1. Overcoming Barriers to Physical Health Care Access for People with Mental Health Disabilities

2. Learning Objectives 1.Explore impact of stigma & discrimination on people with mental health disabilities. 2.Discuss legal issues regarding access to physical health care for people with mental health disabilities. 3.Develop strategies for reducing stigma and overcoming health care access barriers for people with mental health disabilities.

3. Overview of Training Agenda 1.Introduction 2.Stigma & Discrimination 3.Effects of Stigma 4.Models of Treatment: Recovery v. Medical 5.Actions that Discriminate 6.Strategies for Reducing Stigma and Discrimination 7.Legal Issues Feel free to ask questions at any time!

4. DRC SDR Project Goals Reduce stigma & discrimination by -Increasing awareness of laws, policies & practices that address discrimination & support mental health services in non- traditional settings through provision of culturally-relevant and age appropriate training & materials for people with disabilities, their families, providers, and the general population.

5. DRC SDR Project Goals Identifying laws that contribute to stigma and discrimination & writing policy papers that recommend needed policy changes to reduce or eliminate stigma & discrimination.

6. Stigma & Discrimination

7. Different Cultural beliefs about people with mental health disabilities: -Inspired………………Possessed -Respected……………Rejected - Different………………Abnormal

8. What is Stigma? Attitudes and beliefs, based on stereotypes, that lead people to reject, avoid, or fear those they perceive as being different

9. What is Discrimination? -Discrimination occurs when people act on stigma in ways that deprive others of their rights and life opportunities. -Discrimination and stigma are based on the stereotypes that drive a wedge between “us” and “them.”

10. Types of Stigma 1. Public Stigma 2. Institutional Stigma 3. Self Stigma

11. Self Stigma -Self stigma is when a person with a disability accepts the attitudes of society or of the medical community. -Self stigma is rarely discussed, and can lead to hopelessness and helplessness.

12. Stigmatizing Language - Crazy - Insane - Disturbed - Abnormal - Delusional - Incompetent - Out of control - Dependent

13. Effects of Stigma - Low Self-Esteem - Isolation - Feeling Devalued - Social Rejection - Shame

14. Effects of Stigma - Over-interpretation of Behavior - Opinions are Ignored - Not given Responsibility - Not Trusted - Victims of Violence - Barrier to Seeking Treatment

15. Many people say that the stigma associated with their own (or their family member’s) diagnosis was more difficult to bear than the actual illness.

16. What is “Stigma”? Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different Types of stigma: 1. Public Stigma 2. Institutional Stigma 3. Self Stigma All types of stigma are based on stereotypes about people with mental health disabilities.

17. Studies have shown that stigma is even prevalent among the mental health provider community.

18. Knowledge about mental health disabilities does not preclude stereotyping.

19. “One study of mental health consumers and family members cited that stigma related to mental health care…accounted for nearly one quarter of their reported stigma experiences.” - The California Strategic Plan on Reducing Mental Health Stigma and Discrimination

20. Yet people go to mental health professionals for help when they need treatment, understanding and support.

21. People who encounter stigmatizing attitudes from health professionals may avoid seeking or continuing treatment.

22. Mental Health Treatment Models Medical Model vs. Recovery Model

23. Medical Model Mental health assessments and diagnoses too often focus on weaknesses and problems rather than addressing a person’s strengths, interests and goals.

24. Recovery Model Hope Personal Empowerment Respect Social Connections Self-Responsibility

25. Recovery Model -A diagnosis is a “guide” for treatment rather than a “name” for a person. -Mental health disabilities may shape or affect who a person is, but we are not defined by our disability. Medical Model -A diagnosis is a fact. -Mental health providers may refer to people by their diagnosis. -People are their disability.

26. Recovery Model Medical Model People: -Have different realities – there is not “one” reality. -Have insight into their own reality – it just may not be other people’s reality. -Have the ability to take care of themselves, with support as needed People with Mental Health Disabilities: -Lack insight into their own disability -Are unrealistic and unreasonable -Need to be taken care of

27. Recovery Model -People with mental health disabilities can and do get better. -Recovery is unique to each individual. -A person’s recovery can not be defined or determined by others. Medical Model -People with mental health disabilities can never truly recover. -Once someone has a mental health disability, they will always have it.

28. “…hope is one of the most valued ingredients in the professional/client relationship and the strongest predictor of positive outcomes.” - Mood Disorders Society of Canada

30. Actions that Stigmatize

31. -Disrespecting, patronizing or talking down to people -Ignoring what people want -Making decisions for people rather than helping them make their own

32. How to Reduce Stigma and Discrimination

33. -Use Plain Language -Use People First Language: Acknowledge and respect clients as people rather than disabilities. -Treat the illness with the seriousness it deserves, but treat people with dignity and respect.

