mental illness. In the context of race, (Haig,

Byron and David 2003) explored why Latino families were not ranked as one of the top ethnicities to use mental health services. (Haig, Byron and David 2003) revealed that for Latinos

11 families, having a mental illness was synonymous with having a character flaw since it was associated with a sign of weakness. Since having a mental illness was an unfavorable characteristic, (Haig, Byron and David 2003) stated that it was common for individuals to experience a sense of guilt if they looked for help beyond the scope of their family. The same stigmatization is also reflected amongst military veterans. In an investigation examining the barriers to mental health care amongst Iraq and Afghanistan veterans, (Paul et al. 2011) provided veterans with a closed-ended questionnaire asking veterans about their experience with seeking mental health treatment. In this study, some of the most frequent responses from veterans included that they would not seek help because “It would be too embarrassing, it would harm my career, I would be seen as weak, my unit leadership might treat me differently, and members of my unit might have less confidence in me”. Because of public and self-stigma, attitudes toward mentally ill patients create fear; therefore, people who are diagnosed with a mental illness are reluctant to seek care to avoid the stigmatization associated with being mentally ill.

Family Influence

In concurrence with public stigma, the role of the patient’s family can indicate the likelihood of a patient to seek care while simultaneously shaping attitudes of these services. As the mentally ill continue to fight against stigma, (Patrick and Frederick 2004) suggest that stigma for an individual can extend to their family members which in turn can hurt a patient use of mental health services. Despite distinguishing public stigma, (Patrick and Frederick 2004) study revealed that in some instances people believed that parents are to blame for their child’s mental illness. It could be inferred that because stigma can extend to an individual's family, family members may discourage a patient to receive mental health treatment to avoid the 'courtesy stigma' that is evoked by association of someone with a mental illness which may jeopardize the

individual’s family members relationships. As discussed in the earlier section about the medical

mistrust patients may experience, a family member negative experience with their health care

can be transmitted to their family members. The effects of family mistrust in mental health

professionals was reviewed in (Michael, Sean, and Vo 2010). In this study participants were

questioned about their opinion of mental health professionals. Upon being asked several

questions regarding mental health care, the participants in this study disclosed that using these

services inflicted a sense of guilt since their family members believed that their mental illness

could be resolved amongst family members rather than seek help from 'strangers.' In a qualitative

study which included thirty participants, (Alejandro et al. 2007) examined how the role of stigma

leads to the adherence to psychiatric medications. One patient disclosed that her experience with

disclosing her mental illness amongst her family was more of a challenge than dealing with her

mental illness. Regarding taking their antidepressants one patient revealed, “Yes, I went through

a lot, I suffered a lot, and secondly, it was like my family did not understand me. It was as if they

thought that what I had was nothing, a joke. I would explain to them, and they would say to me,

“What you need to do is stop all those medications and throw them out.” For many patients, they

were brought up to believe that they should not air their dirty laundry outside. As a result, many

people will be pressured into not seeking help to maintain the image that they can cope with

life’s hurdles. Alternatively, (Haig, Bryon and David 2003) also suggest that because Latinos

report a high satisfaction of receiving moral support from their family member and place a high

value in privacy, these two factors contribute to the underutilization of mental health services

because patients believe their problems could be solved with their family members. The collection of these scholarships which provide conflicting views on the role family shape the underutilization of mental health services and the attitude that is influenced by external factors.

On the one hand, we are presented with evidence that suggests that family members help aid with the rate of underutilization by wanting to avoid courtesy stigma (Patrick and Frederick

2004). But alternatively, family members influence underutilization of mental health services through a 'positive' way by trying to provide moral support. Rather than seek help with a counselor, a family member may try to help the patient by trying to discourage them from seeking professional help so that they can resolve their problems amongst family members rather than pay a 'stranger' to fix their problems (Haig, Bryon and David 2003).

