Impact of double stigma on seeking mental health treatment

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Studies show that social stigma has a negative effect on individuals seeking mental health treatment. [1] [2] [3] [4] [5] [6] In fact, fifty-two to seventy-four percent of individuals with a mental disorder do not receive treatment. [7] Scholars suggest that this is attributable to the stigma associated with it. [4] Individuals who are part of minority groups such as cultural/ethnic minorities, the elderly, individuals living in poverty, individuals living in rural communities and soldiers suffer from a double stigma. [1] They have stigma because of their minority group and their mental illness. Individuals who suffer from a double stigma are less likely to seek out treatment. [1] Studies show that the way to reduce stigma is to protest, educate and create in person connections. [2]

Social stigma is the disapproval of, or discrimination against, a person based on perceivable social characteristics that serve to distinguish them from other members of a society. Social stigmas are commonly related to culture, gender, race, intelligence and health.

Mental disorder Distressing thought or behavior pattern

A mental disorder, also called a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitting, or occur as a single episode. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional.

Mental disorders are classified as a psychological condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological and often social functioning of the individual. Individuals diagnosed with certain mental disorders can be unable to function normally in society. Mental disorders occasionally consist of a combination of affective, behavioral, cognitive and perceptual components. The acknowledgement and understanding of mental health conditions has changed over time and across cultures. There are still variations in the definition, classification, and treatment of mental disorders.

Contents

Definition of stigma

There are three different components of stigma: self, public and structural. [6] The public and self stigma create the structural stigma and societal barriers. Stigma is created through ignorance, misinformation and prejudice which then leads to discrimination. [5] Within the three different components individuals are marked as shameful and are then shunned or rejected because of that mark. [4]

Prejudice is an affective feeling towards a person based on that person's perceived group membership. The word is often used to refer to a preconceived, usually unfavourable, evaluation of another person based on that person's political affiliation, sex, gender, beliefs, values, social class, age, disability, religion, sexuality, race/ethnicity, language, nationality, beauty, occupation, education, criminality, sport team affiliation or other personal characteristics.

Discrimination Prejudicial treatment based on membership in a certain group

In human social behavior, discrimination is prejudiced treatment or consideration of, or making a distinction towards, a being based on the group, class, or category to which they are perceived to belong. These include age, caste, colour, criminal record, height, disability, ethnicity, family status, gender identity, generation, genetic characteristics, marital status, nationality, race, religion, sex, sexual orientation, social class, and species. Discrimination consists of treatment of an individual or group, based on their actual or perceived membership in a certain group or social category, "in a way that is worse than the way people are usually treated". It involves the group's initial reaction or interaction going on to influence the individual's actual behavior towards the group leader or the group, restricting members of one group from opportunities or privileges that are available to another group, leading to the exclusion of the individual or entities based on illogical or irrational decision making.

This is done in four steps:

  1. Individuals are labeled as an out-group
  2. The differences in the out-group are deemed and labeled negative
  3. The differences create a separation of society into an “us” and “them”
  4. The label and separation lead to discrimination or the structural stigma. [7]

Self stigma

A Theoretical Model of Self-Stigma A Theoretical Model of Self-Stigma.jpg
A Theoretical Model of Self-Stigma

Self-stigma has three distinct steps to it: awareness of the public stigma (stereotypes), agreement with it, and applying it to one’s self. [3] These steps lead to an individual having low self-esteem and low self-efficacy. This can affect the opportunities they engage with and the way they interact with the world. Minorities internalize two different sets of stereotypes that are prevalent in society. [1]

Public stigma

An example of public stigma is label avoidance.  When people have labels and stereotypes associated with them individuals try to avoid being apart of that out-group they want to avoid those labels. [7] The labels that come with public stigma turn into structural stigma through their interaction with the criminal justice and health care systems. Public stigma labels individuals who are mentally ill as dangerous which then leads them to being put in the criminal justice system and not being able to benefit from health care services. [2] Studies show that the publics negative labels are more harmful for minorities because they have labels for their mental illness and minority. [1]

