How stigma prevents people from accessing mental health care and what can be done about it

Oct. 22—In the days after Jennifer Stuber's husband Matt died by suicide, she had a realization. The issue she'd dedicated much of her career to studying — mental health stigma — was partially behind her husband's death.

"Stigma is what killed him," said Stuber, an associate professor of social work at the University of Washington. "His actual thing he said about himself was, 'Who wants a lawyer with a broken brain?'"

Matt's struggle with anxiety and depression was debilitating enough that he felt he needed to step away from his profession as an attorney. Taking a break from his career, which was so important to him, led to dangerous patterns of thinking, Stuber says. Peers at his law firm "thought no less of him," Stuber says; she knows, because she spoke with them. But Matt's self-worth evaporated. He felt the cultural expectations of his duty as a father — and the pressures that came with a high-octane corporate law job — closing in.

Stuber has since dedicated her career to suicide research and advocacy. Suicide is the most serious potential consequence of mental health stigma. But stigma's effects are pervasive: For example, research suggests that stigma is a significant barrier to seeking out and benefiting from mental health treatment.

Stigma is complex. It can keep families from talking about a loved one's mental illness, and can normalize feelings of isolation and loneliness. It can show up in the way individuals act and feel toward themselves — which is known as self-stigma — and can spring from cultural messaging and societal norms.

Experts say that last piece — societal norms — allows stigma to persist. Stigma is rooted deeply in medical and social structures that can perpetuate discrimination and fear. It can prevent someone from securing housing, landing a job or receiving adequate medical attention. Stigma can result in bullying and harassment. Mental health advocates say it's also tied to consistent underfunding of mental health research and treatment development. The National Institute of Mental Health, for instance, receives a third as much as the National Cancer Institute and less than other national institutes dedicated to research on diabetes, neurological conditions, allergies and infectious diseases, among many others. Like many agencies under the National Institutes of Health, NIMH faced a nearly $200 million cut to its $2 billion annual budget this fiscal year.

The Seattle Times spoke with Stuber and other experts about where mental health stigma comes from, how it manifests and how it keeps people from accessing care.

What is stigma?

There's no single definition of stigma. It was originally thought of as a mark that discredits someone as a person and reduces them to someone who is tainted.

But over time, many experts have formalized how we think of stigma by describing it as a complex process. The first step is when society recognizes an individual or a group as "different," says Pamela Collins, professor of psychiatry and behavioral sciences and global health at the University of Washington. The second step is labeling that group. Next, society or specific communities attach stereotypes to the people who fall under a certain label. These stereotypes can support a rationale for devaluing, dehumanizing or discriminating against people with a mental health condition.

"Stigma really happens in the context of power," Collins said. And it can lead to "terrible outcomes" for those with mental health issues, such as a lower life expectancy or inadequate medical treatment, Collins said. As an example, she said, someone struggling to breathe might visit an emergency department for care. But because the physician on duty sees the patient has a preexisting anxiety diagnosis, they might make stigma-based assumptions and assume a heart attack is a panic attack, for example.

Stigma can also be expressed in a variety of ways, depending on a person's cultural context, Collins said. Researchers have studied how a person's attributes, like their race, gender and sexual orientation, are associated with the mental health stigmatization they experience in society, the level of stigmatizing beliefs they hold, and the actions they might take.

Where does stigma come from?

Stigma is rooted in fear, Collins said. Research suggests that stigma is universal, though the extent to which people report feelings of mental health stigma varies by where they live and their cultural background.

Stigma, unfortunately, emerges from many corners of society. Media has a long history of portraying people with mental illness as violent, unpredictable or unable to recover. Certain religions and workplaces dissuade people from acknowledging or treating their mental health concerns. This is true even in the medical field: physicians, for instance, have historically been discouraged from seeking mental health care through medical licensing policies and their own fear that doing so might compromise how they're viewed by peers or managers.

The medical field also has a dark history of treating people with mental health concerns using restrictive, punitive and abusive methods. Stigma shows up in policing practices, arrests and sentencing policies, too. A lack of mental health training — or negative attitudes toward those with mental illness — among police, jurors and judges contributes to an overrepresentation of people with mental illness in jails and prisons.

At the same time that societal institutions have allowed or promoted mental health stigma, mental health advocates argue that institutions also have the responsibility and power to change the conversation.

What is the difference between external and self-stigma, and how are they related?

Stuber describes stigma as a feeling of "thwarted belonging." A person with mental illness might perceive that others have negative thoughts about them — even if it's not true — and "as a result, they internalize those perceptions."

Her point is this: stigma manifests in an "external" way through the systems and attitudes that exist outside of an individual with mental illness. But stigma can grow internally inside someone who feels less-than or discriminated against based on those external cues and their own internal thoughts. In some people, this can tied to feelings that their symptoms will never improve.

Self-stigma, she said, is challenging to "separate from external stigma, prejudice, discrimination and societal stereotypes and conceptions." This challenge is one reason why it can be difficult to end mental health stigma. It also highlights the importance of addressing stigma on an individual basis — and at its cultural roots.

How can stigma influence people's decision to seek mental health care?

Hospitals and clinics are supposed to be the places people turn for help, said Dr. Joshua Bess, a psychiatrist and medical director at SeattleNTC who uses electroconvulsive therapy and other methods to treat people with depression.

But, he said, "there is in many ways more intense stigma there, or more intense negative feelings toward people either in mental health crisis or who have a mental health history."

He has a pile of stories, he said, from patients who've reported feeling they're not listened to or taken seriously during health care visits. If someone is having a panic attack or experiencing psychosis, he said, "the way that they're treated [while seeking care at an emergency department], I find horrifying sometimes," he said.

Bess calls this "institutional" stigma, which can result in people avoiding mental health care because of past experiences with medical providers.

Meghan Romanelli, assistant professor of social work at the University of Washington, said this can be particularly true among LGBTQ+ people, who face additional barriers to care because of their gender identity or sexual orientation.

LGBTQ+ stands for lesbian, gay, bisexual, transgender and queer/questioning, with the + denoting everything along the gender and sexuality spectrum.

"People can be flat out denied and refused care. People can be asked really invasive questions that aren't even related to the reason why they are there. People can be exposed to harsh or abusive language," Romanelli said.

In what ways can society and individuals break down stigma?

Here are some stigma prevention strategies recommended by the American Psychiatric Association, mental health experts and advocacy organizations like the National Alliance on Mental Illness:

* Governments can hold campaigns to raise awareness about mental health stigma and its consequences.

* Workplaces can train managers to identify when employees are in distress. They can welcome accommodations for employees experiencing a mental health condition.

* Professional organizations can change licensing and other policies to make access to mental health care a priority.

* Law enforcement agencies can require employees to undergo comprehensive mental health training.

* Health care training programs, like those for nurses, can create specialties for those who anticipate working in mental health care settings.

* Schools can devise mental health awareness curriculum.

Individuals can drive change, too:

* People with a mental health condition can benefit from talking with peers who are also experiencing mental health symptoms. Making connections with support groups can help.

* Be careful about the words you use to describe mental illness. For example, avoid language that portrays people as weak or less-than.

* Actively speak out against mental health stigma. Talk with friends, relatives and your community about the consequences.

* Normalize mental health treatment. Talking openly with a loved one about seeking mental health care can reduce self-stigma.

* Educate yourself. Learning about mental health can help you intervene when others discriminate against someone with a mental health condition.

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