Religion

Before our current understanding of mental illness, centuries ago, people tried to make sense of mental illness through religion and associated it with demonic possession. Now that over 400 million people in the world practice some form of traditional religion, psychologists have grown an interest in studying the effects religion has on individual’s mental health. Existing literature proposes that religion can be a beneficial method of coping or may hinder mental health delivery. Depending on how each patient views their mental illness, some may refrain from seeking mental health treatment because they believe they could cope with their religious beliefs. Other studies have argued that being religious or spiritual can produce positive mental outcomes by reporting less anxiety and depression than those who are not affiliated with any religion. It is important to note that the absence of practicing a religion does not mean that an individual is more likely to experience a mental illness, nor does practicing a religion guarantee avoidance of a mental illness. To understand the disparity of mental health utilization amongst religious groups (Marco and Kate 1999) revealed that some church dialogue might create a stigma in seeking help. (Marco and Kate 1999) argues that some religious sources may view one’s mental illness as a lack of faith especially those who are experiencing depression or

14 anxiety. It is also articulated that devout believers are discouraged to seek help because psychotherapist may encourage patients to use irreligious ideas or practices that steer from the church's principles. Additionally, religious people may use coping strategies that are endorsed by the church such as engaging in prayer when facing a challenging time. With the combination of satisfaction from seeking support from spiritual leaders, (Deidre et al. 2008) highlights that people continue to solicit mental health help from the church because it is less expensive than professional mental health care. (Deidre et al. 2008) also expresses the concern many of the participants shared such as feeling more comfortable to seek help in a church setting because they believed that consulting a medical professional would mean that their provider would discourage using coping mechanisms such as prayer as being inferior in comparison to mental health treatments. The limitations to this realm of studies include depression being the most studied clinical disorder concerning religion. While religious involvement has lead scholars to believe that religion plays a crucial role in mental health utilization, more research should be developed on how religion influences the utilization of mental illnesses with mental health care utilization with other mental illnesses such as schizophrenia which needs more medical care attention.

Language Barrier

Although the medical field has become increasingly diverse, language continues to be an obstacle to mental health delivery. Despite having interpreters available, the lack of a patient's shared language with their provider continues to present numerous challenges across several ethnicities. In examining the effects of language as a barrier amongst Latinos, (Haig, Byron and

David 2003) argues that the proficiency in English may lead to patients to become overwhelmed when navigating through their health care system. Most of the common barriers that are

15 overlooked continuously include a patient’s inability to complete paperwork to receive mental health treatment or the low success of being able to communicate efficiently with a monolingual therapist. A common theme that prevailed amongst language and mental health treatment was a patient's increased satisfaction from having a therapist who spoke their native language, in these studies specifically; the native language was Spanish. This satisfaction can be attributed to a patient’s ability to express their emotion in Spanish, therefore, increasing their engagement with their provider. Interpreters who mediate these sessions may also run the risk of misinterpreting dialogue, (Donna, Robertson, and Teng 2007) qualitative study argued that having an interpreter present can sometimes feel like an ‘exercise in futility.’ Foreign-born individuals consistently report language as being a barrier to seeking mental health treatment for the same reason that they feel that their interpreter cannot effectively translate their emotions to their provider. For an individual who is not proficient in English, navigating through their health care provider for resources can become overwhelming and discouraging. In a qualitative study which measured the difficulty for immigrant’s mental health accessibility, (Lyren et al.2005) revealed that a typical statement included the challenge for patients to make medical appointments for themselves. One patient disclosed that they had to rely on their son to make appointments since their proficiency in English was limited. The same patient shared that she previously attempted to book an interpreter but the process of finding one was challenging since most interpreters were not available to fit into her schedule. When this same patient was not able to schedule an interpreter, she had no choice but to cancel her appointment. While there is a lot of scholarship discussing the limitations of verbal language posing as a barrier, another language that is often overlooked when discussing mental health patient communication is sign language. In an interview amongst 54 deaf adults, (Annie, Vicki, and Ruth 1998) concurs with existing literature

16 that states that language remains a buffer in utilizing mental health services. The patients that were interviewed reported preferring a deaf therapist over a hearing therapist since a deaf therapist can communicate efficiently without an interpreter. Although interpreters help patients communicate with providers, (Annie, Vicki, and Ruth 1998) argues that clinicians should not remain under the impression that an interpreter ensures adequate communication, the best way to reduce langue barriers is for providers to expand of the diversity of language spoken amongst their physicians.