Structural stigma

Structural stigma not only influences social barriers, it also influences legal barriers. “Not in my backyard” legislation creates barriers for individuals with mental illness to have safe housing and be apart of the community. [4] This legislation was created because of the perceived stigma that individuals in the community had. Two-thirds of the community stated that they did not want individuals with mental illness in their neighborhood. [4] Individuals who are mentally ill and a minority are criminalized at higher rates because they are penalized by two different structural stigmas. [1]

Double stigma

Double stigma is the idea that individuals suffer from the effects of stigma twice; stigma surrounding their minority group and stigma surrounding their mental illness. [1] The combination of having a mental illness and being in a minority group can create more barriers and therefore lead to seeking out treatment less. [1]

There are four added barriers that individuals with minorities have:

Double stigma also affects other minority groups such as soldiers or veterans, individuals who are lower socio-economic status, residents of rural areas, and the elderly population. All minority groups have more to contend with than the public, self and structural stigma that is put on them as an individual with a mental illness.

Stigmas impact on help-seeking behaviors

Studies show that stigma has a negative effect on individuals seeking mental health treatment. [1] [2] [3] [4] [5] [6] [7] Studies also show that stigma is one of the greatest barriers for individuals with mental health in having a satisfying life, and that is because many of them never seek out treatment. [4] Not only does stigma acts as a barrier for mental health care, it also acts as a barrier for social inclusion. [5] Individuals want to avoid the label of being mentally ill and the discrimination that it brings so they do not seek out mental health care and get the support that they need. [2]

Cultural and ethnic minorities

Caucasians seek out mental health treatment at higher rates than cultural and ethnic minorities in the US and the UK. [1] African Americans, American Indian and Alaska native, Asian American and Hispanic American groups seek out psychiatric services less than Caucasians. [1] This is shown in the UK as well, Black Caribbean groups have lower rates of treatment than Caucasians. [5] Cultural minorities in America are most likely to validate stereotypes and stigma of mental illness which leads to more discrimination. [7] Because stigma is a social construct, it is influenced by cultural norms. [7] Collectivist cultures, such as Asian countries, have the ideas that mental illness reflects a flaw in the community or family. [7] African heritage groups are influenced by similar things: community and group identity. This leads to people with african and asian heritage to not seek out treatment because they do not want to dishonor their community or family. [2]

Individuals who are economically disadvantaged

Individuals who are lower socio-economic status are less likely than middle-class or upper-class individuals to seek out treatment. [2]

There are many reasons why that is the case:

  1. They care more about they families reaction and therefore are less likely to seek out treatment. [2]
  2. Individuals who are lower socio-economic status have a distrust of the healthcare system. [1]
  3. Individuals who are lower-socio economic status are more likely to not have health insurance. [5] It is harder and sometimes impossible to seek out and afford mental health care if individuals do not have health insurance. Studies have found that not having insurance is also stigmatizing within the mental health system, which leads to the high rates of distrust with the health care system. [5] The double stigma of being poor and not having insurance leads people to not seek out care at higher rates. [1]

Residents of rural areas

People who live in rural areas are also less likely to seek out mental health care. [5] There are more extreme stereotypes within rural communities when it comes to mental health care. [5] Everyone knows each other in rural towns so therefore the stigma and discrimination against individuals who have mental illness are higher.

Senior citizens

The elderly population seeks treatment at lower rates. [5] They are discriminated against because of their age and their illness. There is a higher level of public stigma was approved by the elderly population, this leads to less elderly individuals seeking mental health treatment [8]

Soldiers and veterans

American Soldiers saluting the American flag Memorial Day Ceremony - North Africa American Cemetery and Memorial - May 31, 2010 (4659119211).jpg
American Soldiers saluting the American flag

Sixty-six to seventy-seven percent of US soldiers do not seek mental health care because of possible stigmatization. [1] Negative attitudes surrounding mental health treatment are prevalent in the army [9] There are also organizational barriers within the army that perpetrate mental health stigmas and make seeking help more difficult. [9]

