The Role of Stigma in the Global Mental Health Crisis: A Literature Review

Author Note

Yvonne I. Larrier, Counseling & Human Services Department, Indiana University South Bend; Monica D. Allen, Department of Health Science and Recreation, San Jose State University; Irwin M. Larrier, Harold Abel School of Psychology, Capella University. Correspondence concerning this article should be addressed to Yvonne Larrier, Counseling & Human Services Department, Indiana University South Bend, South Bend, IN 46615. E-mail: ylarrier@gcscored.com

Abstract

“This oppressive darkness is too much for me to bear alone, but my family and community tells me that nothing’s wrong with me. They say if I would only pray more, or if I would reach out and help others, then I would be fine.” This statement negates the depressive symptoms of the individual and attributes the “oppressive darkness” to the personhood of the individual in a negative light. Underlying those statements are erroneous beliefs, negative attitudes, and discriminatory behaviors related to mental illness. Stigma plays a large role in this. This is prevalent in many Low and Middle Income Countries as well as in High Income Countries. Across the globe, people with mental illness, either common mental health disorders or chronic mental illnesses, are not valued as equally nor treated as respectfully as persons who do not have mental illness. This article addresses the global mental health crisis and the continued need to make it a global health priority.

Keywords: Global mental health, Mental health, Stigma

Introduction to the Mental Health Crisis

According to the World Health Organization (World Health Organization [WHO], 2001, para. 1), one in four people worldwide will be affected by mental disorders at some point in their lives. Experts agree on the most common mental health disorders (CMHDs): depression, anxiety, attention deficit hyperactivity disorder, and some behavioral problems. While effective treatments do exist for these, few individuals have access to such treatments. The barriers to access are stigma and discrimination, insufficient financial resources, shortage of mental health care specialists, and treatment gaps (Collins & Saxena, 2016). For example, in High Income Countries (HICs), an estimated two out of ten adults with CMHDs receive care from a mental health specialist in any given year (Patel et al., 2013); whereas in Low and Middle Income Countries (LAMICs), there is one psychiatrist for every 10 million people seeking mental health care (Collins & Saxena, 2016). Mental illness has always been with us, even when we can’t see or hear it. For every notable and tragic event related to mental illness, there are numerous individuals around the world who are suffering in silence, shame, and isolation without knowledge, treatment and services, and without the support of peers, family, mental health providers, and their community.

The WHO defines mental health as “a state of well-being in which an individual realizes his or her abilities, is able to cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (Centers for Disease Control [CDC], 2013; University of North Carolina-Charlotte, 2016; WHO, 2001, para. 1). Mental health is critical for families, communities, and societies to be productive, safe, and competitive, and is fundamental to everyone’s ability to be a contributing citizen.

Global Mental Health

Global mental health (GMH) is an area of research and practice within global health that places a high priority on improving mental health and achieving equity in mental health for everyone worldwide (Cohen, 2014). In 2001, David Satcher, then Surgeon General of the United States, introduced the phrase “Global Mental Health” in an article titled “Global Mental Health: Its Time Has Come” (Satcher, 2001). Since the turn of the 21st century, GMH proponents, in collaboration with ministries of health, schools of public health, and other health and development disciplines have intentionally focused on ecologically valid, effective, and sustainable promotion, prevention, intervention, and treatment for all people everywhere in need of mental health care (Verdali, 2016). These concerted endeavors have burgeoned into further awareness and initiatives worldwide that identify global mental health as a public health priority issue.

Global Mental Health is a Global Health Priority

Global mental health is a growing field intricately connected to broader health, violence, and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75% of those in lower resource settings with need do not receive intervention (Murray & Jordans, 2016), and 40-60% of people in HICs with mental disorders do not receive the care they need (Collins & Saxena, 2016). This most arresting inequity brings into sharp focus disparities in how care is provided; the lack of respect and human rights for persons living with mental disorders across the globe; persistent personnel shortage; and research, treatment, and intervention gaps (Baingana, Al’Absi, Becker, & Pringle, 2015; Collins & Saxena, 2016; Patel & Prince, 2010). According to the WHO world health report (World Health Organization, 2014a), 10-20% of children and adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14, three-quarters by the mid-20s and nearly 30% of people globally experience a mood, anxiety, or substance use disorder at some time in their life. Nearly one-third of the US population lacks adequate access to mental health care providers (Collins & Saxena, 2016). The numbers demonstrate that CMHDs are the leading causes of disability worldwide (Collins & Saxena, 2016; Wang et al., 2007). It is estimated that, by the year 2020, depression will be the second leading cause of disability throughout the world, trailing only ischemic heart disease (Murray & Lopez, 1996). The Global Burden of Disease report found that five of the top ten global contributors to years lived with disability are mental disorders (Murray & Lopez, 1996). Mental health disorders include, but are not limited to, early drug or alcohol use, antisocial or aggressive behaviors, and violence. The personal, family, community, economic, and societal costs associated with these and other mental health disorders are enormous. For example, in 2010 the economic cost of such disorders was estimated at $2.5 trillion globally, and by 2030 the cost is projected to reach $6.0 trillion (Bloom et al., 2011). Additionally, mental health disorders among young people impede their ability to achieve culturally appropriate developmental tasks, such as learning healthy intra- and interpersonal skills, succeeding in school, and transitioning to college and career. Also compromised are individuals’ abilities to function adequately during their most productive years, when they plan their educational, family, and vocational futures (O’Connell, Boat, & Warner, 2009; Verdali, 2016).