34. -Listen to what clients have to say - Empathize with them, but don’t tell them what they feel or think. - Identify, acknowledge and explore a client’s self-stigma

35. Health professionals are consultants whom clients rely on for information, guidance and support.

36. Be conscious of the power of diagnosis and the labeling process – this might also contribute to a wiser use of diagnoses

37. - Focus on a person’s strengths and what he or she can do. - Teach Self-Advocacy: Help people help themselves

38. Contact a Peer Support Organization, Group or Peer Advocate for Guidance: -Peer/Self-Advocacy Program (PSA) of Disability Rights California www.disabilityrightsca.org www.disabilityrightsca.org -National Empowerment Center www.power2u.org www.power2u.org -National Self-Help Clearinghouse www.mhselfhelp.org www.mhselfhelp.org

39. Legal Issues Understanding and respecting individuals’ legal rights can promote a sense of autonomy, counteract stigma and promote effective treatment.

40. Access to Health Care Access to health care includes the rights to access facilities, services, and information offered by doctors’ offices, other health care providers and insurance plans.

41. Disability Discrimination Laws Americans With Disabilities Act T.II: Public Facilities & Services T.III: Private Facilities & Services (“Public Accommodations”) Rehabilitation Act, Section 504 Facilities & Services Receiving Federal Funds Similar State Laws California Unruh Act

42. Legal Protections for People with Disabilities 1.Full and equal access to health care services and facilities. 2.Reasonable modifications to policies, practices, and procedures that are necessary to make health care services available to people with disabilities. 3.Effective communication, including auxiliary aids and services, such as the provision of sign language interpreters or written materials in alternative formats.

43. Examples of Potentially Discriminatory Conduct Requiring a companion to attend a medical appointment Refusing to provide services because of a mental health disability Making disrespectful or harassing comments about a mental health disability

44. Reasonable Accommodations RA = reasonable modifications in policies, practices and procedures, when necessary to avoid discrimination on the basis of disability. RA ≠ undue financial or administrative burden, or fundamental alteration of the nature of the service.

45. Examples of Reasonable Accommodations Allowing a support person in a medical examination or consultation Scheduling an appointment at a specific time Taking extra time for a consultation

46. Psychiatric Service Animal and Emotional Support Animals ADA allows service animals – but not emotional support animals – to accompany people with disabilities to medical appointments in public or private facilities.

47. Definition of Service Animal -Only dog or miniature horse. -Individually trained to do work or perform specific tasks for the benefit of a person with a disability. -Example: Dog that is trained to recognize and respond to signs of panic attack. -License not required & not determinative.

48. Definition of Emotional Support Animal -Provides comfort to a person with a mental health disability. -Not individually trained to do disability- related tasks.

49. Qualifications on Right to Service Animal -Animal must be well cared-for. -Animal cannot pose a threat to people or property. -Health care providers may make limited inquiries about necessity of service animal, but may not ask questions about an individual’s disability.

50. Other Rights Protecting Access to Health Care -Right to be participate in treatment and discharge planning -Right to challenge decisions of conservator -Right to access to medical records -Right to confidentiality of medical records

51. Culturally and Linguistically Appropriate Services Recipients of federal funds must take reasonable steps to ensure that people with limited English proficiency have meaningful access to programs and services, including health care services. Title VI, Civil Rights Act of 1964 Executive Order 13166, Improving Access to Services for Persons with LEP

52. Culturally and Linguistically Appropriate Services Health care providers should “provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.” National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care www.thinkculturalhealth.hhs.gov

53. How to Address Discrimination By Health Care Providers 1.Talk to the provider directly or through Ombudsman. 2.File complaint with provider’s ADA/504 Compliance Officer. 3.File administrative complaint.

54. Administrative Complaints - OCR U.S. Department of Health and Human Services Office of Civil Rights (OCR) 90 - 7 th Street, Suite 4-100 San Francisco, CA 94103 Telephone: (415) 437-8310 TDD: (415) 437-8311 Fax: (415) 437-8329 www.hhs.gov/ocr/civilrights/complaints

55. Administrative Complaints - DOJ United States Department of Justice (DOJ) 950 Pennsylvania Avenue, NW Washington, DC 20530 Disability Rights Section: (202) 514-4713 E-mail:www.askDOJ@usdoj.gov

56. Administrative Complaints - CDSS California Department of Social Services (CDSS) Civil Rights Bureau (CRB) 744 P Street, M.S. 15-70 Sacramento, CA. 95814 Or call collect at (916) 654-2107 E-mail: crb@dss.ca.gov www.dss.cahwnet.gov/cdssweb/PG49.htm

57. Deadline for Filing Administrative Complaints 180 days from date of discrimination

58. California Department of Managed Care For care or services provided by managed care plans: -File Complaint -Ask for Independent Medical Review (IMR) -File for Medi-Cal Fair Hearing http://www.dmhc.ca.gov/

59. Disability Rights California is funded by a variety of sources, for a complete list of funders, go to http://www.disabilityrightsca.org/ Documents/ListofGrantsAndContracts.html.

60. CalMHSA The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities. Prevention and Early Intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.