How to combat mental health stigma

The Center for Disease Control and Prevention recognizes mental illnesses as a public health issue. [10] The World Health Organization says that stigma and discrimination are barriers in treating the public health issue. [11] In order for the public health issue to be addressed, stigma and discrimination need to be addressed as well. [11] There are three approaches that could help erode the social stigma that surrounds individuals with mental illness; protest, education and contact. [2] Individuals can protest the stereotypes and inaccurate representations of mental illness to the public. Protest campaigns have been successful in getting images that are stigmatizing removed. [12] Education promotes positive attitudes about the mentally ill by providing information about mental disorders so that the public can be more educated. Participation in education programs has led to improved attitudes towards people with mental illness. [13] The research shows that the best thing that can be done to get rid of stigma is having contact with individuals who have mental illness that go against the stereotypes. [2]

Organizations and campaigns

There are many organizations and campaigns that have been created to either protest, educate or create relationships in order to end the stigma.

Organizations and Campaigns
OrganizationLocationAbout the organizationWebsite
Time to change [14] London, UKSocial movement educating communities through sharing stories https://www.time-to-change.org.uk/
See Me [15] ScotlandWork with people to change negative behavior towards individuals with mental illnesses https://www.seemescotland.org/
Families for Depression Awareness [16] Waltham, MAOffer education, training, and support for families of individuals with mood disorders https://www.familyaware.org/
Freedom From Fear [17] Staten Island, NYA mental health advocacy organization through education, research, advocacy and support http://www.freedomfromfear.org/
NoStigmas Network [18] United States and CanadaSupport the creation of peer support communities to eliminate the stigmas surrounding mental health https://nostigmas.org/
Make it Ok [19] United StatesA campaign to help reduce the spread of mental health stigma through education. They also have a podcast. https://makeitok.org/
Bring Change to Mind [20] San Francisco, CACreate multimedia campaigns, storytelling movements and youth programs to start conversation around mental health in order to end the stigma. https://bringchange2mind.org/
National Alliance on Mental Illness [21] United StatesA grassroots mental health organization that does education programs, advocacy work, and support. https://www.nami.org/
Active Minds [22] United StatesOrganization on college campuses (700) creating awareness campaigns, events, advocacy, outreach and support. https://www.activeminds.org/
Treatment Advocacy Center [23] Arlington County, VAAn organization dedicated to eliminating barriers to mental health services through the law, policies and practice https://www.treatmentadvocacycenter.org/index.php

Related Research Articles

National Alliance on Mental Illness organization

The National Alliance On Mental Illness (NAMI) is a United States-based advocacy group originally founded as a grassroots group by family members of people diagnosed with mental illness. NAMI identifies its mission as being "dedicated to building better lives for the millions of Americans affected by mental illness". NAMI offers classes and trainings for people living with mental illnesses, their families, community members, and professionals, including what is termed psychoeducation, or education about mental illness NAMI holds regular events which combine fundraising for the organization and education, including Mental Illness Awareness Week and NAMIWalks.

Mental health Describes a level of psychological well-being, or an absence of a mental disorder

Mental health is the level of psychological well-being or an absence of mental illness. It is the state of someone who is "functioning at a satisfactory level of emotional and behavioural adjustment". From the perspectives of positive psychology or of holism, mental health may include an individual's ability to enjoy life, and to create a balance between life activities and efforts to achieve psychological resilience. According to the World Health Organization (WHO), mental health includes "subjective well-being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one's intellectual and emotional potential, among others." The WHO further states that the well-being of an individual is encompassed in the realization of their abilities, coping with normal stresses of life, productive work and contribution to their community. Cultural differences, subjective assessments, and competing professional theories all affect how one defines "mental health".

