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Week 5: Req Readings: NO REQ Textbook Reading – Req Articles Although the social determinants of health (SDOH) have been a longstanding priority in the healthcare industry, the social determinants of mental health (SDOMH) emerged during the COVID-19 pandemic as an eminent priority (Fink-Samnick (2021b). The intersection of the pandemic, mental health inequities, and structural racism has led to devastating consequences nationally and globally (Shim & Starkes, 2021). Greater emphasis is called for to understand and address the SDOMH. With expertise in holistic mental healthcare, advocacy skills, and interprofessional collaboration, psychiatric mental health nurse practitioners (PMHNPs) are well-equipped to address the social factors that influence mental well-being and advance mental health outcomes and equity. Social Determinants of Health
- Health Care Access and Quality
- Neighborhood and Built Environment
- Social and Community Context
- Economic Stability
- Education Health literacy and culturally sensitive care Review what you have learned about culturally sensitive care in the scenario below. Greg's Case Study Greg is a 42-year-old African American gentleman who is unemployed, homeless, and suffers from malignant hypertension as well as schizophrenia, for which he was prescribed medications. Greg did not graduate from high school, dropping out in his junior year. Currently, he lives at the homeless shelter in downtown Anchorage, Alaska, the largest city in Alaska. He is often seen walking the streets alone responding to internal stimuli (talking to himself). He keeps to himself and has very few friends and no family for support.
Question 1 : Click on the factors that put Greg at risk for disparities in mental health treatment. Correct answers :
- African American
- unemployed
- homeless
- malignant hypertension
- schizophrenia
- did not graduate from high school
- Anchorage, Alaska
- very few friends
- no family Question 2 : Now consider how the social determinants of health may influence Greg's outcomes. Potential Answer : The client is a minority and is unemployed and homeless in a very urban area. His lack of support from family and friends and lack of education also put him at risk, along with his medical and mental health diagnoses. Model Answer : Greg is currently unemployed and homeless; seeking mental health services may be a low priority for him. It is also likely that he may not be taking prescribed medications. Staying well- rested and getting good nutrition are also important in improving mental health. Being homeless is a barrier to both rest and good nutrition. This client is at high risk for not being adequately treated for his mental health diagnosis and will more than likely experience a relapse of symptoms and require future hospitalizations. Disparities in mental health services Review Mental Health Disparities for specific populations and healthcare reform to address disparities.
Trauma Responses Trauma-Informed Care Safety : Safety is the most fundamental principle to avoiding retraumatization. Creating a physical setting and client-provider interactions that generate physical and psychological safety are foundational to providing trauma-informed care. Trust and Transparency : Establishing a trusting relationship or therapeutic alliance is critical to the trauma-informed approach. Trust may be established through engagement in kind, respectful interactions, empowering intake procedures, and transparency in discussions of treatment goals and modalities appropriate to the client’s developmental level. Peer Support : Providing opportunities for connecting with other trauma survivors may help to establish safety, foster hope, and promote healing through shared experience. Collaboration: Empowering the client to play an active role in decisions about their treatment, when developmentally appropriate, fosters a sense of responsibility and helps to balance the level of power between the provider and client.
Empowerment & Choice : Listening to and acknowledging the client will help them find their voice and give them a sense of control over their story. Prioritizing choice empowers clients to be partners in their care, which can promote self-efficacy, agency, and dignity. Cultural, Historical, and Gender Awareness : Trauma-informed care acknowledges that some trauma may be a result of a client’s culture, historical events such as war or conflict, or being a part of a marginalized or minority group. Sensitivity to a client’s cultural, historical, or gender identity is important to ensuring their comfort and safety during treatment. The Social Determinants of Mental Health (SDOMH) and Racial Trauma Background The social determinants of health (SDOH) are an eminent priority in the healthcare industry. Robust data links these social, economic, and environmental factors with poor health outcomes (Anderson et al., 2022; Bitsko et al., 2022). In the aftermath of the COVID-19 pandemic, the intersection of these inequities with structural racism has spotlighted disturbing health disparities, morbidity, and mortality, especially in mental health (Shim, 2021). Greater emphasis is called for to understand and address the SDOMH. Although the SDOMH impact all aspects of mental health, their effect on complex mental health diagnoses is particularly challenging, influencing the development, progression, and outcomes of these conditions. Socioeconomic Status : Low income, poverty, unemployment, job insecurity, and a lack of access to resources can negatively affect mental health Education : Lower educational attainment plays a role in mental health outcomes, as less education influences the knowledge, skills, and opportunities for personal and professional growth Social Support : A lack of supportive relationships with family, friends, communities, or