Perceived self-stigma in the utilization of mental health services in foster care and post foster care among foster care alumni

Accepted Manuscript Perceived self-stigma in the utilization of mental health services in foster care and post foster care among foster care alumni

Margarita Villagrana, Cindy Guillen, Vanessa Macedo, Sei-Young Lee PII: DOI: Reference:

S0190-7409(17)30486-3 doi:10.1016/j.childyouth.2017.10.040 CYSR 3552

To appear in:

Children and Youth Services Review

Received date: Revised date: Accepted date:

7 June 2017 27 October 2017 27 October 2017

Please cite this article as: Margarita Villagrana, Cindy Guillen, Vanessa Macedo, SeiYoung Lee , Perceived self-stigma in the utilization of mental health services in foster care and post foster care among foster care alumni. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Cysr(2017), doi:10.1016/j.childyouth.2017.10.040

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ACCEPTED MANUSCRIPT Perceived Self-Stigma in the Utilization of Mental Health Services in Foster Care and post Foster Care among Foster Care Alumni

Margarita Villagrana*

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Cindy Guillen

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Sei-Young Lee

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Vanessa Macedo

*Corresponding Author: San Diego State University School of Social Work 5500 Campanile Drive San Diego, CA 92182-4119 Tel: 619-594-550 Email: [email protected]

ACCEPTED MANUSCRIPT Perceived Self-Stigma in the Utilization of Mental Health Services in Foster Care and post Foster

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Care among Foster Care Alumni

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Abstract Foster youth experience higher rates of mental health disorders and receive higher rates of mental health services in comparison to the general population. Yet, upon foster care exit, mental

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health service use drastically declines. Little is known as to the reasons for mental health service

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decline after foster care exit. However, research studies in the mental health literature have

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consistently shown that self-stigma and public stigma are significant in mental health service receipt. Studies have also shown that self-stigma affects an adolescent’s self-identity, self-

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efficacy, and interpersonal relationships, which impact self-sufficiency once youth leave foster

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care. This study explores self-stigma in the utilization of mental health services while in foster care and whether the stigma developed while in foster care impacts mental health service use

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upon foster care exit. The role of public stigma in the utilization of mental health services post

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foster care is also examined. Thirteen former foster youth with a mental health treatment history while in foster care were interviewed. Results show that foster youth experienced self-stigma,

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which increased the negative impact of mental health service receipt while in foster care. After

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foster care exit, youth who identified experiencing self-stigma while in foster care tended to discontinue mental health services after foster care exit. In contrast, foster youth who did not

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identified self-stigma in the receipt of mental health services while in foster care continued accessing services upon foster care exit. Public stigma was not identified as influencing mental health service use post foster care, but was coupled with negative labels, stereotypes, and negative perceptions. Implications for preventive and intervention measures are also discussed.

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1. Introduction Studies have consistently shown that foster youth continue to experience higher rates of

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mental health disorders in comparison to the general population (Anticil, McCubbin, O’Brien &

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Pecora, 2007; Courtney and Dworsky, 2006; Pecora, Jensen, Romanelli, Jackson, & Ortiz,

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2009; Scozzaro & Janikowski, 2015). This prevalence can be partly attributed to traumatic histories (Greeson et al., 2011) and genetic predispositions (Munson & McMillen, 2010).

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Consequently, while in foster care, foster youth receive higher than average mental health

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services when compared to youth in the general population (Harman, Childs, & Kelleher, 2000; Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004; McMillen, Zima, Scott, Ollie, Munson, &

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Spitznagel, 2004). However, the quality, consistency, and appropriateness of the mental health

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services provided vary (Raghavan & McMillen, 2008; Zito et al. 2008). For example, Munson and McMillen (2010) found foster youth’s depression levels to remain relatively consistent

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after foster care exit.

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before and after exiting foster care, even though their mental health utilization generally declined

Studies have also shown that after foster care exit there is a dramatic drop (54-60%) in

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mental health service use (McMillen & Raghavan, 2009; Villagrana, 2016). This is concerning considering that mental health disorders experienced by foster youth have a high tendency to remain well into adulthood, especially when left untreated (Munson, Narendorf,& McMillen, 2011). For instance, Pecora et al., (2003) examined the reported mental health problems experienced by foster youth and young adults in the general population, finding that former foster youth fared worse than their counterparts with 54.4% of former foster youth reporting a

ACCEPTED MANUSCRIPT current mental health problem compared to only 22.1% of the general population. Rates of posttraumatic stress disorder (PTSD) were also significantly higher with 25.2% compared to only 4% of the general population, and major depression was also higher for former foster care youth than the general population with 20% and 10%, respectively.

