There is a well-known discrepancy between the number of service members with sub-clinical mental health symptoms and those who actually seek care. Research estimates that more than half of service members exhibiting clinically significant mental health symptoms do not seek mental health care. This underutilization of care may be attributable in part to mental health stigma, the process of stereotyping, in which negative labels (i.e., dangerous, unpredictable, violent) are attached to a category (i.e., posttraumatic stress disorder and other mental health disorders), thereby differentiating individuals as abnormal or unusual. Mental health stigma can manifest itself in three ways:
1. Public stigma is the process by which the general public engages in stereotypes of mental health conditions and the result is discrimination (e.g., “He/she has a mental health disorder and is therefore dangerous”).
2. Self-stigma occurs when individuals internalize negative perceptions and therefore discriminate against themselves (e.g., “I am different and will never be normal”). A consequence of self-stigma is often low self-esteem or self-efficacy.
3. Institutional stigma can result from the policies and/or the culture of an organization that intentionally or unintentionally reflects negative attitudes and beliefs about mental health disorders (e.g. the military practices strength, therefore seeking help for mental health is weak). This type of stigma can result in restricted opportunities or options.
Negative labeling can occur across all three types of stigma, as seen in the examples. For individuals being labeled, these cognitive processes often translate into label avoidance or the attempt to avoid stigma by denying their status as a member of a group (e.g., individual with a mental health condition/disorder) and refraining from seeking care or discontinuing services all together (e.g., “A mental health diagnosis means I’ll be crazy, so I won’t go to be evaluated or seek treatment”).
Research indicates there are three overarching themes with regards to how individuals with mental health conditions are labeled:
1. Individuals are seen as unable to take care of themselves and therefore, irresponsible.
2. Individuals with mental health conditions should be feared and are dangerous.
3. Individuals with mental health conditions are seen as childlike, naïve, and innocent.
Clearly not all individuals with mental health conditions fit these characteristics. For example, most individuals with a mental health condition are not prone to violent tendencies. In fact, people with mental health conditions are more often the victims of crimes and more vulnerable to attacks. Similarly, a minority of individuals with a mental health condition need others to take care of them; mental health conditions are treatable and manageable.
Literature also suggests that one pervasive way in which health care providers unintentionally create institutional stigma is through their word choices. Using outdated terms such as “the handicapped” or “mentally ill” or using a diagnosis to describe someone (e.g. the schizophrenic) reduces a person to a diagnosis, implying that a person is defined by this one condition. Similarly, language that ties mental health disorders to one’s character or moral turpitude implies that a history of mental health disorders is related to someone's moral character. This type of labeling also can have far-reaching consequences. As such, person-first language (e.g. person with schizophrenia versus schizophrenic) has been championed by organizations such as the Centers for Disease Control and Prevention (CDC) as the preferred way of writing or speaking about someone with any kind of medical condition. This language clarifies that the person has a condition that can be evaluated, managed or treated.
Military mental health providers have a duty to avoid labeling and ultimately dispel myths and stereotypes about mental health conditions and treatment, which in turn can help combat underutilization of health care services and decrease stigma. Consider the following recommendations:
1. Policies impact military culture, therefore providers should seek to take a closer look at their organizations’ policies related to mental health for potentially stigmatizing language and labels.
2. Words do matter. Providers should work to try and choose their words more carefully. Be cognizant of inadvertent labels and potential negative terminology. People-first language is preferable to combat labeling.
3. Finally, service members should avoid self-labeling. Engaging in the process of treatment will likely help to build service members’ self-esteem by the potential to gain more self-control and overcome self-judgement by taking care of their health.
Ms. Lauren Restivo is a health systems specialist at the Psychological Health Center of Excellence. She has a master’s degree in criminal justice with a specialty in victimology and substance abuse.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.