other social connections can increase stress and feelings of isolation and decrease resilience and self-esteem Childhood Experiences : Adverse childhood experiences (ACEs) can have long-lasting effects on mental health and increase the risk of developing mental disorders later in life Discrimination and Mental Health Stigma : Experiencing discrimination or stigma against serious mental illness, substance use disorders, or other forms of mental disorders can lead to chronic stress, low self- esteem, and isolation, and prevent timely diagnosis, treatment, and support Access to Reimbursement for Mental Healthcare : Limited access to and reimbursement for mental healthcare services can prevent timely diagnosis, treatment, and support, exacerbating mental health issues Criminalization of Mental Health Behaviors : Failure of the justice system to recognize the behaviors of poorly treated serious mental illness and substance use disorders can worsen mental health outcomes Physical Environment : Living in unsafe, violent, or unhealthy physical environments can contribute to chronic stress and negatively impact mental health
Symptoms of Racial Trauma
- Depression, social anxiety, stress, substance abuse, agoraphobia, suicidal ideology, psychosis
- Intrusion symptoms (e.g., nightmares, flashbacks, physical reactions in the presence of reminders)
- Avoidance behaviors (e.g., staying away from places that are reminders of racist experiences)
- Negative changes to thoughts or mood (e.g., feelings of isolation, a belief that the world is unsafe,
- Decreased interest in previously enjoyable activities)
- Changes in arousal and reactivity
- Cultural paranoia, avoidance of White people (dominant group members), somatic complaints, and excessive worries about loved ones Learn by Applying Apply what you have learned to a clinical scenario. Complete the activity below to learn more about how structural racism can impact mental health, including those with complex mental health diagnoses.
- Agnieszka has experienced persistent racial discrimination since immigrating to the United States, which has led to chronic stress, anxiety, depression, and post-traumatic stress disorder (PTSD), exacerbating her chronic depression. (Discrimination and racial trauma)
- Princiana has encountered ongoing barriers to accessing housing and quality education. Her job insecurity and a lack of housing opportunities have escalated her feelings of hopelessness, powerlessness, and low self-esteem, detouring her from timely treatment for her mental health. (Limited access to resources)
- Mateo has experienced ongoing racism as a person of color (POC), which has caused him to mistrust the mental healthcare system, resulting in inadequate care and treatment for his chronic schizophrenia. (Cultural mistrust and mental healthcare disparities)
- Diona is homeless due to substance use disorder and has chronic pain. In the emergency department, she self-reports a pain rating of 10 out of 10 and does not receive the same assessment and treatment as her White counterparts. (Intersections with other social determinants) Discover More Learn more about the effects of structural racism on physical and mental health Stigma and Structural Racism Systemic racism often leads to pervasive stigma, impacting the quality and timely access to mental healthcare and treatment. Four types of mental health stigmas are associated with poor client outcomes, delays in care provision, and client treatment adherence (Fink-Samnick, 2021b).
Learn More
- Perceptions of social beliefs (e.g., stereotypes, prejudice, discrimination) that occur on the part of the client or provider (Perceived)
- Perceptions of being a victim of stereotypes, prejudice, or discrimination that occur on the part of the client (Experienced)
- Taking inward stereotypes, prejudice, or social discrimination that occur on the part of the client (Internalized)
- Expectations of discrimination that occur on the part of the client (Anticipated) Discover More Watch this video to learn about the lived experience of individuals who experienced mental health stigma and the effects of racism Now, watch this video to learn about addressing a client with internalized stigma COVID-19, SDOMH, and Racial Trauma The COVID-19 pandemic and the SDOMH are co-occurring historic epidemics (Fink-Samnick, 2021b). Social isolation, grief and loss, economic stressors, and fear of the virus have increased anxiety, depression, and other mental health conditions. Rapidly rising rates of mental health post-pandemic are a pressing concern, with socially disadvantaged groups experiencing the greatest incidence of behavioral health manifestations. The pandemic has retriggered many individuals who have experienced historical racial trauma and discrimination. Others have experienced a new onset of trauma- and stressor-related disorders, including depression, anxiety, and insomnia. Still, others have started or increased substance use to cope with pandemic-related stress or emotions. The multilayered traumatic stress associated with the pandemic has disproportionately affected marginalized populations. Covid Impact on Marginalized Populations Marginalized populations Victims of trauma
- Historical
- Continuous
- Pervasive Covid-19 trauma impact
- Fear of present and future infections
- Routine disruptions and isolation
- Economic impact
- Disability and mortality
Trauma-Informed Interventions Trauma-informed care is essential for caring for clients who have experienced racial trauma. This approach helps the provider better understand trauma’s impact on a client’s life and effectively determine a treatment plan while avoiding re-traumatization. Trauma-informed care highlights five fundamental principles in a phased approach (Fink-Samnick, 2021a). Safety to Empowerment (Viewed from the bottom of the book stack to the top.)
