Date of Award

6-1-2015

Document Type

Open Access Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Policy

First Advisor

Donna Haig Friedman

Second Advisor

Amy E. Smith

Third Advisor

Edward A. Miller

Abstract

In the United States, approximately 50 percent of people experience mental illness during their lifetimes (Cunningham, 2009). However, previous studies estimate that up to 80 percent of people living with a mental illness do not access services (Mackenzie et al., 2007). While there are numerous explanations for such disparity, this study posited that stigma associated with mental illness is a significant contributory factor.

In an attempt to address the gap between prevalence of mental illness and access to services, the Patient Protection and Affordable Care Act (PPACA), 2010 (US Government Printing Office, (a) 2011) mandated that Federally Qualified Health Centers (FQHCs) integrate physical and mental healthcare. This research employed case study methods to examine the implementation of this federal policy in FQHCs, focusing on what role, if any, stigma plays in such implementation. Analyzing data obtained from in-depth interviews and direct observations at two case study sites, as well as key informant interviews, and background information, this research explores the following questions: Does stigma impact the implementation of mental health policy and affect access to treatment in FQHCs for people living with mental illness? And, if stigma does impact mental health policy implementation and access to mental healthcare in FQHCs, how does this occur?

Study findings include: multiple definitions of and approaches for integrating physical and mental healthcare; mental healthcare being subsumed into, rather than integrated with, the medical model; and institutional stigma persisting in the agencies studied, resulting in the reinforcement of exclusionary policies and practices and limited access to mental healthcare for FQHC patients.

Empirical findings inform a new theoretical framework that identifies the role of institutional stigma in mental health policy development and implementation in FQHCs. Policy recommendations include: the adoption of non-stigmatizing practices in FQHCs; the inclusion of a single clear definition of integration within enabling legislation; restructuring of mental healthcare funding streams to facilitate agencies' access to resources; and federally mandated reporting of mental health outcomes to improve FQHC accountability. These recommendations aim to promote the equitable implementation of integration policy within FQHCs and increase access to mental healthcare for those persons in need.

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