1. Improving mental health services to address perceptions
of stigma among Veterans with homeless experiences
Aaron Reyes, MS2 and Sonya Gabrielian, MD, MPH
BACKGROUND
• Interviews lasted 30-40 minutes and data was collected
using written field notes.
• We performed thematic analyses using a top-level
codebook from a semi-structured interview guide that
was complemented by emergent themes from the
qualitative data.
SETTING
CONCEPTUAL FRAMEWORK
• The Domiciliary Care Program is a 296 bed residential
treatment facility located on the VA Greater Los Angeles
campus that serves homeless Veterans through multiple
services including mental health care, addiction therapy,
and housing services for an average 6 months.
METHODS (CONTINUED)
CONCLUSIONS
ROOT CAUSE ANALYSIS
RESULTS
VA Greater Los Angeles and UCLA David Geffen School of Medicine
REFERENCES
Theme Exemplary Narrative
Social Support
• Provider: “Veterans are alienated and
lack social support.”
Independence
• Veteran: “I get up and make my own
way, whether in the streets or not. It’s
what you do to survive.”
Continuity of
Care
• Veteran: Leaving the VA is “when the real
test starts.”
• Mental health stigma encompasses the negative
experiences that occur due to public and individual
understandings of mental illness.
• Perceptions of stigma among persons with serious mental
illness is linked to poor mental health outcomes.
• Homeless Veterans have high rates of serious mental
illness, but we know little about how stigma in this
particular vulnerable group is associated with mental
health outcomes.
1. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of
mental illness: psychometric properties of a new measure.
Psychiatry Res. 2003;121(1):31-49.
2. Boyd JE, Hayward H, Bassett ED, Hoff R. Internalized stigma of
mental illness and depressive and psychotic symptoms in homeless
veterans over 6 months. Psychiatry Res. 2016;240:253-9.
Stigma
Mental Health
Perceptions
Person-Level
Factors
Vulnerability
Factors
Mental Health
Outcomes
• Three key themes affecting stigma were salient across
provider and Veteran interviews: social support,
independence, and continuity of care.
• Factors related to decreased social support promote the
negative effects of stigma
• Experiences that limit independence contribute to lowered
self esteem, self efficacy, and trust
• Disrupted continuity of care across programs amplifies
mental health symptoms, negatively impacting interactions
with providers and other Veterans
• Mental health stigma is common and impactful among
homeless Veterans with serious mental illness.
• Three key themes serve to highlight actionable steps to
address stigma within this vulnerable group:
Acknowledgements: This project was supported by the Medical Student Summer Research Fellowship in Psychiatry and Biobehavioral Sciences through David Geffen School of Medicine.
Stigma
Reception
Perceived
Discrimination
Adaptation
Stereotype
Endorsement
Execution
Alienation
Social Withdrawal
METHODS
• Participants included: 1) a purposive sample of
interdisciplinary mental health care providers (n=5) and
2) a convenience sample of homeless Veterans with
serious mental illness (n=7).
• We performed qualitative interviews using a semi-
structured interview guide focused on three key
domains: reception, adaptation, and execution of stigma.
Working model for the process of mental health stigma
Theme Actionable Steps
Increase
social support
• Family-focused therapy
• Community-based Veteran networks
• VA provider mental health training
Enhance
independence
• Independent living skills training tailored
to serious mental illness
• Veteran advocacy and leadership
opportunities
• Increased belongings security
Improve
continuity of
care
• Health care provider continuity across
homeless programs
• Reliable VA campus transportation
• Exit aftercare and transition programs
Questions
1. What factors influence mental health stigma among
homeless Veterans with serious mental illness?
2. How can we improve VA mental health services for
homeless Veterans to address perceived stigma in
this vulnerable population?
Causal factors influencing mental health stigma