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Living with a mental health disorder and facing other social obstacles while transitioning

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to young adulthood, places foster youth at a higher risk for negative life outcomes such as

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homelessness, unemployment, incarceration, school drop-outs, health complications, and drug abuse (Bender, Yang, Ferguson & Thompson, 2015; Courtney & Dworsky, 2006; Cusick,

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Havlicek & Courtney, 2012; Harris, Jackson, O’Brien & Pecora, 2009; Iglehart & Becerra, 2002;

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Lee, Courtney & Tajima, 2014; Villegas, Rosenthal, O’Brien, & Pecora, 2011; White, O’Brien, Pecora & Buher, 2015). The compilation of these circumstances, coupled with a lack of mental

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health services, increases the difficulty in obtaining self-sufficiency. For example, Lenz-Rashid

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(2006) found that homeless transitional youth with a history of foster care and mental health issues were less likely to find employment and earn far less than youth with no history of foster

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care and mental health issues. Similarly, Naccarato, Brophy, and Courtney (2010) found that

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youth with a history of PTDS and/or affective disorders earned significantly less than youth without these disorders.

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To assist in addressing negative outcomes experienced by transitioning age youth, Assembly Bill (AB) 12 was passed in 2010, extending foster care to the age of 21. The goal was to increase the creation of safety networks for foster youth and provide educational and employment opportunities to better assist during the transition to adulthood (CA AB 12, 2015). The Affordable Care Act (ACA) was also passed in 2010, extending the provision of Medi-Caid to the age of 26 for foster youth (Jaudes, Pawelski, Pellegrini & Walter, 2012; Emam & Golden,

ACCEPTED MANUSCRIPT 2014). Both policies promote the continuation of social services, including mental and behavioral health services (Sommers, Buchmueller, Decker, Carey, & Kronick, 2013). Notably, foster youth that continue in foster care after turning 18 yr. old are more likely to access health services resulting in positive outcomes, in contrast to foster youth who exit care at age 18

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(Courtney & Dworsky, 2006).

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Although policies have been put in place to assist former foster youth in the continuation

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of mental health services, reasons for the underutilization of mental health services once youth exit foster care are unclear. Studies examining treatment adherence with former foster youth

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have mainly focused on the therapeutic relationship and effectiveness of treatment (Lee,

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Munson, Ware, Ollie, Scott, & McMillen, 2006; Scott, Munson, & White, 2009). Few studies, however, have focused on the stigma surrounding mental health service use. Stigma can be

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defined as negative labels that are imposed and devalue and stereotype the person being

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addressed (Link & Phelan, 2001). Stigma can be experienced both internally (i.e., self-stigma) and externally (i.e., public stigma), with self-stigmatization fueling self-condemnation and

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(Link & Phelan, 2001).

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ridicule, and public-stigmatization fueling judgments and limitations imposed by other people

Mental health stigma brands mental health recipients with unfavorable labels that are

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intended to confine them, such remarks may label someone as “retarded”, “crazy”, “incompetent”, and/or “challenged” (Jorm & Griffiths, 2008). In studies with youth in the general population, mental health stigma has been associated with the avoidance of seeking treatment as youth fear being labeled “crazy” (Lindsey et al., 2006), and are afraid of negative responses from peers (Pinto-Foltz, Hines-Martin, & Logsdon, 2010). With youth in foster care, researchers have found that some youth believe that a person receiving mental health treatment

ACCEPTED MANUSCRIPT would be devalued and discriminated against (Scott, Munson, McMillen & Snowden, 2007). Youth in foster care have also reported dual stigma with being a mental health recipient and placed in foster care (Jee, Conn, Toth, Szilagyi, & Chin, 2014). For example, researchers found that foster youth were hesitant to utilize mental health services, fearing they would be viewed

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different due to, not only being in foster care, but also being perceived as mentally unbalanced

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(Jee et al., 2014).

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2. Significance of current study

Studies of stigma in the mental health literature have consistently found that self-stigma

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is deleterious to an adolescent’s self-identity and self-efficacy, which in part, devalues their self-

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esteem and impacts the development of autonomy during a crucial developmental stage (Kranke, Floersch, Kranke, & Muson, 2011; Kools, 1997). With adolescents in foster care, stigma not

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only affects their self-identity, but also impacts interpersonal relationships and future aspirations,

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thus impacting self-sufficiency once youth leave foster care (Kools, 1997). Research has also found that self-stigmatization impacts an individual’s willingness to access mental health

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services for fear of public discrimination (Corrigan & Kleinlein, 2005). However, few studies in

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the child welfare literature have examined self-stigma in the utilization of mental health services among former foster youth, and even fewer studies, have used in-depth interviews to gauge the

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lived experiences on whether self-stigma might affect former foster youth’s continued use of mental health services post foster care exit. The present qualitative study seeks to address the gap in the literature by exploring the perception of self-stigma youth form while in foster care, and the influence it may have upon foster care exit in the utilization of mental health services. Quality research is invaluable in shedding light on lived experiences of how stigma affects an individual’s life; understanding the stigma associated with the utilization of mental health

ACCEPTED MANUSCRIPT services among former foster youth is critical in developing appropriate methods of providing mental health interventions to youth while in foster care and upon exit from the foster care

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system.

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3. Method

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3.1. Sampling Procedures

This study used purposive, convenience sampling. Participant inclusion criteria included:

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1) between 18-24 yr. old; 2) emancipated or aged out of the foster care system; and 3) received

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mental health services while in foster care. All participants were recruited from one county in Southern California. Flyers and announcements were distributed to agencies within the county

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serving foster care alumni. Additional participants were recruited using snow ball sampling in

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which participants referred other foster care alumni who met the selection criteria. Participants were asked to contact the principal investigator by telephone or text message to obtain

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information about the study. Participants were screened for eligibility via text message (all

3.2. Participants

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participants made contact via text message), and invited to participate in a face to face interview.

