In honor of LGBTQ awareness month Jon is answering some questions about mental health counseling and the LGBTQ community. Today’s question: How can a qualified therapist serve LGBTQ identified clients.
Mental Health Stigma (hereby referred to as stigma) are the negative attitudes, stereotypes, and beliefs that people hold towards folk living with mental health disorders. Stigma can be external (held towards other people) or internal (directed at oneself). Stigma motivates people to fear, reject, avoid and discriminate against people with mental health issues.
There are plenty of examples of stigma in the public domain. This happens when we blame mass murders by White men as mental illness, but other acts of killing as terrorism, war, or standing ground. It happens when we blame traumatized people who struggle with addiction for not having stronger willpower. The effects of stigma are likely present each day when 22 veterans kill themselves and do not receive the help they need.
Stigma happens behind closed doors too. It plays a role when a doctor dismisses a patient’s pain concerns as hysteria, only for her to discover after years of suffering that she actually has had fibromyalgia all along. It occurs when a teacher assumes a child with a learning disability is lazy or stupid instead of connecting them with the assistance they need. It’s present when a guy gets bullied for being a coward, because his panic reaction is so severe his nervous system causes him to freeze with tension. It’s the casual statement of some obscene act being labeled “cray cray.” There are widespread beliefs that people with mental health issues are more dangerous, have high rates of criminality, are lazy, and are more likely to be incompetent compared to people who do not.
Meanwhile the evidence demonstrates that mental health disorders are normal stress reactions and not indicative of character flaws. People with mental health disorders are more likely to be the victims of violence, not the perpetrators of it. And we know that mental health issues are incredibly common, about 25% of Americans will experience a mental health issue, that’s 3 times as common as asthma. Furthermore about 78-89% of adults polled believe mental health issues can be treated effectively. Would we be so callous as to blame the people with asthma for their breathing problems?
The problem is, is that there are some pretty significant effects of stigma. Stigma, when internalized, can be a major source of shame. Such shame can be so severe that it prevents people from seeking out and receiving the treatment they need. It also tends to increase the severity of anxiety, depressive, traumatic, and hallucinogenic symptoms. According to NAMI the average time between the onset of mental health symptoms and receiving professional intervention is an 8-10 year waiting period. Of the approximately 63 million adults who experience a mental health disorder this year, only 41% of them will seek treatment. That means over 37 million people, more than 10% of the entire U.S. population will struggle with a disorder that impairs functioning and causes distress without treatment. In a society of such great abundance and knowledge, that seems like a fact worth changing
Cultural and demographic groups in the U.S. react to stigma in a variety of different ways. For example, Hispanic and African Americans will seek out treatment for mental health issues at 50% of the rate of Caucasian Americans. Asian Americans tend to seek out mental healthcare even less, only 33% compared to Caucasian Americans. As a group, African Americans tend to look upon mental health treatment more favorably than other groups. As for gender differences, it’s been observed that on average males will wait longer, and develop more severe symptoms before they seek treatment compared to females. In one study, men cited embarrassment as the most common reason they did not seek out treatment, whereas women cited the cost. Some theorize our cultural norms and toxic masculinity are likely causes for such gender differences.
Not only does stigma affect how people approach (or rather avoid) getting treatment, it affects the way that communities treat people perceived to be having mental health issues. People are more likely to create social distance between themselves and persons with a mental disorder. This reaction results in a rather vicious cycle of events. The people experiencing mental health disorders become isolated, which in itself exacerbates the disorder making the symptoms more severe. As a result there is a desire by the community to create more social distance and there tends to be a void with regards to ensuring suffering people get sufficient human contact and dignity. Research shows that persons with mental health disorders that live within inclusive and accepting cultures tend to have less severe symptoms and distress compared to people who live in other cultures. Other research demonstrates that Americans who have an education about, or a solid relationship with someone who has a mental health issue, stigma decreases significantly.
Stigma has a pretty significant impact on our health and economy as well. Problems with mental health are the number one cause of disability in the U.S. Additionally people who are living with severe mental health issues – roughly 1 in 10 Americans – are at increased risk for developing chronic health issues, and more likely to die of treatable physical conditions. Their life expectancy is 25 years shorter than the average Americans. Mental health problems cost the U.S. economy approximately $210 billion annually due to reduced productivity for people at work, and increased absenteeism. It’s pretty clear that mental health disorders, and the stigma associated with them cause a lot of illness, suffering, stress, and challenges with productivity.
The good news is, there is a lot we can do about stigma. Studies demonstrate that stigma significantly decreases when people receive education about mental health, or have experience with a friend or family member who experiences mental health symptoms. If we foster an attitude of openness, provide support for people experiencing mental health issues, embrace educating ourselves and each other about mental health we can normalize common mental health problems. We can be less stressed, healthier, more productive, and happier as a collective. That would be pretty awesome.
To review, mental health stigma are the negative attitudes and beliefs that people hold towards persons living with mental health issues. Despite the fact we know that mental health disorders are incredibly common, and normal stress reactions, stigma persists. Stigma exacerbates symptoms of mental health, takes a toll on the economy, causes significant distress, and tends to isolate people living with mental health disorders. We know that when people gain exposure to knowledge about mental health issues stigma declines. Will you help in the battle against stigma and create a healthier community?