Cultural Representation

Most patients have reported an increase of satisfaction from receiving treatment by physicians of their ethnic group. One advantage is the lower risk of language posing as a barrier as examined earlier, but this also allows the opportunity for patients to connect culturally to their provider. (Haig, Byron and David 2003) found that an increasing number of Mexican Americans preferred a physician who shared their background. Depending on the individual, if they have a strong connection to their cultural heritage, patients found it easier to connect with their physician based on the assumption that their physician will be able to understand the problems that are unique to their ethnic group. The proposed idea that utilization of mental health services can be increased from ethnic representation is also affirmed in (Marco and Kate 1999) which discussed the concern in having a physician who would not understand the cultural differences of their patient. In this study, one black respondent revealed that he believed a black medical professional would be more sympathetic and understanding to a black patient than a provider from a different race. The same preference for a provider who shares the same ethnicity as their patient was seen amongst a Muslim respondent who shared that “I think our depression is different to a white person because our circumstances are different. Our personality is different;

our family background is different” (Marco and Kate 1999). Between (Haig, Byron and David

2003) and (Marco and Kate 1999) these two studies express that because ethnic groups deal with

issues such as immigration or discrimination differently from other groups, this binding factor of

ethnic similarities between patients and providers can increase the confidence amongst patients

to consider using mental health services.

Cost

Although the number of insured Americans has increased from previous decades, out of

pocket costs continue to discourage people from using mental health services. When

interviewing patients regarding how they pay for their mental health services, one patient in

(Lyren et al. 2005) study revealed that despite having her therapy covered, the medication that

was prescribed from her doctor was too expensive for her to pay out of pocket despite being

insured. She later explained that her dosage required her to take two pills at a time which would

cost her 200 hundred dollars a month. Since financing her medication was a concern for her, she

revealed that she would most likely consult help from an herbalist despite knowing that these

medicines would not produce the same results as would using the prescribed medication. For

individuals who are immigrants, the likelihood for their health insurance to cover their expenses

would be unlikely; therefore, they increasingly rely on public community health clinics. Another financial cost that poses a barrier in seeking help is the money that is lost when a worker calls out of work in order to attend a mental health treatment session. In their qualitative study, (Haig,

Byron and David 2003) expressed that for an individual to call off from work to attend mental health treatments was too much of a burden for low working class Mexican Americans. Since

Hispanic workers typically earned less money than non-Hispanic workers it was difficult for

these patients to call off work to seek help. (Haig, Byron and David 2003) stated that if people

from low socio-economic background could not afford to lose a days’ worth of work to get help,

then it was just as likely for them not to be able to pay for services that were more than likely not

covered amongst their insurance plan.

Lack of Information about Mental Health Services

As with any form of health care service provided, the expansion of patient's knowledge

of available resources can increase the likelihood of services to be utilized. This same pattern is

exhibited amongst mental health services; most individuals are unaware of the services that are

created to improve an individual's mental health, therefore, hindering the utilization of the

resources that are available. Amongst all existing literature about mental health services and their

attitudes toward these resources, scholars overwhelming agree that providers should increase

their community outreach about the services that are available. (Saecho et al. 2011) qualitative analysis explored the barrier in mental health accessibility by highlighting that the lack of information regarding mental health services. In all the six groups that were interviewed in this study, all groups reported that “they were unaware of mental health services in general or they did not know the process in which someone can access these services.” (Saecho et al. 2011) suggest that mental health education can be broken up into two tiers. The first tier includes exposing community members to the services that are available to them, and secondly how one would go about in enrolling in these programs. By having an active effort in dispersing mental health services, (Saecho et al. 2011) argues that this would bring awareness to community members of the services that are available for them to use. Not only will people become increasingly aware of what is available to them but over time it can destigmatize the use of these services and lead to public attitudes regarding mental illness into a favorable one. In combination of knowing what mental health services are available, (Haig, Byron and David 2003) proposes

19 that educating community members about services can work as a preventive measure of one’s mental illness from worsening since they can identify mental illness signs, can become educated on how mental health services can treat mental illness and family can become educated in the importance of taking someone with a mental illness to received mental health care. Depending on the community, this can be achieved by partnering with community clubs, associations, and religious organizations.