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Thirteen former foster youth (hereafter foster care alumni) participated in in-depth semistructured interviews. The majority of participants (85%) had completed some college or had graduated high school as part of their education. The majority of participants were also female (70%), and 39% of participants identified as bi-racial or multi-racial, 23% as Caucasian, 23% as Latino, and 15% as African American. The average age of participants was 21 yr. old, with two having been married at some point, but currently divorced. Only three participants had children,

ACCEPTED MANUSCRIPT with two having had their child placed in kinship care. The average number of living arrangements since emancipating from foster care among participants was 6 different homes, ranging from 1 to 19. All participants had Medi-cal and almost half had received food stamps. The average number of jobs held since emancipating from foster care was 3, with a range from

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1-8. The majority of participants had entered the foster care system only once (62%), followed

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by two times (31%), and four times (7%). Age at first entry into foster care ranged from

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newborn to 14 yr. old, with the majority of participants being 0-5 yr. old (54%) and 6-10 yr. old (31%) when entering for the first time. Overwhelmingly, the majority of participants had been

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removed from their home due to allegations of neglect (85%). The average number of

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placements experienced by all participants was 13, with 54% having been placed in up to 10 different placements, 31% in up to 20 different placements, and 15% in up to 30 or more

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placements.

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All participants had received weekly individual therapy as part of their mental health treatment, only two had also received group and family therapy, 70% had received at least one

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type of psychotropic medication, and length of time in treatment ranged from 1 year to 12 years

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(𝑥̅ = 6), or the duration of the participant’s time in foster care. However, participants who reported a longer time in treatment also reported disruption in mental health service use due to

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foster care placement changes. 3.3. Interviews

In-depth semi-structure interviews were used to obtain foster care alumni perceptions of mental health stigma in the receipt of mental health services while in foster care, and their current perceptions of individuals with a mental illness. The interview guide was developed by the first author and consisted of asking participants about negative experiences while receiving

ACCEPTED MANUSCRIPT mental health services while in foster care (i.e., “Was there ever a time when you thought receiving mental health services might give a negative impression or negative label? If so, can you provide me with an example of where this happened?”), and about public perceptions of mental health consumers. For the latter, questions were modified from Wahl’s (1999) Mental

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Health Consumers’ Experience of Stigma survey, where Wahl constructed questions based on

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stigma and discrimination experiences using first person accounts of mental illness and input

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from representatives of the National Alliance for the Mentally Ill (NAMI). For the current study, five questions were used and modified to include personal experiences in avoiding telling others

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of mental health service receipt and the perceptions others have about consumers of mental

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health services. Questions included probes to provide detailed experiences and specific examples from participants to better gauge the participants’ perceptions. Interviews also

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included questions on demographic information, foster care history, and receipt of mental health

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services while in foster care and upon emancipation from foster care. The interview guide was pilot tested prior to administration. Interviews were face to face at a location chosen by the

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participant. Interviews were audio recorded with the participant’s permission and lasted

3.4. Analysis

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approximately one hour. All participants were compensated with a $30 gift card for their time.

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Audio-recordings of interviews were transcribed verbatim. Transcripts were analyzed using content analysis as outlined by Corbin and Strauss (2015). The first and third author coded the transcripts using open and axial coding. The first stage in coding consisted of open coding where each distinct incident or idea was identified and labeled, the incidents or ideas were then grouped to represent a category (i.e., phenomena), followed by the labeling of the categories, and then the development of properties for each identified category. The second stage consisted of

ACCEPTED MANUSCRIPT axial coding where connections between categories and subcategories were made. The purpose of axial coding is to relate categories and concepts to each other (Corbin & Strauss). For this study, axial coding focused on the perceived stigma (i.e., self-stigma and public stigma) by the foster youth during foster care and after foster care exit in the process of continued use of mental

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health services (see Figure 1). To assess for inter-rater reliability, both authors reviewed the

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coding results to determine agreement on each phase of coding with 90% interrater agreement.

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Limitations of the study include the small sample size, participants recruited from only one urban Southern California county, retrospective accounts of mental health service use and

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foster care experiences from the participants, and no other data were collected such as case

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record reviews to triangulate the participants account of events. Given these limitations, the results are presented below.

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4. Results

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Figure 1 is the conceptual model of foster care alumni perceptions of mental health stigma and service use. The model was developed based on interview content and focuses on the

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perceptions of mental health self-stigma while the youth were receiving mental health services in

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foster care and after foster care exit, the public stigma toward consumers of mental health services, and whether youth were currently receiving mental health services. Self-stigma is

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defined as the acceptance of prejudicial notions and internalized images by individuals with a mental illness that lead to a lower self-esteem, and public stigma as the negative social behaviors, reactions, and beliefs directed toward those with a mental illness (Corrigan & Kleinlein, 2005). Findings show that the perceptions of self-stigma formed while in foster care continued post foster care and influence the continued use of mental health services after foster care exit. Perceptions of public stigma of consumers of mental health services post foster care

ACCEPTED MANUSCRIPT do not seem to influence current mental health service use. However, they do appear to

Post Foster Care

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Foster Care

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influence the youth’s understanding of society’s perception of individuals with a mental illness.

