Have you ever thought “I should probably see a therapist” or “maybe a therapist would be helpful for this” and then never gone to seek help? How come?

This is a common experience, as many people who need and/or would benefit from mental health treatment never seek help. Some estimates suggest that this treatment gap affects as many as 70% of people who need mental health treatment, but never seek it out (Thornicroft, 2007). One of the primary contributing factors to this treatment gap is stigma both toward mental illness and toward seeking help. This article will explore what stigma is, where it comes from, and how we can work together to reduce its effects.  

What is stigma?

Stigma regarding mental health is generally the disapproval or shame placed on folks who live with mental health concerns and/or seek help for mental health concerns. Research has consistently shown that there are two types of stigma: public stigma and self stigma. Public stigma refers to the perception that society as a whole deems a person undesirable, unworthy, or socially unacceptable if they experience a mental health concern or seek help. 

Self-stigma, on the other hand, refers to the internalization of this societal messaging and adopting these beliefs for oneself. This results in a decrease in one’s self-esteem or feelings of self-worth because of mental illness. This internalization of public stigma only results in worse mental health outcomes for those individuals (Vogel et al., 2013). 

Research shows that one’s perception of how society views those who need/seek mental health help (public stigma) is linked with our levels of self-stigma, which then is negatively related to our attitudes toward counseling and actual help-seeking behaviors. In essence, those who endorse these feelings of stigma are less likely to seek help for a mental health concern, contributing to the treatment gap (Vogel et al., 2007). Additionally, those high in self-stigma are half as likely to even seek out information about mental health concerns and treatment (Lannin et al., 2016). 

Importantly, anyone can hold and perpetuate stigmatizing views toward mental health. Even mental health providers are not immune to stigma and there is evidence that when mental health providers endorse higher levels of stigma, they provide poorer quality care to their clients (Dell et al., 2020). 

Where does stigma come from?

So, where does this mental health stigma even originate? Unfortunately, it is sort of baked into the fabric of how we have treated people with mental illness for hundreds of years. People have attempted to explain mental illness using many theories (demonic possession, imbalance of bodily fluids, etc.), but most of them imply that folks experiencing mental illness are different, bad, scary, and/or dangerous. Particular behaviors and characteristics exhibited by certain groups have historically been labeled as mental illness because they deviated from societal norms (most commonly based on standards set by white men with immense privilege). As a result, though stigma impacts everyone, it disproportionately targets certain marginalized groups (for example, women often being labeled as hysterical or Black men as inherently violent). In addition, there are several contemporary contributing factors to mental health stigma, a few of which are described below. 

• Media stereotypes: When you think about film and television that depicts mental illness, what comes to mind? Chances are good you can think of a number of examples. Though the accuracy and level of stereotyping in the media exists on a spectrum, it is very common for film and television to portray stereotypical and often harmful depictions of mental illness. Regardless of the condition being depicted (depression, schizophrenia, etc.), it is common for the attitude to be that the person experiencing mental illness is unpredictable, dangerous, and even criminal (Stuart, 2006). These negative and often inaccurate messages contribute to society’s beliefs and attitudes regarding mental illness.
   
• Familial messaging: There are so many people I have seen in therapy who tell me their family would never accept them going to therapy. Some report that their families just don’t believe in therapy, others believe that help-seeking should be done in a church or family setting, and others still just believe that you should be able to just pull yourself up by your bootstraps to get over mental health concerns. These messages can be either explicit or implicit within the family, but regardless, they work their way into the minds of children and youth and impact future help-seeking behaviors.
   
• Fear and misconceptions: So much of stigma around mental health stems from a fear and misunderstanding of people with mental illness. For example, many people believe that folks with mental illness are violent or dangerous. A large majority of people with mental illness are not violent, but people with severe mental illness are much more likely to actually be victims of crime than people without mental illness (mentalhealth.gov, 2017). This often leads to fear of people with mental illness, which perpetuates stigma and may even contribute to discrimination and injustice. 

• Systemic-level factors: In addition to beliefs and attitudes, there are systemic factors that contribute to and perpetuate mental health stigma. For example, there are significant barriers to accessing mental health care for many communities. People in low-income neighborhoods, those with poor health insurance coverage, and communities with long histories of exploitation and maltreatment by mental health providers (often based on race or other marginalized identities) all experience higher levels of stigma and also lower rates of help-seeking (Phu, 2021). For example, conversion therapy where providers attempted to change individuals’ sexual orientation not only was traumatic, but also created high levels of stigma and distrust, contributing to the treatment gap.
   
• Lack of education: Finally, society generally lacks education and knowledge regarding all facets of mental health concerns. People don’t often know what mental health concerns there are, where to go for help, what treatment options exist, or how the change process occurs. This leaves many people uncertain of how to assist friends and family members when they are experiencing mental health concerns. It might also mean that people develop and perpetuate common misunderstandings based on a single example or experience (real life or in media). 

