COVID-19 has caused a collective crash in our mental health that has drawn much public attention, but the menacing shadow of mental illness – stigma – can be even more devastating than the illness itself.
Four decades of public education on mental health have failed to remove the stigma – and actually made it worse. Only a recent change in how we talk about mental health is starting to make a positive impact.
“Stigma has always been important to me because I recognize it as one of the things that stopped me from getting any help,” says University of British Columbia researcher and professor Jehannine Austin. “I had PTSD after a car crash. No one wanted to talk about how I was psychologically struggling. People just kept saying, ‘But you’re OK, though’ because all I had was bruises.
“It was one of the worst and most isolating experiences. I came out of it very much feeling like I was not going to be acceptable to people if they knew about my depression and anxiety and that I certainly wasn’t a good candidate to make the sort of difference in the world as a leader that I wanted to make.”
Now, as Canada Research Chair, Executive Director of the B.C. Mental Health & Substance Use Services Research Institute, and founder of the Adapt Clinic, Austin is a celebrated leader pushing to change the way we talk about mental health.
Her Adapt Clinic is the first and only clinic in Canada to provide free counselling to B.C. residents for a better understanding of why they might have mental health problems and how to protect their mental health.
What is stigma?
Austin says stigma is hard to define and often oversimplified into a single, discrete entity – which it isn’t.
There’s stigma at the institutional level. “If you have a history of mental illness, you’re at the bottom of the list for organ transplant,” she says. “In the U.S., there are many states where you can’t hold office if you’ve had a history of mental health problems.”
There is stigma at the societal level, where a person with a mental health condition is often marginalized. For example, a Canadian survey of the general public in 2008 found high levels of stigma toward people with mental health conditions:
- 42 per cent would no longer socialize with a friend diagnosed with mental illness;
- 55 per cent wouldn’t marry someone who suffered from mental illness;
- 25 per cent were afraid of being around someone who suffers from mental illness; and
- 50 per cent would not tell friends or coworkers that a family member was suffering from mental illness.
And there’s stigma at the individual level. “When people internalize these messages – ‘Oh you’re not as good,’ or ‘You’ll never achieve as much’ – it’s the most damaging bit for people who live with psychiatric disorders,” says Austin.
Four decades of doing it wrong
Since the 1960s and 1970s, psychiatrists have argued that mental health conditions are as real as any other disease, says Joel Braslow, professor of Psychiatry and History at the University of California, Los Angeles. Public education campaigns spotlighted the biological aspects of mental health conditions – “a disease like any other” – and framed them as “brain disorders,” aiming to reduce stigma through a biological understanding of the illness.
“The studies (on the campaigns) have been done and that’s not what we find at all,” says Austin. As the public adopted a more biological conception of mental health conditions, the stigma got worse. Biological attributions were linked to less blame but also created a desire for social distance, avoidance and perceptions of unpredictability and dangerousness, resulting in an “us versus them” mentality and defining those with mental health conditions as fundamentally different and broken. Mental health conditions were seen as more persistent and serious and people living with them viewed as unlikely to recover.
The same studies, however, also showed that talking about mental health conditions in the context of psychological or social stressors normalized symptoms, creating a healthier public perception of mental health problems.
What causes mental health conditions?
But the true causes of mental health conditions are actually not as simple as biological attributes, Austin and Braslow argue. In reality, mental health challenges result from a complicated dance between our biology and social, psychological, spiritual, cultural and historical forces too, says Braslow. He says that to fully understand mental health conditions, we need to consider the complex interplay between all of these factors.
Austin created the Adapt Clinic to deal with the stigma people internalize. Her research shows that when her genetic counsellors personalize and explain the true, complex forces that lead to mental health conditions and explore how to reduce or manage these risk factors, they see increased empowerment and reduced internalized stigma in their participants with mental health conditions.
She teaches people that everyone has a certain amount of genetic vulnerability – that no one is immune. “It’s so common in the population and there are so many genetic variations that we all have some of them,” Austin says. “That can be a profound thing for people who have psychiatric disorders just straight away, because they often think ‘I must be biologically defective or different in some way,’ so this can be a really powerful message that they’re not.”
The empowerment gives “people a sense of greater control over their own lives. Psychiatric genetic counselling is something that we have a ton of evidence for. I would like to see way more people getting it.”
Telling your story to reduce stigma
Another new evidence-based strategy is “contact-based education” -– having people share their diverse, complicated, human stories of their mental health journeys. In this way, rather than dividing us into the mentally ill and the healthy, we can all relate to these experiences and see that mental health problems are all part of being human.
“I started talking about my story when really no one was,” says Victoria Maxwell, an award-winning keynote speaker, playwright and mental health educator who holds workshops and performs plays that share her story of living with bipolar disorder. “Now, there are hundreds, if not thousands, of people talking about their stories. It’s helpful to have a variety of stories so people can recognize that there’s different experiences and different faces of mental illness.”
Her keynote address, That’s Just Crazy Talk, was named one of the top anti-stigma interventions in the country by the Mental Health Commission of Canada.
“They’re hearing that I went psychotic. I ran down the street naked. I was picked up by police. I was hospitalized four times, five times. I’m on medication. I have been for 20 years,” says Maxwell. “And they actually might want to be my friend, which flies in the face of what’s often splashed in the headlines or in people’s mind.”
This strategy is snowballing with Bell’s Let’s Talk campaign. A survey of Canadians showed that 83 per cent believe attitudes about mental health conditions have changed for the better since the campaign began 10 years ago.
“When I see stigma, it’s more that I see people’s myths. And so I use them as an opportunity to just explain my experience,” says Maxwell.
A new opportunity
Perhaps a silver lining of COVID-19 is that mental health is no longer out of sight. We can’t ignore that so many of us are struggling right now. Whether experiencing it ourselves or recognizing it in our loved ones, we are all learning that there is no health without mental health.
This is an opportunity to see how the complex storm we are in – of biological threat, political turmoil, social inequity, spiritual reckoning and historical trauma– come together to create mental health symptoms.
There has been no easier time to talk about mental health than during this pandemic because no one’s a stranger to it anymore.
This is our time to overcome stigma.