III. Hypothesis

According to scholars who have examined the factors of current underutilization of mental health services, a patient’s multi-layer identity such as race, immigration status, sexual orientation, or socioeconomic status may limit an individual’s mental health delivery. Based on previous literature the following hypothesis can be made:

H1: Limited knowledge of mental health education negatively affects public opinion of mental health services.

Alternatively, the null hypothesis for this research is mental health education does not affect public attitudes of mental health services.

IV. Methodology

To measure current public attitudes surrounding mental illness, I pursued a quantitative study in which I created my data by distributing a hard copy survey to Cal Poly Pomona

Students. My survey (see Appendix A) consisted of twenty questions of which the first five questions inquired about the respondent’s demographics such as the respondent's age, income, race, and gender. As with any other research survey, I asked these first five question with the objective to get a sense of who my respondents are. The other fifteen questions asked about the

20 respondent’s attitudes about mental illness and their attitudes about mental health services. The questions I asked included but were not limited to the respondent’s ability knowledge of accessing mental health services, attitudes about themselves if they developed a mental illness, and attitudes of someone else other than themselves developing mental illness. Since my research is examining the effects of mental health education and how this variable may affect mental health service opinions, I created questions which would specifically measure mental health service attitudes. For my independent variable which is mental health education, I will examine the response for the following question: “Have you ever received any education about mental illnesses from a medical professional ?”, for this question, respondents could mark either yes or no. Alternatively, for my dependent variables which are the attitudes of mental health services, I will use the following questions to assess the relationship between my independent and dependent variables: “I would feel inadequate if I went to a therapist for psychological help”,

“I would seek help if I were worried or upset for an extended period of time”, and “Personal troubles can work out by themselves without professional help”. For these statements which I will be using as my dependent variables, respondents marked each statement based on the following semantic differential scale:1: Strongly Disagree 2: Disagree 3: Neither Agree nor

Disagree 4: Agree 5: Strongly Agree.

Procedure

In order to obtain a diverse opinion which can be reflective amongst a general population,

I specifically choose to distribute my survey to three general Ed courses on campus so that my population sample could be diverse as possible. While I did not seek a specific demographic for my population such as someone who has or previously had a mental illness, the purpose of choosing students from the three following classes such as Ethnic Women Studies 375,

Biology110, and Ethnic Women Studies 145 was to examine the attitudes of different demographics. These general Ed classes are intended to be open for all majors to take in order to fulfill a requirement in their curriculum; therefore, these classes can measure different attitudes about mental health service attitudes since there are different people are in these classes. To further demonstrate that my sample for my research was diverse, I created a question in which participants were asked to list their major. Although this question was not used to interpret any data, I used this question to make sure that my sample size came from different majors which would increase variability of respondent’s attitudes. After I emailed each professor asking if it was okay for me to distribute my survey on set day of instruction, on the day of distributing my surveys, I announced to each class who I was and a brief background of my study. Upon stating that these results were going to remain unanimous and that this survey would not directly ask them if they have or had a mental illness nor any sensitive information about them, I expressed to the class that it was an option not to take the survey altogether if they chose not to want to be a participant.

Since my independent variable is mental health education whose responses are nominal values and my dependent variables are based on the scale, the test I will be using to examine the relationship between my independent and dependent variable will be the Chi-square test. By conducting a Chi-square for my hypothesis, I can explore the relationship between my two categorical variables, mental health education and attitudes of mental health services.

Participants

For my population size which consists of sixty-five respondents, the demographics of my sample consisted of mostly female participants whose ages ranged between 18-23, whose ethnicity/race mainly was identified as Hispanic/ Latino and whose income often ranged from

22 less than $15,000 per year. These demographics of my respondents were to be expected since the demographics of Cal Poly Pomona’s student body are overwhelming of Latinos/ Hispanic and

Asians decent. The qualifications to take part of study was minimal, as long as you were in any of the classes I choose, participants were given the option to take part of research or the had the chance to return a blank survey to me.

Limitations

As with any other research study, my investigation does yield some limitations.