How do we reduce stigma?

Given this information, what can we do about it? It is most likely that we have to tackle stigma from all angles in order to make substantive changes. We need to change policies, increase equitable access to mental health care, increase mental health education for all, and help people change their attitudes and beliefs about mental illness. However, here are a few ways that you personally can contribute to this goal!

• Educate yourself: Educate yourself on mental health concerns. There are many programs through various agencies designed to educate community members on mental health issues and how to refer people to options for treatment (mental health first aid, mental health 101, etc.). It may be a good idea, even if you don’t think you’ll ever need it, to take a course like this and help to educate others. After all, chances are very good that you know someone right now who is struggling with mental illness, but who doesn’t know how to seek help. You could be that person to facilitate their next steps.
   
• Compassion: Find a way to foster a sense of compassion rather than judgment toward people who are experiencing mental health concerns. You might also consider reading personal, first-hand accounts from people who have experienced mental health concerns. This often requires you to unlearn long held biases and leave negative attitudes in the past and cultivate a sense of empathy. However, it can be helpful to see the person as a whole rather than defining them by their mental health concern.
   
• Talk about it!: When we fail to talk about our own mental health concerns due to fear, shame, embarrassment, or any number of other reasons, that only perpetuates mental health stigma. Therefore, one helpful way to combat stigma (both public- and self-stigma) is to talk about any mental health concerns you personally have or have had in the past with trusted people in your life. For folks who are already in recovery or have good support systems, you might speak out with the express purpose of reducing stigma. Lean into the fear here and share your story. On the other hand, if you feel you need help but don’t know where to go, maybe approach folks you trust and know are allies to assist you in the help-seeking process.  
   
• Knowledge of resources: One major contributor to mental health stigma is a lack of awareness of mental health resources and treatment options. Therefore, increasing your awareness of local, national, and even international resources to aid in facilitating services for folks who need them is a great way to decrease stigma. You can find local resources through online tools like Therapy Den or the Psychology Today Find a Provider Tool. Many agencies provide national-level resources like the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Mental Health (NIMH), or the National Alliance on Mental Illness (NAMI) to name just a few. For information on resources internationally, CheckPoint can serve as a good way to locate services. There are even free, confidential national crisis lines to call (1-800-273-TALK [8255]) or text (text HOME to 741741) to receive near immediate crisis services.
   
• Interact with people with mental illness: This may seem like an interesting tip for many. However, sometimes stigma around mental health concerns stems from a lack of exposure to or experience with people who experience them. This makes people rely on their current, and often misinformed, understanding of mental health concerns. If you think this is true for you, it is likely there are people in your life struggling with mental health concerns right now. When you do meet or find out someone has a mental health concern, elicit that compassion and get to know them holistically as a person. Be careful to not ask them to educate you and/or hold them up as a tokenized version of that particular mental health concern.
   
• Be aware of language: The language that we use to talk about the world can unknowingly perpetuate stigma against mental health concerns. When we use language like “I’m so OCD” or “They’re crazy” flippantly, that can lead to a minimization of certain mental health concerns and can be experienced as incredibly trivializing. Read this article for more on why you should be aware of your language. 

In what ways have you seen stigma impact your life and/or the lives of people you care about? What ideas do you have for decreasing stigma and the treatment gap? We would love to hear from you in the comments!

References

Dell, N. A., Vidovic, K. R., Vaught, M. G., & Sasaki, N. (2021). Mental health provider stigma, expectations for recovery, and perceived quality of care provided to persons with mental illness. Stigma and Health, 6(2), 247-250. 

Lannin, D. G., Vogel, D. L., Brenner, R. E., Abraham, W. T., & Heath, P. J. (2016). Does self-stigma reduce the probability of seeking mental health information? Journal of Counseling Psychology, 26(3), 351-358. 

Mentalhealth.gov (2017, August 29). Mental health myths and facts. Mentalhealth.gov: Let’s talk about it. https://www.mentalhealth.gov/basics/mental-health-myths-facts.

Phu, K. (2021, August 25). Stigma and systemic barriers: Why mental health care is not the same for everyone. Colorado Health Institute. https://www.coloradohealthinstitute.org/research/stigma-systemic-barriers-mental-health-care.

Stuart, H. (2006). Media portrayal of mental illness and its treatments. CNS drugs, 20(2), 99-106.

Thornicroft, G. (2007). Most people with mental illness are not treated. The Lancet.

Vogel, D. L., Wade, N. G., & Hackler, A. H., (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40-50. 

Vogel, D. L., Bitman, R. L., Hammer, J. H., & Wade, N. G. (2013). Is stigma internalized? The longitudinal impact of public stigma on self-stigma. Journal of Counseling Psychology, 60(2), 311-316.