stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
mental illness are weak or dangerous.” Prejudice brings in an affective component. The
third construct, discrimination, is a behavioral result.
The other part of our model is types of stigma, which Bernice Pescosolido discussed
earlier. Public stigma is what the public does to people with mental illness
when we endorse stigma about them. Self stigma is what people with mental illness
do to themselves if they internalize the stigma they receive. Structural stigma involves
socioeconomic forces that result in laws, statutes, and unclear structures that keep a
group down. The group we are interested in and the kind of stigma we are interested
in at our center is what we have come to call label avoidance because it does not seem
to fit under any other type.
Label avoidance does not necessarily involve a person with mental illness. It is
also not the concern of the public. It is the concern of a person who fears there might
be mental illness and in order to avoid that fear they avoid the label. The best way to
avoid the label is to avoid all mental health professionals because the easiest way to
get labeled is to be seen coming out of a psychiatrist’s office or have people learn that
you are taking psychiatric drugs. We realize the reason people do not get treatment is
to avoid the shame of serious mental illness, therefore avoiding discrimination.
What is of particular concern is adherence. We have come to understand adherence
in two separate ways. Both might be a function of label avoidance. One is to not seek
care. We looked at NCS and ECA (Epidemiologic Catchment Area) to get a sense of
the huge number of people who never seek care when they are in need. The other way
we understand adherence is by looking at people who do seek out care, but who do
not stay in treatment.
In thinking about developing an anti-stigma program we have to be clear about
what we are focusing on, which is people who are trying to avoid the label. We are
looking at one small part of stigma. One of the important behaviors we are interested
in is getting people to participate in treatment. One way to assess that is website use
because all PSAs include websites with the hope that people will use them for significant
information and to get direct help for their problems.
Our research group distinguishes between the processes and the vehicles of stigma
change, what an individual might do to change mental illness and the vehicles they
might employ to do so. There are three different processes for stigma change. Education
is the one that readily comes to mind for most people: If we provide more information
about mental illness, people are more likely to give up the myth. The second process,
protest, is probably the way a Baptist minister would approach stigma change, “Shame
on us for thinking that way. We should not pursue this kind of viewpoint anymore.”
The third process is something that is still used, especially in school settings, and that
is contact. I agree with what was said earlier—if you had to throw all your money at
something, contact is the thing to look at.
Education tends to be a comparison between the myths of mental illness and the
facts. For example, one of the myths of mental illness is that serious mental illness is
rare. This is known as the “leprosy myth,” the idea that leprosy was this evil rare thing
for which people were thrown out of the world. In reality we know that, depending
on whose numbers and what epidemiologic study you are looking at, schizophrenia
is about 0.8% of the population. That is difficult to get a handle on until you realize
that Chicago has about 64,000 people with schizophrenia. That is the same number
of people who live in Joliet, Illinois. That is just people with schizophrenia. If you
throw in bipolar disorder and significant psychotic depression, serious mental illness
is common and frequent.