According to Mental Health America 2017 data which ranks states based on their best to worst mental health services, California is listed as number twenty-five on a national ranking. Since

California is ranked as number twenty-five, my respondents have an advantage to the limited knowledge they possess in comparison to people who live in states such as Oklahoma or Nevada who on this same list are ranked as the last two states regarding access to care. To extrapolate this data which was conducted on a college campus in Southern California to represent attitudes on a national level would not be a reflective representation since the certain demographics of people who live in Southern California is not equally seen across the United States. Another limitation of this study is my sample size. Since I was only able to collect sixty-five responses limiting my population to only sixty-five individuals this sample is not as reflective as it could be, by increasing the number of respondents in my research, my findings would be a more representative sample.

V. Results

Based on the recurrent theme that there is a lack of mental health education, I expect that limited mental health education will negatively affect the opinion of mental health services. To

examine the relationship between mental health education and attitudes of mental health

services, I used the statistical program SPSS by running three chi-square tests with three

different dependent variables while keeping the independent variable the same in all three-

separate analysis. By conducting three Chi-square tests, I was able to demonstrate that if an

individual receives mental health education, they are more likely to report lower negative

attitudes towards mental health services while at the same time finding that an individual who reported not having mental health education are more likely to report negative attitudes toward mental illness treatments.

Figure 1: Report of Respondent Mental Health Education

Based on the survey data retrieved, when examining the independent variable of whether

respondents received mental health education most of this population responded that they did not

receive mental health education. As the bar graph in figure 1 above demonstrates, a total of forty-

two respondents reported that they did not receive mental health education whereas only twenty-

three respondents reported that they did.

Figure 2: Respondents attitudes of feeling inadequate by utilizing psychological help

When examining the first statement: “I would feel inadequate if I received psychological

help,” the crosstabulation table demonstrates that a total of sixteen individuals reported that they

neither agree nor disagree with the statement based on the variable that they did not receive

mental health education. While we can only infer that based on this statement regarding mental

health services that an individual who did not receive mental health education can increasingly

make respondents report a 'neutral' attitude about mental health services, it is worth noting the

staggering difference amongst those who reported that they received mental health education.

Aside from the sixteen individuals who reported a neutral feeling, the second leading response was that eleven respondents reported that they disagreed with the statement that they would feel inadequate. Although the second leading response reports a positive attitude about mental health services, most of the responds held a neutral view which equally plays a role shaping public attitudes about mental health services. In the case of individuals who received mental health education, the leading response for the statement being examined was that a total of twelve respondents indicated that they disagreed with the statement that they would feel inadequate upon seeking psychological help via therapy. Although twelve respondents stated that they

disagree with the statement, it is also worth noting that the second leading opinion of those who

received mental health education was that a total of nine respondents who reported that they

strongly disagree with the statement. In this statement alone, at least 90% of respondents who

received mental health education rated a positive response to mental health services in

comparison to only 42% of individuals who did not receive mental health education. To further

demonstrated that there is a relationship amongst these two variables, the Pearson chi-square

value is 14.734 and the significance for this chi-square test is .005 which falls under the

threshold of .05 making this a significant value to report.

Figure 3: Respondent attitudes if they would seek help if they worried/ upset for an extended period of time

For the second statement which will examine respondent’s attitudes if they would seek

help if they were worried or upset for an extended period of time, the cross-tabulation for this

Chi-Square test demonstrates again that mental health education plays a crucial role in the attitudes of mental health services. For the second crosstabulation table, individuals who did not receive mental health education overwhelming reported that they would disagree in seeking help if they experienced troubles for a prolonged period. On the other hand, when examining this statement, the respondents who reported that they did receive mental health education, indicated

that they would agree to seek help if they were worried or upset over an extended period.

Amongst the category of individuals who did receive mental health education, the second leading

response was that seven respondents stated that they strongly agreed with this statement, making

at least 78% of respondents who received mental health education more likely to report a

positive attitude about mental health services in comparison to only 33% for those who did not

receive mental health education. The Pearson Chi-square values for this test is 14.701 and as seen with the first Chi-Square, the significance value for this test .005 which makes the relationship between these two variables significant. With the combination of the data outputted by the cross-tabulation table and the significance value for this test falling below .05, these statements further prove my hypothesis that if individuals report that they receive mental health education they are more likely to report a favorable attitude towards these services in compared to individuals who did not receive mental health education. For this statement in particular, 33 % of respondents who did not receive mental health education reported a positive attitude in contrast to 78% of those who did receive mental health education. Although this statement left the mental health treatment as unknown for the respondent to interpret, for this study, this statement can be used in examining mental health services because it corresponds with the idea that any mental health service is more likely to be viewed in a negative light depending on the individual’s mental health education.