Current Mental Health Utilization

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Public Stigma Negative (Harsher) Perception

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+ Self-Stigma

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Self-Stigma

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_ Service Use

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Public Stigma Positive (Kinder) Perception Figure 1. Foster Care Alumni Perceptions of Mental Health Stigma and Service Utilization + = stronger; MH service use - = weaker; no MH service use

ACCEPTED MANUSCRIPT Table 1 presents reported self-stigma while in foster care, self-stigma post foster care, public stigma post foster care, and current mental health service use. The majority of youth reported self-stigma while in foster care (70%). Once youth exited the foster care system, the self-stigma developed while in foster care appeared to carry over and influence the youth’s

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current mental health service use. Only 38% (5) of the youth either continued with their current

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mental health services or were able to secure services after leaving foster care. However, only

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three youth who reported no stigma in the utilization of mental health services while in foster care continued receiving services after foster care exit. Two youth who reported self-stigma

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while in foster care were receiving mental health services, but one youth was only seeing a

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psychiatrist once a month for approximately five minutes for medication management and the other youth reported no self-stigma post foster care. Further research is warranted to better

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understand the factors behind the findings for these two youths. The majority (62%) of youth

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were not receiving mental health services and indicated they either had worked out their issues while in foster care or did not feel they needed to continue with services. These youths,

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however, were also the same youth who reported self-stigma while in foster care. Youth who

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reported no self-stigma during foster care and post foster care also reported that public stigma was a misunderstanding of society’s views of consumers of mental health services as the public

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did not fully understand what mental health treatment entailed nor the reasons for someone seeking services. Participant

Foster Care

Post Foster Care

Self-Stigma

Self-Stigma

Society’s View of Consumers of MHS -

Current MHS Use

Public Stigma 1

No

No

Misunderstanding

Therapist as needed

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Yes

Negative Label

No therapy

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No

No

Misunderstanding

Weekly therapy

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Yes

Yes

Stereotypes/Negative Label

No therapy

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No

No

Misunderstanding

Individual therapy

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Yes

Yes

Stereotypes/Negative Label

No therapy

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No

No

Stereotypes

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Yes

Yes

Negative Label

9

Yes

Yes

Stereotypes/Negative Labels

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Yes

Yes

Negative Label

No therapy

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Yes

Yes

Stereotypes/Negative Label

Psychiatrist

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Yes

No

13

Yes

Yes

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No therapy – has attempted 3 times No therapy No therapy

Negative label

Therapy

Stereotypes/Negative Labels

No therapy

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Table 1. Self-stigma while in the foster care system and self-stigma and public stigma post foster care and current mental health service use among foster care alumni.

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Several themes emerged while in foster care and after foster care exit. In examining self-

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stigma while in foster care, two main themes emerged: dual stigma and avoidance of sharing receiving mental health services. The themes related to self-stigma that emerged after foster care

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exit consisted of avoidance of sharing having received mental health services while in foster care or currently receiving mental health services, and being given a negative label for having received mental health services. In examining public stigma related to an individual’s perception of consumers of mental health services, three themes emerged: lack of understanding, negative perceptions, and stereotypes of consumers of mental health services. 4.1. Self-Stigma while in foster care

ACCEPTED MANUSCRIPT Foster care alumni were asked to remember if there had ever been a time while they were in foster care, and receiving mental health services, if they thought that receiving mental health services would give others a negative impression of them or give them a negative label. Two themes emerged:

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4.1.1. Dual stigma

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The majority of foster care alumni (70%) indicated there was already a stigma with being

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a foster youth and others knowing they were also receiving mental health services only exacerbated the stigma. In the next quotes, foster care alumni explain what they perceived others

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thought of them being in foster care and receiving mental health services.

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I just didn’t like people asking so many questions all the time. ‘Cause it was already weird enough for them to ask me, “Oh, why do you live with your cousin?” You know, it was like already I was getting a lot of that and my cousin was, my cousin was really like not jealous of me, but she, she did show that jealousy. You know like she would like tell them like, “Oh, I don’t like her living with me” or something you know. So, them knowing I was going to therapy was just not good, you know.

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I don’t know. I feel like, I think they really view you differently once you’re a foster kid, you know. And then like, “No, I’m not just a foster kid, I’m a foster kid like with some deep issues”. I think when most people think of like people in therapy, they think like people that are like extremely suicidal or like really violent, you know.

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Uh, kind of like the same thing with the whole foster kid thing like, “Oh, that kid’s in…they need therapy. They need help. Like obviously they’re fucked up. Like stay away from them”. Like I used to get that a lot when I was younger.

4.1.2. Avoidance of Sharing Foster care alumni also worried that if others knew they were receiving mental health services while in foster care, it might give them a negative label, so they avoided bringing up the subject or telling others they received mental health services. The following quotes display the foster youth’s concern with others finding out.