Health equity synonymous with health disparity refers to the study and causes of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. It is not possible to work towards complete equality in health, as there are some factors of health that are beyond human influence. Inequity implies some kinds of social injustice. Thus, if one population dies younger than another because of genetic differences, a non-remediable/controllable factor, we tend to say that there is a health inequality. On the other hand, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" between populations with a different race, ethnicity, sexual orientation or socioeconomic status.

Immigrant health care in the United States overview of social and economic factors in health policies for immigrants

Immigrant health care in the United States refers to the collective systems in the United States that deliver health care services to immigrants. The term "immigrant" is often used to encompass non-citizens of varying status; this includes permanent legal residents, refugees, and undocumented residents.

Mental distress is a term used, both by some mental health practitioners and users of mental health services, to describe a range of symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing or out of the ordinary.

Mental health literacy has been defined as "knowledge and beliefs about mental disorders which aid their recognition, management or prevention. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking". The concept of mental health literacy was derived from health literacy, which aims to increase patient knowledge about physical health, illnesses, and treatments.

Mentalism or sanism describes discrimination and oppression against a mental trait or condition a person has, or is judged to have. This discrimination may or may not be characterized in terms of mental disorder or cognitive impairment. The discrimination is based on numerous factors such as stereotypes about neurodivergence, for example [Aspergers], learning disorders, ADHD, bipolar, schizophrenia, and personality disorders, specific behavioral phenomena such as stuttering and tics, or intellectual disability.

Discrimination against people with HIV/AIDS or serophobia is the prejudice, fear, rejection and discrimination against people afflicted with HIV/AIDS. Discrimination is one manifestation of stigma, and stigmatizing attitudes and behaviors may fall under the rubric of discrimination depending on the legislation of a particular country. HIV stands for human immunodeficiency virus. If left untreated, HIV can lead to the disease AIDS. HIV/AIDS is a sexually transmitted disease and cannot be cured, but with proper treatment, the individual can live just as long as without the disease.

The social stigma of obesity or anti-fat bias has caused difficulties and disadvantages for overweight and obese people. Weight stigma is similar and has been broadly defined as bias or discriminatory behaviors targeted at individuals because of their weight. Such social stigmas can span one's entire life, as long as excess weight is present, starting from a young age and lasting into adulthood. Several studies from across the world indicate overweight and obese individuals experience higher levels of stigma relative to their thinner counterparts. In addition, they marry less often, experience fewer educational and career opportunities, and on average earn a lesser income than normal weight individuals. Although public support regarding disability services, civil rights and anti-workplace discrimination laws for obese individuals have gained support across the years, overweight and obese individuals still experience discrimination, which may have implications to physiological and psychological health. These issues are compounded with the significant negative physiological effects associated with obesity.

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless suffer from mental illness. Studies have found that there is a correlation between homelessness and incarceration. Those with mental illness or substance abuse problems were found to be incarcerated at a higher frequency than the general population. Fischer and Breakey have identified the chronically mentally ill as one of the four main subtypes of homeless persons; the others being the street people, chronic alcoholics, and the situationally distressed.

Transgender health care refers to how medical institutions, communities and individuals approach the care of transgender people. It includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies. In this article, you will find information about gender variance, sex reassignment therapy, health risks, access to healthcare for trans people in different countries around the world, and specific information about transgender youth and transgender older adults.

The mental health of Filipino Americans is emotional and cognitive status of Americans of Filipino descent. Filipino Americans are more likely to suffer from mental illness than other Asian Americans due to a variety of social and economic factors. Filipino-Americans utilize mental health services less than other Asian-American groups.

Mental health inequality refers to the differences in the quality, access, and health care different communities and populations receive for mental health services. Globally, the World Health Organization estimates that 350 million people are affected with depressive disorders. Mental health can be defined as an individual's well-being and/or the absence of clinically defined mental illness. Inequalities that can occur in mental healthcare may include mental health status, access to and quality of care, and mental health outcomes, which may differ across populations of different race, ethnicity, sexual orientation, sex, gender, socioeconomic statuses, education level, and geographic location. Social determinants of health that can influence an individual's susceptibility to developing mental disorders and illnesses include, but are not limited to, economic status, education level, demographics, geographic location and genetics.

