Author ORCID Identifier
https://orcid.org/0009-0002-2717-0731
Defense Date
2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Social Work
First Advisor
Gary Cuddeback
Second Advisor
Denise Burnette
Third Advisor
Jacob Fritz-Goffnett
Fourth Advisor
Rebecca Etz
Fifth Advisor
Nev Jones
Abstract
People with serious mental illnesses (SMI) die 15 to 20 years before their peers without mental illness primarily due to chronic physical health conditions. Preventative care and treatment for chronic physical health conditions primarily occurs through primary care, but the experience of people with SMI in primary care is understudied. This constructivist grounded theory dissertation explored the experiences of people with SMI in primary care. Theoretical sampling resulted in 19 participants who were adults with SMI and long-term anti-psychotic use. Data was collected through one-to-two-hour long intensive interviews. The analytical process occurred concurrently with data collection. The abductive analytical process consisted of open, focused, and theoretical coding utilizing constant comparison methods, theoretical sampling, and memo writing. The sequential theory of how patients with SMI experience primary care begins with conditions structuring primary care interactions including systems and structural factors, patient factors, and clinician factors. Patient processes consist of managing identity, the central process, and claiming expertise and emotional labor, supporting processes. Outcomes of primary care interactions are affirming humanity, patient-clinician relationship trajectory, and meeting health needs. The theory conceptualizes emotional labor feedback loops, vigilance-to-depletion and affirmation-to-safety, which explain why concealment becomes unsustainable and disclosure becomes sustainable for people with SMI in primary care. Five relationship typologies, configurations of patient disclosure strategies and primary care clinician communication strategies, are developed which identify specific actions patients and clinicians can take to move between relationship typologies. The theory extends stigma scholarship by reframing concealment as a reasoned choice, not necessarily shame or internalized stigma and hypothesizing the sustainability of disclosure strategies through the emotional labor feedback loops of vigilance-to-depletion and affirmation-to-safety. Primary care scholarship is extended by centering the perspectives of people with SMI and services as received to develop patient-side communication strategies. Implications for practice are patient strategies for managing identity, claiming expertise, and reducing emotional labor and clinician communication skills to affirm the humanity of patients with SMI, improve health outcomes, and create safer, trauma informed primary care experiences for people with SMI.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
8-6-2026