ACCEPTED MANUSCRIPT I wasn’t necessarily telling my friends like, “I see a therapist every week”. So, I just like the, the other kids at the group home like, knew that I see the therapist because they had one too, but like outside of like, the foster care system, I wasn’t telling my friends like, “Oh yeah, I see a therapist every week.” I was hiding it… I just didn’t want to be seen as different than them.

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A lot of it was feeling like I think it relates back to the stigma. I think people think that, you know, oh like I, I was worried what people might think or judge me or that they wouldn’t understand. Or, um, you ask a lot of questions and that, that can be extremely uncomfortable. So it was kinda like, um, just wanting to avoid the conversation and I knew if I didn’t bring it up then the conversation never gonna happen, so.

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Um, when I was 13… my friends would ask me, “Hey, where were you during fifth period? Where were you in sixth period?” Because I wasn’t, I mean, I was the one to skip school on occasion… but not when I was around my friends. Like if it was the same period as them, I wouldn’t skip it. So, I’d never say, “Hey, I have therapy,” you know, “I go to therapy.” I would just tell them, “Ah, I felt sick,” or “I just decided I didn’t want to go,” or… “I just had to leave you guys because I think it’s cool to be by myself,” and… so I lied a lot. 4.2 Self-Stigma after foster care exit

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As current foster care alumni, youth were asked whether they had shared or told friends

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and/or family of the receipt of mental health services while in foster care, and if currently receiving mental health services, if they were open about the use of services.

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4.2.1. No Stigma

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Youth who reported no stigma or concern of a negative label while in foster care, tended to be open about the fact that they had received mental health services as a foster youth, and if

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currently receiving services were also open about it. Yeah. No, I didn’t really withhold the information, ‘cause I didn’t see any reason to. You know, I wasn’t embarrassed, or I didn’t think there was anything wrong with it, personally. Um, Oh I tell people that, “You know, yeah, throughout my life as a foster child I went to therapy.” Yeah, it’s not a bad thing to go to therapy. 4.2.2. Avoidance of sharing

ACCEPTED MANUSCRIPT Foster care alumni who indicated there was a double stigma attached to being a foster youth and receiving mental health services while in foster care, tended to have the same perception as young adults. The majority avoided telling others they received mental health services either as a foster youth or were currently receiving services because they were

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embarrassed or didn’t want to be perceived as not being able to handle issues.

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Yeah, because they think you’re crazy or something. Or like even if, like even if you come across as like you’re not like a basket case but if you say that you’re receiving therapy, people start to think like, “Oh, God, she must really be a basket case.” Like if they think like if you’re receiving therapeutic services that something must like not be held there or you must be crazy or, you know, like they don’t want to deal with it, you know. You must have issues.

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Yeah, to this day I am. Um, not afraid but, um, I just don’t tend to disclose that information because people can be close minded and judgmental and there’s a stigma attached to it. So I tend to not disclose that because people think like, they either want to look down upon you or they want to pity you or they want to judge you, or they think that you’re like a basket case or something.

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(Chuckle) I don’t know. I think it’s embarrassing. I don’t know like the fact like, I can’t deal with my issues on my own. So like I think that’s embarrassing. Um, I don’t know, I just normally don’t tell people.

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4.2.3. Labeling

Foster care alumni indicated they were concern about being given a label, if they

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disclosed they had or were receiving mental health services. Most stated people didn’t

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understand the experiences foster youth had to go through and were concern about being given a negative label.

Sometimes people don’t understand like situations or what you’ve been through. Like you know you can’t just get over certain things. Like you can’t get over the fact that you know your dad is like the worse kind of person, you know. Well, um, I don’t know what to say. I think the only thing that I don’t like about that is I don’t like being called mental. I don’t like being called disabled and I really don’t like people telling me that I have a disability. I already know that but, you know, it’s not a disability to me. It’s just something… it’s something extra that was added to my personality.

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4.3. Public perception of mental illness To gauge external influences on the youth’s perception of mental health stigma, youth were also asked about public perception of consumers of mental health services. Youth were

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asked whether consumers of mental health services were viewed unfavorably or treated as less

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competent, and whether they had heard offensive things said about someone with a mental

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illness. 4.3.1. Lack of understanding

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Most foster care alumni indicated that people in general have a lack of understanding

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toward individuals with a mental illness. Youth also indicated that most people do not understand what therapy is and why someone attends therapy. Additionally, youth who were

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comfortable with having had mental health services while in foster care and were open about

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their current use tended to have a more favorable perception of mental health services.

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Well, depending, yeah, there is sometimes like depending on the situation and how they’re coping with it, like a lot of people think, like, that they’re crazy when they’re going to therapy you know. Or like, or you know they, they think like it’s, ah that’s legit, something like crazy going on in their mind, when you have a therapist, and it’s like, “No”, like therapists are also used just to talk to, you know.