The conceptual ideology of a strong black woman identifies women of color as victims of intersectionality within a patriarchal society in which they are pushed to fit the standard mold of a traditional strong black woman versus what it means to be a woman to themselves. Used interchangeably, the "Black Superwomen Syndrome" is the pressure & expectation of a woman of color to manage multiple roles of the mother, worker, homemaker, student and any other roles that usually inclusive to one person or sex. Keep in mind, this is different then a career woman because rather than sacrifice the role that supports her family in order to excel in her career, the superwoman is forced to support both the traditional Suzy Homemaker role and a career woman. This mold of being self-reliant & self-contained is damaging in a sense because if you are unable to be self-reliant and/or self-contained then culturally you aren’t a true strong black woman and you aren’t to be depended on. This arrangement of social paradoxes creates a deadly environment that is damned if you, damned if you don’t stigma for black women across the diaspora. Historically, this stigma is what held black families together because of the systemic lack of strong balanced male authority is the same thing that is killing our women. When a woman has no choice to be strong all the time without a chance to breathe, anything that isn’t related to fulfilling all the roles that are needed are suppressed such as sadness or pain because of its deemed weakness.

Suicide awareness

Suicide awareness is a proactive effort to raise awareness around suicidal behaviors. It is focused on reducing social stigmas and ambiguity, by bringing attention to suicide statistically and sociologically, and encouraging positive dialogue and engagement as a means to prevent suicide. Suicide awareness is linked to suicide prevention as both address suicide education and the dissemination of information to ultimately decrease the rate of suicide. Awareness is a first stage that can ease the need for prevention. Awareness signifies a fundamental consciousness of the threat, while prevention focuses on stopping the act. Suicide awareness is not a medical engagement, but a combination of medical, social, emotional and financial counseling. Suicide awareness in adolescents focuses on the age group between 10–24 years, beginning with the onset of puberty.

The Attribution Questionnaire (AQ) is a 27-item self-report assessment tool designed to measure public stigma towards people with mental illnesses. It assesses emotional reaction and discriminatory responses based on answers to a hypothetical vignette about a man with schizophrenia named Harry. There are several different versions of the vignette that test multiple forms of attribution. Responses assessing stigma towards Harry are in the form of 27 items rated on a Likert scale ranging from 1 to 9. There are 9 subscales within the AQ that breakdown the responses one could have towards a person with mental illness into different categories. The AQ was created in 2003 by Dr. Patrick Corrigan and colleagues and has since been revised into smaller tests because of the complexity and hypothetical that did not capture children and adolescent's stigmas well. The later scales are the Attribution Questionnaire-9 (AQ-9), the revised Attribution Questionnaire (r-AQ), and the children's Attribution Questionnaire (AQ-8-C).

Discrimination against drug addicts is a form of discrimination against individuals who suffer from a drug addiction. In the process of stigmatization, drug addicts are stereotyped as having a particular set of undesirable traits, in turn causing other individuals to act in a fearful or prejudicial manner toward them. Drug use discrimination also leads to many users being secretive about drug use. As it relates to healthcare stigmatizing attitudes surrounding drug use can cause barriers to treatment uptake and engagement. In some of its manifestations, discrimination against drug addicts involves a violation of human rights.

Paternal depression is a psychological disorder derived from parental depression. Paternal depression affects the mood of men; fathers and caregivers in particular. 'Father' may refer to the biological father, foster parent, social parent, step-parent or simply the carer of the child. This mood disorder exhibits symptoms similar to postpartum depression (PPD) including anxiety, insomnia, irritability, consistent breakdown and crying episodes, and low energy. This may negatively impact family relationships and the upbringing of children. Parents diagnosed with parental depression often experience increased stress and anxiety levels during early pregnancy, labor and postpartum. Those with parental depression may have developed it early on but some are diagnosed later on from when the child is a toddler up until a young adult.

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