- Safety
- Choice
- Collaboration
- Trustworthiness
- Empowerment
HEART Framework The healing ethno-racial trauma (HEART) framework integrates four phases, each aligned with a distinct goal to guide the client in understanding and reconciling trauma to attain growth and healing (Fink- Samnick, 2021a). Although the framework was initially developed for Latinx populations, it is now being used for other marginalized and oppressed groups. Addressing Ethno-racial Trauma (ERT): HEART Framework Phase Goal Example I. Establish sanctuary space for clients experiencing ERT
- Assist with immediate relief from the effects of ERT - Create mission statements that underscore nondiscrimination specific to immigration status - Set a safe, nurturing space to meet - Allow for crisis intervention through intakes, walk-ins, and/or team consultations - Ensure privacy and confidentiality - Reflect acceptance through empathy II. Acknowledge, reprocess, and cope with symptoms of ERT
- Help clients develop an awareness of how systems of oppression impact the self, family, and community
- Reprocess traumatic experiences and provide support to cope with emotional stress and symptoms associated with ERT
- Use trauma-informed care interventions to affirm consistent acceptance
- Use psychoeducation to present trauma impact
- Reframe client as survivor vs. victim
- Connect client with social and professional support, including appropriate referrals to behavioral health practitioners trained in trauma-informed practices III. Strengthen and connect individuals, families, and communities to survival strategies and cultural traditions that heal
- Assist individuals, families, and communities to connect to the Latinx (or other) culture, learn and utilize collective cultural strengths, and engage in
- Ensure awareness of client stage/status of (racial, cultural, ethnic) identify
- Organize events and programs on dimensions of ERT
- Encourage development of coping strategies
- Role-play and model appreciation of connection to culture of origin
Summary Discrimination and racial injustice are prevalent in the United States and extensively impact mental health. These social, economic, and environmental factors, or social determinants of mental health (SDOMH), have fueled mental health inequities among racial and ethnic population groups. Key Points
- Although the social determinants of health (SDOH) have been a longstanding priority in the healthcare industry, the social determinants of mental health (SDOMH) emerged during the COVID-19 pandemic as an eminent priority (Fink-Samnick, 2021b).
- The SDOMH impact all aspects of mental health; their effect on complex mental health diagnoses is particularly challenging, influencing the development, progression, and outcomes of these conditions.
- Structural racism is endemic within the healthcare industry and refers to how institutions, policies, and practices systematically disadvantage some racial or ethnic groups while privileging others.
- Racial and ethnic minority groups consistently experience higher rates of psychological distress, mental illness, and poor mental health outcomes than their White counterparts (Jeste & Pender, 2022). This disparity is attributed to the chronic stressors and adverse experiences of living in a racist society.
- The cumulative impact of racism can lead to racial trauma or race-based traumatic stress (RBTS).
- Systemic racism often leads to pervasive stigma, impacting the quality and timely access to mental healthcare and treatment.
- The COVID-19 pandemic and the SDOMH are co-occurring historic epidemics (Fink-Samnick, 2021b).
- Treatment challenges include reimbursement inequities, provider shortages, delayed response time, and lack of mental health parity, as well as identifying and measuring symptoms for proper diagnosis and treatment (Fink-Samnick, 2021b).
- The Racial Trauma Scale (RTS) is a newly developed self-report measure to quantify and assess trauma symptoms specific to racial discrimination (Williams et al., 2022).
- Trauma-informed care is essential for caring for clients who have experienced racial trauma.
- The healing ethno-racial trauma (HEART) framework integrates four phases, each aligned with a distinct goal to guide the client in understanding and reconciling trauma to attain growth and healing (Fink-Samnick, 2021a).
- Community collaboration and advocacy are needed to address the SDOMH and systematic and structural racism (Kuehnert et al., 2022). Reflection on Learning Reflective inquiry allows for expansion of self-awareness, identification of knowledge gaps, and assessment of learning goals. As you reflect on your readiness to provide care to clients as a psychiatric mental health nurse practitioner (PMHNP), take a few minutes to consider what you’ve learned.
- What strategies are needed to advocate for policies and practices addressing bias and discrimination within the mental health system?