Significance

Central to the WHO Mental Health Action Plan (World Health Organization, 2014b) is the principle that there is no health without mental health. The world has a growing need for mental health care that is culturally responsive and accessible both locally and globally. Personal and societal crises, such as police brutality, school shootings, and the heroin epidemic in the US, combine with the trauma, shame, discrimination, and human rights abuses suffered by millions of refugees fleeing their homes due to conflict and violence.

These personal and societal crises lay the foundation for mental health care to become a GMH priority because the current resources available to address them are inadequate, unequally distributed, inaccessible, inefficiently used, and static (Collins & Saxena, 2016). Unfortunately, according to WHO, for every 100,000 people globally, there are only nine mental health providers; and an extra 1.7 million mental health workers are needed in LAMICs (Collins & Saxena, 2016). Furthermore, the Mental Health Atlas (World Health Organization, 2014c) reported that most countries classified as LAMICs spend less than $2 USD per person; while in the US and other HICs, expenditure is estimated to be over $50 USD per person. Much of this expenditure is allocated for inpatient mental health care and mental health hospitals (WHO, 2014). Given these facts, it is safe to surmise that individuals with CMHDs most likely will not receive mental health care services.

In HICs, the shortage of mental health care providers is such that an estimated 40-60% of individuals with CMHDs do not receive the care they need (Bruckner et al., 2011). In LAMICs, the need is gargantuan; however, their ability to single-handedly bear such a huge disease burden requires help from all individuals, institutions, systems, and countries.

According to Collins and Saxena (2016), when it comes to mental health, all countries can be classified as developing countries.

Stigma as a Barrier to Mental Health

People avoid seeking mental health treatment for many reasons. Stigma is recognized as one of the toughest barriers to overcome, and can significantly complicate the experiences of individuals with a mental illness as well as those of their families (Bathje & Pryor, 2011; Corrigan, 2007). Satcher (1999) and Ben-Porath (2002) suggest that people are afraid to acknowledge that they have a CMHD, and at the same time are afraid to seek and receive treatment. Recognizing, seeking and receiving treatment appear to be stigmatizing. Public stigma can have profound adverse effects (e.g., devaluation, rejection, etc.) on individuals who are diagnosed with a CMHD. The consequences of stigma have the capacity to create more suffering and isolation than the actual mental illness itself (Martinez, Piff, Denton-Mendoza, & Hinshaw, 2011)

Stigma refers to a cluster of negative beliefs, attitudes, and behaviors that motivate societies to fear, reject, avoid, and discriminate against a particular trait, individual, or group of people (Mehta & Thornicroft, 2014). It is about disrespect, shaming, discrediting, and isolating, as well as about labels and language (Braithwaite & Ray, 1993; Centers for Disease Control and Prevention [CDC], 2010; Granello & Gibbs, 2016; Goffman, 1968; ISU Institute of Rural Health, 2011; Link & Phelan, 2001; Thornicroft, Wyllie, Thornicroft, & Mehta, 2014).

The general populace tends to view mental illness through four lenses: psychiatric symptoms, social skills deficits, physical appearance, and labels (Bathje & Pryor, 2011). All of these are negative and have unfavorable outcomes for the individuals with mental illness. Persons with a CMHD have less value placed on them and are treated differently than people without a CMHD (Mehta & Thornicroft, 2014). For instance, individuals with a CMHD lose out on jobs, housing, supportive relationships, and other opportunities that are commonly enjoyed by individuals without a CMHD (Corrigan, Watson, Byrne, & Davis, 2005). Across the globe, stigma has been found to be common among all socio-demographic groups. Many individuals attributed their attitudes and interactions toward persons with mental illness to a variety of etiologies of CMHDs, including biology, genetics, medical disease models, supernatural forces, drug and alcohol use, social and life events, and psychological trauma (Magaard, Schulz, & Brutt, 2017; Mehta & Farina, 1997; Mehta & Thornicroft, 2014; Phelan, Cruz-Rojas, & Reiff, 2002). Given the varied belief systems at play here, it is no wonder that many individuals do not seek help for CMHDs, which creates unnecessary suffering and missed opportunities.