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I feel as though people, uh, will tend to look at people who are in therapy like, “Oh, I need to tip toe around you because obviously there’s something wrong with you.” And which is kind of ridiculous because there are some people that you do have to tip toe around, but as a generalization stereotype, it’s a little bit disrespectful and it makes it harder for people to come out and be like, “Hey, I have issues. I need help.” Because a lot of the times people think that because you see a therapist, there’s something seriously wrong with you. Like, “Oh there’s something wrong with you. You have this problem. You must be crazy. You must need medication.” And it’s not necessarily like that. Like I said it’s [therapy] just like venting to any of your friends. 4.3.2. Negative perceptions

ACCEPTED MANUSCRIPT Youth indicated that people in general have a negative perception of someone with a mental illness and will tend to view them less favorably or less competent. I just think they, they look down upon you and they pity you. They think that you’re not like capable. Like you know, like, “Oh, God. Poor you”. You must just, you know, not be like, be able to be self-sufficient because you’re so damaged and traumatized. You know?

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I think that if, you know, I think if you went into a job and you had these two exact same resumes and one disclosed that, you know, I was in therapy for two years, like that candidate would be chosen lesser than the one that doesn’t disclose that. It’s not viewed as something positive or that, “Oh, I, you know, I, respect you for doing that or I acknowledge where you’ve come from.” It tends to be like, oh, like people think maybe like this is something we’re going to have to worry about in the future or is this something that is gonna affect you now. Like what, what happened that caused that? There’s a lot of questions so that, I, I can’t really think of, of a situation where that would be a positive that, to share that.

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4.3.3. Stereotypes

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Youth also indicated that the general public uses a mental health disability or illness to offend people when they are viewed as not capable. Stereotypes are the norm when identifying

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someone who doesn’t meet the standard, especially among young people.

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Anyone who has anything is disabled. Like if you have ADHD, you’re disabled, if you have… Like they just… Everything is disabled to them, unless you’re a perfect, normal person who is able to do everything and perfectly, which is not gonna happen, just FYI cuz there is no one perfect…

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But I have heard how people talk really bad about some friends that I know like, “Oh, yeah, he’s schizophrenic, he’s fucking crazy. Stay away from him. He’s a weirdo. He’s a schizo, Eew.” Like, stuff like that. Friends, they, like, yeah, they do it, but they don’t do it realizing that, you know that could potentially hurt somebody, you know… People are like, “Oh, that guy’s retarded”, you know and he’s not retarded, but maybe there’s somebody behind you who is really retarded, you know. Or has, um, maybe like autism, or you know, like they, and a lot of people label things the wrong way, you know. 4.4. Current mental health service use

ACCEPTED MANUSCRIPT Current mental health service use by foster care alumni was indicative of whether the youth had a positive perception of mental health services. Youth who indicated there was a double stigma in being a foster youth and receiving mental health services while in foster care (70%), were less likely to have continued services or identified a need for continued service use.

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Conversely, youth who reported a positive perception of mental health service use while in foster

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given for continued services or for stopping services:

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care and were open about service use (30%) continued service use after foster care exit. Reasons

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I’ve been able to process some things that happened to me. And it’s, so it wasn’t… I’m not so much living in it now. It’s kinda just moving forward and I didn’t feel like I needed extra support in that. It’s something I’ve kinda handled on my own.

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Because I believe I don’t need them [mental health services].

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I just noticed that like sometimes I would just be like agitated, or like, I would feel stressed out or things, when it’s like “why am I stressed out, I don’t even need to be stressed out right now.” You know, and it was like oh, like, maybe, I should just go talk about everything, you know, so it was just like to vent to somebody that would listen without being biased, or think, like “Oh why are you mad at me?”

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Because I feel like if you do have problems in your life, you know, if you do go through something as traumatic as the [foster care] system, you should go see a therapist.

5. Discussion

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Because I would like to start therapy to work on my anger issues.

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The purpose of the current study was to explore the perceived stigma associated with the receipt of mental health services while in foster care and upon foster care exit by foster care alumni. This study adds to the literature on mental health services research for foster care alumni as few studies have examined mental health service use among foster care alumni. The examination of perceived stigma provides information as a potential factor that may contribute to the continuation of mental health service receipt or the disruption of service use once youth leave foster care.

ACCEPTED MANUSCRIPT The current findings show that while in foster care, youth perceived being in foster care as having a stigmatizing effect on their ability to be accepted by their peers. Few studies have examined the effect being in foster care has on a youth’s status within their peer group and the impact the internalized stigma of foster care has on the youth’s development. However, this is

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an important research finding because adolescence is a time for identity formation, and

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internalized self-stigmatized attitudes can hinder a youth’s ability to developed self-sufficiency.

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For example, Kools (1997) conducted a study on the impact of long-term foster care on adolescent identity, and found that the experiences encountered and perceptions developed while

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in foster care lead to the adolescent’s devaluation of self by others and the protection of self.

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The placement in a foster home led to the youth’s status of “foster child” in which the status was perceived as “abnormal”, “bad”, and “damaged”. These labels also led to negative stereotypes of

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“delinquent” or “psychologically impaired” in which the youth was expected to behave and be

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treated accordingly. Kools further found that the stigma associated with being a foster youth often leads to social isolation as the youth disconnects to avoid the perceived differences in being

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a foster youth, which often leads to difficulty in establishing and maintaining interpersonal

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relationships. Coupled with the stigma associated with the receipt of mental health services, this only serves to exacerbate the youth’s ability to form and develop peer relationships and hinders

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the utilization of mental health services that are often needed to address behavioral issues that may further impact the youth’s ability to remain and maintain stability in placement. For instance, Jee, Conn, Toth, Szilagyi, and Chin (2014) found that double stigma was a barrier in accessing mental health services as youth feared being viewed differently due to being in foster care and considered “mentally unstable” or “defective”.

