It’s not just social
Reflections on the urgency of addressing the structural side of mental health stigma
If you Google the phrase “mental health stigma,” nearly 91 million results are returned. Multiple professional societies, large health systems, and individuals with lived experience all offer some insight into what stigma is, as well as what can be done about it. There are a lot of opinions out there and, undoubtedly, a lot of good ideas on solutions.
The problem is, most of these opinions only focus on the social side of stigma—and there’s much more to stigma than just that.
Don’t get me wrong, it’s great news that our society and our institutions are paying closer attention to the stigma associated with mental health. After all, 86% of Americans believe the term “mental illness” carries a stigma with it, and shame that individuals sometimes feel when addressing their mental health can prevent them from seeking the care they need. Despite greater openness to the legitimacy of mental health issues, too many people still may wonder if their mental health issues that are unseen and sometimes hard to comprehend (compared to, say, a broken bone) deserve to be treated with seriousness and compassion (pro tip: they do).
But while efforts to combat the stigma of mental health in public life are admirable, they are inadequate for changing the way we care for individuals who are struggling. That’s why it’s insufficient to only look at the social side – how we talk about it – and why it’s imperative that we address the other side of stigma: the structural side.
Defining stigma
Let’s start by defining stigma and then get into this structural component.
Stigma has many definitions, but the one I most frequently use comes from a tremendous article by Bruce Link and Jo Phelan:
“…stigma exists when elements of labeling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them.”
There’s a lot to break down here, but for the purpose of this article, let’s think of stigma as difference + deviance. What that means is that for stigma to exist, an “in-group” that has power over an “out-group” (difference) has to treat that out-group as if there’s something wrong with them (deviance). We have some control over the social side—how people talk about mental health with each other—but it’s harder to address the power structures and policies that reinforce differences. Now, what exactly is structural stigma?
Simply put, it’s the codified health delivery systems and practices that create barriers to effective treatment. It’s also the entrenched power structures that reinforce in-groups and out-groups. For example, if a child in a school is experiencing a mental health crisis, in many cases, law enforcement will still be the standard response rather than a mental health professional.
This is a structure that reinforces stigma around mental health. It highlights in/out-group dynamic as well as a power differential. While that student may not be deviant, an officer’s presence signifies that the mental health issue is being treated differently. Even if administrators are sympathetic to the student’s needs and circumstances, the broader response mechanism is not suitable for those particular needs and circumstances. It is built into the structure.
In other words, by sending the wrong people to respond, the wrong message is sent to individuals and communities that those suffering from mental illness are a societal problem. This sort of structure reinforces stereotypes and furthers stigma.
Researchers have found that structural aspects of stigma have harmful effects for individuals with mental illness. It is viewed by scholars as an “under-recognized mechanism producing health inequalities” that is baked into all aspects of the system. Moreover, structural stigma has been routinely found in state legislation. This can range from which types of people respond to mental health incidents to funding mechanisms for treatment, and some researchers have gone so far as to describe the status quo as a “downward spiral of systemic exclusion.”
This is hardly the world that we want to be building—one in which individuals are sympathetic to the real challenges posed by mental illness but are trapped by structures that reinforce, rather than break down, stigma.
What do we do?
One of the first positive steps we can take to break down structural stigma associated with mental illness is to talk about it. Similar efforts have made enormous progress in breaking down the social stigma associated with this issue. So, in our conversations about policy, at county board meetings, in our schools, at our places of work, and in so many other areas of life, we should remind ourselves that while it’s great to have campaigns about normalizing mental health, if the structures don’t change, we are only addressing half the problem. In fact, you can join me on Oct. 13 at 12:30 ET as several colleagues and I address both halves of the problem, discussing the steps we can take to reduce mental health and substance use disorder stigma.
More than just talking about it, though, we can take specific actions that will break down structural stigma associated with mental health. For starters, we could focus on developing response systems that see mental health professionals, rather than law enforcement, handling the majority of cases involving those who are facing mental health crises. Addressing how we respond has a big role to play in the success of efforts to tackle structural stigma because it can create a more integrated structure that avoids stigma.
Specific policy changes could help, too. For example, bringing primary care and mental health together stands to make a significant impact on how care is delivered, allowing for greater ease of access for so many individuals who see mental health challenges as outliers rather than as normal issues commonly faced by people all across the country.
At the end of the day, I have to say I’ve been encouraged by the ways in which researchers, leaders, and other stakeholders are shining a light on the importance of mental health. We can see this in the growing acceptance of mental illness as fully legitimate, the focus of policymakers on bipartisan approaches to mental health challenges, and a research agenda that is incorporating structural stigma, not just social stigma, into studies and analysis.
My hope is that by addressing both sides of stigma, we can more effectively care for our fellow citizens who have been hurting during an unprecedented time of isolation and stress. It’s an urgent need, and by tackling these twin challenges simultaneously, we can surely rise to meet it.