Numerous programs have been developed and implemented to reduce the effects of mental illness stigma (Griffiths, Carron-Arthur, Parsons, & Reid, 2014; Henderson, O’Hara, Thornicroft, & Webber, 2014; Horgan & Sweeney, 2010; Lloyd-Evans et al., 2015). However, many of these programs only seem to worsen the stigma by reinforcing beliefs of individual differences and defects (Corrigan et al., 2005). It is incumbent upon researchers, practitioners, and other stakeholders to develop models of intervention that take into account factors that impede the use of mental health services (Vogel, Wade, & Hackler, 2007).

The direness of the GMH shortages, treatment gaps, and burden of disease have propelled us to explore and propose the use of social-emotional competencies (SECs) terminology instead of mental health terminology as a stepping stone toward de-stigmatizing mental illness. This alternate use of terminology led the authors to develop an agricultural metaphor to use as a mental health promotion strategy and as a stigma reducing alternative. Corrigan (2007) suggested that practitioners consider using and understanding diagnosis dimensionally rather than categorically as a solution to the stigma problem. In other words, instead of assigning an individual to a category and giving him or her a label (e.g., conduct disorder), the focus should be on the profile of symptoms, behaviors, or competencies (exhibiting poor self-awareness, relationship management skills, and self-management skills), thus unlinking from the mental health terminology and thereby reducing the stigma (Erreger & Foreman, 2016; Granello & Gibbs, 2016). Therefore, one of the goals of the proposed agricultural metaphor is to be a stepping stone in facilitating the transition from the use of mental health terminology to social-emotional language. The WHO in their Thinking Healthy Intervention manual emphasizes the need to employ commonly used terms such as stress and burden instead of depressive disorder or illness to avoid stigma (World Health Organization, 2015).

De-Stigmatization: Labeling and Language Matter

Stigma is presented in many forms, and researchers suggest that one of those forms is the continued use of labels and language associated with mental illness. Language can become a spotlight that highlights certain attributes or qualities of objects or people, making particular aspects of the world more prominent than others (Granello & Gibbs, 2016; Wolff & Holmes, 2011). For instance, the movement toward person-first language emerged from concerns that the use of labels to refer to individuals had the potential to promote bias, devalue others, and express negative attitudes (Granello & Gibbs, 2016). This person-first movement is grounded in the philosophy of linguistic relativity that states that language shapes perceptions of the world and significantly influences cognitive processes (Wolff & Holmes, 2011). In other words, the labels and language we use to describe persons with mental illnesses shape how they perceive and treat themselves as well as how others perceive and treat them. These perceptions help to influence whether or not they pursue treatment and support.

A study conducted by Granello and Gibbs (2016) emphasized this principle that the terminology used to describe individuals in need of mental health support does matter. Three groups (undergraduate college students in general education courses, community adults, and professional counselors/counselors in training attending a counseling conference) completed the Community Attitudes Toward the Mentally Ill (CAMI) survey. Participants were randomly given a version of the instrument that used the term “the mentally ill” or another version that used the term “people with mental illnesses.” The results showed that, in each of the three groups, the participants who received the survey using the term “the mentally ill” had significantly lower tolerance scores than participants who received the survey using the term “people with mental illnesses.” People who had the lower tolerance scores perceived “the mentally ill” person as inferior and as a threat to society; these participants had less empathy for clients. The difference in tolerance based on words used was noticeable, meaningful, and real (Granello & Gibbs, 2016).

Full Engagement While Moving Forward (Every Piece Matters)

The fact that 40-60% of people in HICs with severe mental disorders do not receive the treatment they need paints a dismal picture for individuals in LAMICs with CMHDs. Clearly, when it comes to mental health, truly all countries are developing countries (Collins & Saxena, 2016). Stigma has been identified as one of the leading causes of individuals not receiving the care they need. This in turn translates to needless suffering, potentially causing individuals to deny symptoms, delay treatment and refrain from daily activities. Stigma can exclude people from access to housing, employment, insurance, and appropriate medical care. Thus, stigma can interfere with prevention efforts (CDC, 2010).

De-stigmatizing mental illness requires full engagement globally from stakeholders at every level. No longer can disciplines afford to work in silos and expect this global crisis to be resolved. The global mental health crisis demands trained mental health specialists, concerned and committed lay people, practitioners, researchers, policy-makers, philanthropists, and governmental and non-governmental organizations from HICs and LAMICs to work together with one goal in mind: to increase access to culturally responsive mental health services by any means necessary.

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