ACCEPTED MANUSCRIPT Youth also feared being given a negative label by their peers if receipt of mental health services was known. Since adolescence is a time where affiliation and identification with a social group is critical, being associated with a peer group provides adolescents an evaluative norm (Leavey, 2005; Pescosolido, Perry, Martin, McLeod, & Jensen, 2007; Moses, 2014), and

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being labeled as different only serves to further stigmatize the youth. For example, Kranke,

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Floersch, Kranke, and Munson (2011), examined the self-stigma among adolescents taking

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psychotropic medication in the general population, and found that adolescents compared themselves with those not taking medication and mirrored their behavior to fit in with their social

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environment. Youth were also reluctant to accept themselves when using medication because

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they felt shame as they viewed themselves different from their peers. Consistent with previous research studies, results show that foster care alumni avoided

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disclosing past or present use of mental health services. These findings are not surprising as the

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public’s opinion of mental health consumers can lead to stigmatizing labels. For example, in a study of adolescents with no foster care history who had recently been hospitalized for a mental

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health problem, the majority of youth reported experiencing some form of mental health stigma

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which consisted of being devalued, disrespected, emotionally insulted, and being under estimated (Moses, 2014). In a similar study, Chandra and Minkovitz (2007) found that a mental illness

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was perceived as a weakness on the part of the individual and being the person’s fault. Further, non-disclosure of mental health service receipt appears to protect the individual from negative perceptions and/or labels. For instance, Kranke, Floersch, Kranke, and Munson (2011) found that adolescents protected their self-image and reputation by not sharing or covering up any evidence that linked them to a mental illness or use of psychotropic medication. Similarly, in a study conducted by Moses (2010) of adolescents in the general population with diagnosed

ACCEPTED MANUSCRIPT emotional and behavioral disorders, results showed that adolescents who reported no peer stigma were the ones who did not disclose their mental health status or were careful never to bring it up in conversation. Moses (2009b) further stated that while avoidance of sharing receipt of mental health services is not related to negative psychological well-being, the consequences of coping

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with the stigma in this manner as a long-term strategy may result in lack of social support and

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anticipatory anxiety.

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The public’s perception of mental illness did not appear to hinder utilization of mental health services, as the stigmatizing attitudes formed while in foster care carried over into young

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adulthood; however, the public’s perceptions were significant in developing the youth’s

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understanding of consumers of mental health services. Consistent with previous research findings, youth reported a lack of understanding, negative perceptions, and stereotypes by the

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public toward individuals with a mental illness. Similar to the current study’s findings, Chandra

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and Minkovitz (2007) found that youth tended to equate good mental health with intelligence, and conversely, poor mental health with mental retardation. In the same study, youth also tended

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to describe individuals with a mental illness with lack of hope and limited options as well as with

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more negative stereotypes. Similarly, using a nationally representative sample of adults in the US, Pescosolido, Perry, Martin, McLeod, and Jensen (2007) also found that over half of the

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sample agreed that mental health treatment would make a child an outsider at school and the child would suffer as an adult if others learned that he/she had received mental health treatment when young. Using the same study, Martin, Pescosolido, Olafsdottir, and McLeod (2007) found that one in five adults were reluctant to have their children interact (i.e., living next door, in the same classroom, or as a friend) with other children who displayed clinical symptomatology.

ACCEPTED MANUSCRIPT While the majority of youth were not currently receiving mental health services, the selfstigma they had developed while in foster care was not the reason given for discontinuation of mental health services or lack of continued interest in service receipt. The majority of youth indicated they did not perceive a need for mental health services. This finding is concerning as

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adolescent mental health issues that go unresolved have the potential to develop into chronic

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mental health conditions in adulthood (Munson, Narendorf, & McMillen, 2011). Lack of

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understanding of their own mental health and the stigmatizing attitudes and perceptions formed while in foster care can be attributed to the fact that youth may distance themselves from any

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notion of having mental health issues as a means of protecting themselves. For example, in a

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study conducted by Moses (2009a) of non-foster youth receiving mental health services, results showed that more than a third of the sample did not view themselves as having a mental health

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issue and attributed their “behavioral” problems as normal and minimized the seriousness of the

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problem. Youth in the same study also tended to show confusion or uncertainty in

mental health issue.

