Mental Health Matters: How stigma affects mental health care

This is the first installment of a two-part series on stigma and mental health. Part I defines what stigma is and how it affects the everyday life of those who live with mental health conditions. Next time, we will look at what we can do about stigma!

When I have the opportunity to speak in the community about mental wellness and mental illness, I typically start out by asking a simple question. “If you had to choose which kind of illness to be burdened with, would you choose a mental health condition or a physical health condition?”  Remarkably, to the person, everyone picks the physical health option! When I ask why, it is clear that even for those who do not know much about mental health, they understand that it is important to have your mental health on your side in order to figure out what to do about your condition. I also try to start the conversation from a bit of a lighthearted space. We know that about 1 out of 5 people experience mental illness every year. And I quickly follow up with “the other four are living with them.”

The truth of the matter is that physical and mental health are intertwined with one another. I was at a conference years ago and met a woman with whom I shared some common experiences. At one point, she disclosed that her mother had recently passed, and that she was still very much in grief over this loss. A bit further into our conversation, I asked about the nature of her mom’s end of life. She shared that while her mother dealt with depression, that wasn’t what took her life. Her mother had died of cardiac disease. She then thought for a minute, reconsidered and added that because her mother suffered from depression, she was unable to take care of her physical health in a way that could have perhaps prevented or at least alleviated her cardiac condition to have made it manageable.

Indeed, our physical and mental health are pretty tightly intertwined. It is also interesting that our culture takes physical health much more seriously than mental health. If we treated cardiac disease like we treat mental health, we would have people dying on every street corner. There are some reasons for that. One of those reasons is that when someone is dealing with a physical health condition, there are times when it is clear and obvious that they are ill. You can see a cast on someone’s leg. At some point in their recovery, people who have had a hip or knee replacement may rely on crutches or a walker. It is visible.

Mental health is not always so obvious. Many people suffer with degrees of depression and/or anxiety that simply are not visible on the outside, and most of us work very hard at appearing “normal” or mentally well. Some people have lived with these conditions their whole life, and they themselves may not even know they are living with a mental health condition.

A far bigger problem is that of stigma. Merriam-Webster defines it as “a mark of disgrace, a negative stereotype or a strong disapproval attached to a person, group or circumstances.” The stigma itself is also often linked to prejudice, (a negative attitude toward something or someone), exclusion, (you find yourself on the outside of the circled wagons) and discrimination (when someone is treated as “less than”).

In the Disney animated movie “Mulan” (1998), the main character is a young girl named Mulan. The expectations in her culture are that young women should aspire to marrying into a respectable family and that they should retain a passive role in life. At one point in the story, Mulan “accidentally” sabotages a meeting with a prospective suitor, a man much older than she. Afterward, she is chided by her mother and the matchmaker herself. “You are a disgrace! You may look like a bride, but you will never bring your family honor!  You bring shame upon the family!”  Mulan was dealing with stigma!  Imagine what the family and community must have thought when Mulan disguised herself as a young man, joined the military and became a central figure in defeating a marauding band of invaders who intended to destroy Mulan’s culture. Nothing passive about this girl at all! But it comes with a price: stigma.

Ultimately, stigma around mental health affects every corner, a common denominator if you will, in almost every element of that person’s experience.  Let’s look at some of the real-life implications of stigma. Approximately 50% of people with mental health conditions were suffering prior to the age of 14. That is when most of us were in late middle school to early high school. Sadly, many cases of mental health that are traceable to that age are not treated at all. Why might that be? No one wants to think of their child as having a mental illness if they even consider that to be the cause of their child’s situation. It is because of stigma.

It is a frightening thing for most parents to even think about. Likewise, our education system is not designed to treat mental illness.  I bring up education because outside of the family, school is where most children spend the next largest portion of their time.  Many people simply miss, or misinterpret, the signs of mental illness in children and treat it like it’s a ‘behavior problem.” Which means that our goal is to make the behavior go away. This does not address the health condition underneath the behavior. In addition, adolescents and teens learn to cover it up so as not to face the stigma.

Mental health conditions are much like any other condition. The earlier they are detected, the earlier treatment can begin, and the likelihood of altering the course of the disease increases.  For people suffering with bipolar disorder, getting an accurate diagnosis can take up to 12 years. That is a lot of time for a condition to wreak havoc in someone’s life.  A lot of time for a child to be affected by stigma.

Think about all of the milestones a 14-year-old has ahead of them. Doing well in middle school is important for doing well in high school. Doing well in school in general is an indicator of children staying in school. Staying in school helps young people transition into adulthood by either finding gainful and meaningful employment or entering a career through college/university/tech school. Doing well in school is also correlated with later initiation into alcohol and/or drug use, as well as delayed sexual activity.  Conversely, approximately 20-50% of students who drop out of high school do so because of an underlying, often untreated or undiagnosed psychiatric disorder. They are often untreated and/or undiagnosed because of stigma.

When a student has an undetected mental health condition, there is an academic “cascade” that follows. They are affected by internal suffering. Conditions such as anxiety, depression and trauma manifest as executive dysfunction, poor sleep and chronic fatigue. This can easily lead to behavioral mislabeling. Chronic tardies and absences are usually met with disciplinary actions rather than psychological interventions. Academic failures and lack of treatment lead many young folks to be funneled out of the academic system and into the juvenile justice system. The Child Mind Institute reports that over 70% of youth in the juvenile justice system meet the diagnostic criteria of a diagnosable psychiatric illness(es). It is less stigmatizing to be seen as a delinquent as opposed to being seen as mentally ill. Because of the stigma.

Adults with untreated mental health conditions from childhood are significantly affected as well. JAMA Psychiatry published a longitudinal study that indicated  teens with unmanaged psychiatric disorders have six times higher odds of experiencing health, legal, financial and social problems as adults compared to healthy peers. Because of stigma.

How does that work? As adults, this population faces economic and educational deficits. Employment and economic opportunities are greatly reduced.  They are also more likely to face financial instability. They are more likely to face chronic physical diseases as high anxiety eats away at the immune system. The risk of severe substance and alcohol addictions also increases. They are also more likely to face life threatening crises, including severe clinical depression, self-harm and/or chronic suicidal ideation. And finally, they are more likely to face legal and social “friction.” Because of … stigma.

You may wonder if I have overdone the stigma thing here. I admit, that’s a lot to get your mind wrapped around. But not nearly as much as it is for children, adolescents and teens who live with the internal struggle of mental illness, which then follows them into their adulthood with that same struggle.

So next time, we’ll look at some things we can do to shine a light on the realities of mental illness and mental health.  There are options, depending on how much you want to invest in this issue, for everyone who is concerned. Meanwhile, see what happens when you share your own experiences, or open up a conversation with others about mental health. You can run your own research experiment!

Have questions you’d like to ask Shirley? Message her at oasistherapyservices@gmail.com.