Pacesepe, A.M & Cabassa Leopoldo J. (2013) Public stigma of mental illness in the united states; a systematic literature review. Administrative Policy Mental Health 40(5) doi: 10.1007/210488-012-0430-z
DHHS (1999) Mental Health: Culture, race, and ethnicity. A Report of the Surgeon General.
National Alliance on Mental Illness (2018) Mental Health by the Numbers. Retrieved from https://www.nami.org/learn-more/mental-health-by-the-numbers
Abizu-Garcia, C. E., Alegria, M., Freeman, D., & Vera, M. (2001) Gender and health services use for a mental health problem. Social Science Medicine 53(7) 865-878
St. Michael’s Hospital (2014) Men, women use mental health services differently.
Doherty, D. T., & O’Doherty, Y. K., (2010) Gender and self-reproted mental health problems: predictors of help-seeking from a general practitioner. British Journal of Health Psychology 15(1) 213-228
Watters, E. (2010) The Globalization of the American Psyche Crazy Like Us. Free Press, New York, NY.
Today we are going to explore the nature of mental health disorders. Mental health disorders are real, prevalent, and can impact anyone. 1 in 5 Americans will experience a diagnosable behavioral health condition this year. They cause emotional, physical, psychic, and relational suffering, and can severely impact life functioning. For the most part mental health disorders are not a disease. Rather, they are normal stress reactions, and expressions of variety within our species. The most common threads linking mental health disorders are stress, trauma, genetics, and access (or lack-there-of) to coping skills and resources.
A lot of times the normal emotions that get labeled as “negative” are often healthy responses to our environment. The sadness and fatigue we experience while we mourn the loss of a loved one, tell us to slow down, rest, and take time to understand our loss and make sense of our new environment. The energy of anxiety can propel us into problem-solving action like studying for that big test. The hypervigilance and wariness that trauma survivors experience help us keep on the lookout for danger, a key to survival while living in an unsafe and threatening environment. Many times it is when these healthy adaptations are present when they are no longer needed, or when they become maladaptive and impact the quality of our lives or impact our functioning, that we label them a mental health disorder.
It makes sense that most of us misconstrue and misunderstand mental health experiences. The majority of funding to provide treatment for mental wellness is paid for by health insurance here in the US. Insurance companies operate by the disease model of mental health. That is to say the way they classify mental health is that you either have a disease that is making you unhealthy, or you are healthy and no longer in need of treatment. Clinicians are expected to take notes that use language which indicates they are assessing and treating a disease. Such a model limits our view of mental health, having us merely focus on symptoms. Such a model does not provide credence to wellness factors like resilience, creativity, socializing, perspective taking, courage and other adaptive mental functions which contribute to health.
Another contributor to the misconception of mental health are the marketing and sales of psychopharmaceuticals. Major pharmaceutical companies medicalize normal human conditions such as sadness and worry. There is a multi-billion dollar market out there trying to convince people across the globe that experiencing human misery is a sickness that can be cured with medicine, and not only that, but long-term medicine. This isn’t to say that you should not pursue medicine. Internal and external stressors can cause our brain chemistry to get out of whack and cause needless suffering. Psychopharmaceuticals have helped millions cope, and if it helps you I am glad you’re taking them. What this is to suggest, is that misery is part of the human condition and the perspective of viewing mental health as a disease is problematic.
The problem is, is that the disease model doesn’t hold up under scrutiny. Mental health disorders are culturally dependent, while diseases are not. Cancer, the flu, HIV and other diseases look the same, no matter where you are in the world. Anthropologists have done many studies and have found that mental health disorder symptoms change depending on the geo-cultural location. Depression, anxiety, and schizophrenia, look different in the US than they do in Japan, Tanzania or India for example. Other studies have demonstrated that depending on the culture, traditional medicine folk are about equally effective in treating mental health disorders as mental health professionals.
Culture plays a significant role in our views of mental health as well. The DSM used to classify being gay as a disorder; today being gay, lesbian, pansexual, or bisexual are widely accepted (as they should be) as part of our normal sexual diversity. Emotional and cognitive responses like sexuality, height, and weight, also exist on a spectrum. Some of us are more emotionally sensitive than others, some of us are more expressive, some of us less. 20% of the population will experience a mental health issue this year. This suggests that these are pretty common stress responses. I have yet to work with a person who is experiencing a mental health issue who was living in a healthy environment, felt secure in their needs, had no experience of trauma, was well connected with their community, existed in healthy relationships, was engaging in meaningful activities, and in good health.
And that leads to another important question. Are mental health disorders unhealthy responses to healthy circumstances, or are they healthy responses to unhealthy circumstances. Nobody has ever proven that the collection of mental health disorders in the DSM or defined by the WHO are unhealthy responses to healthy circumstances. There is plenty of evidence to suggest that disorders PTSD, anxiety, and depression are normal stress responses to unhealthy circumstances like abuse, violence, neglect, or not being able to meet ones needs.
So what does this all mean for how we view mental health? Mental health disorders create suffering, have significant impacts on functioning, and are worthy of being treated as the serious and real conditions that they are. Perhaps this means we as a collective have to re-examine our definitions of wellness and how we as a society want to achieve our individual and collective wellness. Perhaps this means we need to re-examine and redefine how we provide resources to treat suffering. Maybe this means we should be a little more gentle and understanding with others and ourselves, knowing that if we’re not feeling well, behaving well, not thinking well, or not communicating well we are doing our best and probably responding to our internal and external environmental experiences. We are only human, after all.