Figure 4: Respondent attitudes if personal troubles can work out themselves without professional help

For the last Chi-Square test, the statement which will be examined is if the respondents

believed that personal troubles could work out by themselves without professional help. Based

on the last two patterns shared amongst individuals who received and did not receive mental

health education, the third Chi-Square test followed the same route. For this statement, the crosstabulation output displayed that the leading response for individuals who received mental health education can be interpreted a positive attitude. On this statement, fourteen individuals who received mental health education disagreed with the statement that personal troubles could work out without professional help. These results paralleled my hypothesis because it demonstrates that individuals who report not having metal health education will state a less favorable attitude towards mental health services than those who have had mental service education. On the other hand, for the individuals who indicated that they did not receive mental health education, the leading response in this category stated that twenty respondents agreed that personal troubled could work on their own without professional help. Although it could only be inferred that those who did receive mental health education would use mental health services should the need arise, this statement is useful in examining mental service attitudes because as the data suggest between these two groups individuals who at some point received mental health education are more likely to report positive attitudes than those who have not received mental education. For the Chi-Square created for these two variables the Pearson Chi Square values is 13.829 and the significance values is recorded at .008 which meets the significance values of being less than .05.

VI. Conclusion

While current literature suggests that negative attitudes about mental health services is

rooted in an individual’s multi-layer identity such as race or social class, my research contributes

to this current scholarship by noting that an individual’s limited mental health education may

also work as a driving force in fostering negative attitudes. As the data from my research

indicates, there are stark differences in the way respondents ranked each statement based on the

factor of whether the respondent received mental health education. For the three cases that this

study examined, more than half of the individuals who received mental health education reported

positive feelings towards mental health services in comparison to only an average of 32% of

those who did not receive mental health education. While some statements as seen with figure 2.

exhibit neutrality on the statement if they would feel inadequate if they received psychological

help, for all three tests, all three cross tabulations indicate individuals who did receive mental

health education were more likely to report positive attitudes towards mental health treatment.

Referring to the cross tabulations provided, while there were only twenty-three individuals who

indicated that they received mental health education, this small group collectively reported more

positive attitudes in comparison to those who did not receive mental health education. Although

we cannot root negative opinion of mental health services specifically to the lack of mental

health education, it is worth examining if the increasing efforts to educate large numbers of

populations would decrease negative attitudes as seen with this population size. Despite an

increase of mental health education, other factors can influence individual’s perceptions of mental health services such as the case of challenging an individual’s ideas via socialization which has been taught to them over the years of their life.

This is not to say that individuals are not aware of mental illnesses or the common

misconceptions surrounding mental illness. For this population, despite not having mental health

education both groups who did and did not receive mental health education reported positive

attitudes towards people who have a mental illness as seen in the statement “I would feel

comfortable working with someone who disclosed their mental illness towards me.” In the case,

respondents who did not receive mental health education were just as likely to report similar

attitudes to those who did receive mental health education to indicate that they would feel

comfortable with working with someone who disclosed their mental illness to them. In a similar

fashion, both groups reported that issues such as media depiction of the mentally ill usually

conveyed the mentally ill in a negative light. While there is some knowledge about the mentally

ill amongst those who reported that they did not receive mental health education, it is evident

that much work must be done to increase the knowledge we know about mental illness. One

example demonstrating our limited understanding of mental illness is the ability to name mental

illnesses that are beyond mental illnesses that are commonly known. For my last question in my

questionnaire, I asked respondents if they could list three mental illnesses that they were aware

of, after collecting all sixty-five responses, the top three mental illnesses that were reported (see