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conceptualizing their mental health problems and were unsure as to whether they actually had a

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6. Implications for practice

Several implications are derived from the study’s findings for prevention and intervention

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strategies geared toward addressing the self-stigma and public stigma associated with the receipt of mental health services by youth in foster care. Support groups is an intervention strategy that has been shown to be successful with youth and a preferred method for foster care alumni (Munson & Lox, 2012). Research supports the use of groups for helping with the stigma associated with a mental illness. For example, Crabtree, Haslam, Postmes, and Haslam (2010) found that within a mental health support group the identity and affiliation with peers who also

ACCEPTED MANUSCRIPT share the same struggles may help combat interpersonal stigma, with the group serving as “stigma resistance” and providing a more positive self- image as group members are less likely to buy into stereotypes. Other studies have also found similar findings in that social acceptance is greatest with peers who share similar mental health problems (Kranke, Floersch, Townsend, &

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Munson, 2010; Moses, 2011). Social support systems are also crucial in buffering the effects of

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mental health stigma. For example, Mueller, Nordt, Lauber, Rueesch, Meyer and Roessler

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(2006) found that social support predicted less stigma for adults who had been recently hospitalized with a diagnosed severe mental illness. Providing support groups in place of or in

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addition to individual therapy and other treatments has the potential to assist older youth in foster

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care and foster care alumni to develop coping mechanisms and resiliency in better understanding their mental health, form support networks, and develop self-efficacy in managing mental health

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issues post foster care.

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Education has also been a widely used tactic as a prevention strategy in tackling the stigma associated with a mental illness and has been found to be successful in addressing

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stigmatizing attitudes. For example, in a study conducted by Chandra and Minkovitz (2007) of

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8th grade students, researchers found that students who had limited or inaccurate information were more likely to have stigmatizing attitudes toward individuals with a mental illness and had

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more negative views about using mental health services. In contrast, youth who had gained knowledge about mental health were more likely to have more positive views of an individual with a mental illness. Although research findings indicate that mental health attitudes changed due to educational trainings are not maintained over time (Corrigan et al., 2001); Public Service Announcements (PSAs) can be beneficial if the focus is the target of change (Corrigan & Wassel, 2008). Additionally, research in the reduction of stigma has found that social contact

ACCEPTED MANUSCRIPT based interventions are more effective than education alone (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Corrigan, Green, Lundin, Kubiak, & Penn, 2001). However, the mere contact of an individual is not enough, it’s the quality of the contact which needs to be voluntary, equal, intensive, prolonged, and rewarding (Martin, Pescosolido, Olafsdottir, & McLeod, 2007).

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Since youth reported self-stigma associated with being in foster care, educational efforts

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can also be implemented to address the stigma associated with being in foster care. Addressing

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the stigma associated with being a “foster child or youth” can have the potential to provide the public with a better understanding as to the needs for mental health services for this population

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due to the trauma experienced from the abuse, the removal from the home, the acclimation to a

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new foster care placement, new school, and the experiences of the court and child welfare systems. Studies have shown that a high rate of social empathy can serve as a buffer in

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endorsing stigmatizing attitudes about a group (Batson, Chang, Orr, & Rowland, 2002).

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Education may have the potential to elicit empathy with, not only the public, but with all those involved with such a vulnerable population.

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7. Conclusion

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The child welfare system has most recently enacted policies to address the mental health needs of children and youth who enter the foster care system. For example, the efforts put in

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place in California due to the Katie A settlement agreement in which there is a collaborative effort for the child welfare and mental health systems, and service providers, to provide needed mental health services for children, youth, and families who enter the child welfare system (i.e., Pathways to Mental Health Services – Core Practice Model) (DHCS.ca.gov, 2017). However, while efforts are in place to address the mental health needs for children and youth, less is known about the outcomes of these efforts. Research has consistently shown that once youth exit the

ACCEPTED MANUSCRIPT foster care system, mental health service use drops dramatically (54-60%) (McMillen & Raghavan, 2009; Villagrana, 2016), also evidenced by the current study’s findings with 62% of the youth not continuing with mental health services post foster care. Reasons for the dramatic drop in mental health service use are unknown, but the importance of understanding the stigma

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associated with the receipt of mental health services is crucial as it can have serious

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consequences and lead to unfavorable behaviors such as impaired self-esteem and avoidance of

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treatment (Pescosolido, Perry, Martin, McLeod, & Jensen, 2007; Mukolo, Heflinger, & Wallston, 2010), which can perpetuate already poor mental health issues (Corrigan & Watson,

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2002). Additionally, the stigma associated with being in foster care coupled with the stigma

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associated with the receipt of mental health services can dramatically influence an adolescent’s sense of autonomy during an important developmental stage in which self-esteem, self-efficacy,

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and resiliency are important in forming peer relationships (Azmitia, 2002) that can lead to

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positive support systems, that in turn, can lead to not only better mental health outcomes, but better outcomes in self-sufficiency post foster care.

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Funding

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This research was supported by a grant from San Diego State University’s Research Foundation University Grants Program to the first author.

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ACCEPTED MANUSCRIPT

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ACCEPTED MANUSCRIPT White, C., O’Brien, K., Pecora, P., & Buher, A. (2015). Mental health and educational outcomes for youth transitioning from foster care in Michigan. Family in Society: The Journal of Contemporary Social Services, 96(1), 17-24. Zito, J. M., Safer, D. J., Sai, D., Gardner, J. F., Thomas, D., Coombes, P.,…Mendez-Lewis, M.

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(2008). Psychotropic medication patterns among youth in foster care. Pediatrics, 121,

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ACCEPTED MANUSCRIPT Conflict of Interest

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Authors report no conflict of interest