Appendix B) were Depression, Anxiety, and Bi-Polar Disorder. For this question, a total of 195 responses were possible in which depression was reported a total of forty-five times, anxiety thirty-two, and bipolar was reported a total of twenty-six times. I specifically chose to create a question measuring how frequent a mental illness is reported to demonstrate that while we do have some ‘knowledge’ about mental illnesses certain mental illnesses have gained more attention than others. By examining what individuals know and do not know about mental illness, we can start to create a dialogue about other mental illnesses that have often been overlooked publicly. On this same question, a point of equal importance is the number of responses each respondent was able to answer. While most respondents were able to list three

mental illnesses, as seen in the bar graph depicting the number of times individuals reported a

mental illness (see Appendix B), five respondents were only able to list two, three respondents

could just list one, and a total of seven respondents were unable to any. Although we cannot

conclude why some respondents could not list any responses, it further demonstrates that even in

a small population as my own which consisted of sixty-five respondents some individuals to this day are not aware of mental health services let alone what a mental illness constitutes as. While there always runs a possibility that the respondents did not list a mental illness based on the mere fact that they wanted to turn in the survey to carry on with their day, it worth exploring how someone who could not list any mental illness rates attitudes of mental health services.

Although this study was dependent on the question of whether an individual received mental health education, and how it affects their attitudes about mental health services, by conditionally accepting that mental health educations plays a significant role, future studies should examine several types of mental health educations and the effectiveness of each program attitudes on mental health services. As reiterated in my literature review, mental health education can manifest itself in several ways. It can be as simple as what services are available and how one would go about accessing these services to how these services can help an individual who experiences a mental illness to prevent someone from ending their treatment prematurely.

Alternatively, mental health education can also inform individuals about the different programs that are available which can be tailored to individual’s specific needs. In the case of people who may report that their health care provider does not speak their native language, by educating individuals about the mental health services that have providers who speak the patient’s native language, it can be inferred that they may use these services with the combination of being educated about other aspects such as how the treatment will work or how they can pay for their

31 services. As demonstrated, mental health education can take many forms, so it would be insightful to focus on one type of mental health education and the implications of how different each kind of education can affect attitudes of mental health services. Studies in the future who discuss the opinion of mental health services should also control for variables such as people who currently have or had a mental illness in comparison to those who have not experienced mental illness themselves. One could only assume that someone who has a mental illness may have different attitudes about mental health services than those who are diagnosed with a mental illness. When narrowing attitudes between these two groups, it can further our understanding in our development in creating effective mental health education which can read broad audience members.

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Appendix A

Questionnaire:

1. What is your current major: ______

2. Gender: Male Female Other: (Please Specify) ______

3. Age: ______

4. Ethnicity/Race: Asian/ Pacific Islander Black/African American Hispanic/Latino Native American/ Indian White Other ______5. Which category includes your total individual income: Less than $15,000 $15,000 to $24,999 $25,000 to $49,999 More than $50,000

6. To the best of your knowledge, does your current insurance cover mental health treatments? Yes No Not Sure Does Not apply

Please rate the following statements. Mark an “X”.

Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree

7. “I know where I can seek mental health services”

8. “If I developed a mental illness, I would not want others to know”

9. “I believe that someone with a mental illness can benefit from a mental health treatment”

10. “People with mental illness cannot make decisions for themselves”

Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree

11. “I would feel comfortable working with someone who disclosed their mental illness to me”

12. “Personal troubles can work out by themselves without professional help”

13. “I would seek help if I was worried or upset for an extended period of time”

14. “Someone who was hospitalized for a mental illness is just as trustworthy as an average citizen”

15. “The Media accurately depicts the tendencies of someone with a mental illness”

16. “I would feel inadequate if I went to a therapist for psychological help”

17. “Once someone is diagnosed with a mental illness they will never get better”

18. Have you ever received any knowledge about mental illnesses from a medical professional? Yes No 19. Have you came across an individual who has or formerly had a mental illness? Yes No 20. List three mental illnesses that you are aware of: 1. ______2. ______3. ______

Appendix B

Mental Illness Student Free Response

Schizophrenia 17 PTSD 6 Other 11

OCD 6 Not A Mental Illness 3 No Responses 7 Depression 45 Bi Polar Disorder 26

Autism 7 Anxiety 32 Alzheimers 9

0 5 10 15 20 25 30 35 40 45 50

Number of Responses Recorded Per Student

None 7

One Response 3

Two Responses 5

Three Responses 50

0 10 20 30 40 50 60

Figure 5: Respondents answer to: Please list three mental illnesses that you are aware: