John Hoey and Mary Cannon from Department of Psychiatry, RCSI University of Medicine and Health Sciences, Dublin, Ireland, share their research around breaking mental health stigma to empower voices
Research consistently shows that people from marginalised groups are almost four times as likely to experience mental conditions such as psychotic symptoms than the majority population (van der Ven et al., 2022). Yet, they are much less likely to seek timely clinical intervention or reach out to friends and family for support. Why is this, and what can be done to encourage people to seek help?
In our April 2024 blog “Can the Arts be an Effective Tool to Combat Psychosis Stigma,” we described stigma, as defined in the Oxford English Dictionary, as “Negative feelings that people have about particular circumstances or characteristics that somebody may have.” Although in recent years, attitudes towards certain mental conditions such as anxiety or depression have become more ‘normalised’ and openly discussed, other conditions, such as psychotic symptoms, remain stubbornly stigmatic and shrouded in fear. When it comes to mental health, those who both fear most, and are the subjects of fear, are marginalised groups, which can negatively impact both engagement and recovery.
Breaking mental health stigma research
Research consistently shows that identifying as being in a sexual, gender, racial or ethnic minority is associated with an increased probability of reporting psychotic experiences (Gonçalves et al., 2024; Oh et al., 2014).
Despite this, barriers remain when accessing timely and non-stigmatising support. For example, compared to their white peers, black service users in the United States experience a longer timeframe between symptom onset and first contact with mental health services (van der Ven et al., 2022).
They are also more likely to be lost at follow-up, reporting cultural and religious differences, perceived discrimination, and mistrust as contributing factors. Cultural conceptions of mental health may cause minoritised groups to manifest stigma differently; quite often, people who experience psychotic symptoms receive little support from family, as such experiences are seen as a mark of shame, rather than a condition that necessitates person-centred and recovery-oriented care.
Suicide rates in Irish Travellers, (Ireland’s only indigenous marginalised group), are six times higher when compared to the general population, accounting for approximately 11% of all Traveller deaths in both Ireland and the United Kingdom (Gregory et al., 2024). Structural racism and discrimination have been identified as underpinning Travellers’ experiences when engaging with mental health services (Villani & Barry, 2021). Combined with a tendency to regard the topic of mental health as taboo and not to be discussed, Travellers are much less likely to engage with clinical services during a mental health crisis.
More broadly, there have been consistent failures at a European level to take concrete steps to tackle anti- Roma racism. This continues to have a devastating impact on the mental health and well-being of these children and young people, who comprise Europe’s largest and youngest ethnic minority population. Thankfully, however, a different landscape is emerging, as a new generation of researchers, activists, and community advocates are less willing to accept societal indifference to experiences of discrimination by using their voices to speak up for the marginalised.
How can stigma both towards and within marginalised groups be addressed to break the cycle of fear and improve access to mental healthcare?
Encouragingly, a growing number of younger people are becoming less likely to accept cultural taboos, as they reclaim the narrative and speak up about their mental health at a grassroots level. A prime example is the Involve Youth Project in Meath, Ireland, which supports young people from the Traveller community and economically disadvantaged areas. Local youth between the ages of 15 and 20 developed the “No Shame” mental health board game, designed to tackle mental health stigma through relatable scenarios that foster open discussions.
This innovative tool has earned the project numerous accolades. In 2023, Involve, Ireland’s largest Traveller youth service led by CEO Michael Power, was awarded substantial funding by Rethink Ireland to expand the concept. The game is part of a broader campaign, including a podcast series, which empowers these young creators as they dismantle mental health stigma across Irish Traveller communities.
Changing the Status Quo
University of Pittsburgh researcher Shannon Pagdon (2024) argues that a path forward to ensure equity, justice, diversity, and inclusion in mental healthcare is to prioritise integrating people from marginalised groups as consultants, trainees, coresearchers and primary investigators.
As an example, Involve have recently teamed up with the Psychosis Ireland Structured Training and Research Programme (PSI-STAR) based at the RCSI University of Medicine and Health Sciences. The aim is to co-investigate the role of stigma in young Travellers who experience psychotic symptoms through their lived experience, drawing on these narratives to develop accessible online psychoeducational animations.
Such initiatives do not merely ‘bring people to the table;’ they transform the table through meaningful, deep engagement, with a will on both sides to change the status quo.
People from under-represented groups should receive more investment to undertake roles that require formal training, supported by academic institutions across the education-to-practice pipeline. Recruitment of people with marginalised identities within mental health fields would reduce the experience of feeling ‘unseen’ in care settings, giving way to a dismantling of structural barriers and inequities and alleviating the endemic mistrust that delays help-seeking behaviour during a mental health crisis.
To break the cycle of stigma in minoritised communities, we must empower younger generations to reclaim the mental health narrative, integrate diverse voices in mental healthcare, and prioritise culturally tailored, stigma-reducing initiatives.
References
- Gonçalves, C. C., Waters, Z., Quirk, S. E., Haddad, P. M., Lin, A., Williams, L. J., & Yung, A. R. (2024). Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol. Systematic Reviews, 13(1), 143. https://doi.org/10.1186/s13643-024-02566-5
- Gregory, L., Iafrati, S., & Crew, T. (2024). Diversity and Welfare Provision: Tension and Discrimination in 21st Century Britain. Diversity and Welfare Provision. Policy Press. https://doi.org/10.51952/9781447365174
- Oh, H., Yang, L. H., Anglin, D. M., & DeVylder, J. E. (2014). Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States. Schizophrenia Research, 157(1), 259-265. https://doi.org/https://doi.org/10.1016/j.schres.2014.04.036
- Pagdon, S., Shahriar, S. S., Murphy, S., Babusci, C. B., Flores, A. T., Rivens, A. J., … Bennett, M. E. (2024). From Rhetoric to Action: Justice, Equity, Diversity, and Inclusion in Coordinated Specialty Care for Early Psychosis. Psychiatric Services, 0(0). https://doi.org/10.1176/appi.ps.20240041
- van der Ven, E., Jones, N., Bareis, N., Scodes, J. M., Dambreville, R., Ngo, H., Mathai, C. M., Bello, I., Martínez-Alés, G., Mascayano, F., Lee, R. J., Veling, W., Anglin, D. M., Lewis-Fernandez, R., Susser, E. S., Compton, M. T., Dixon, L. B., & Wall, M. M. (2022).
An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care. JAMA Psychiatry, 79(8), 790-798. https://doi.org/10.1001/jamapsychiatry.2022.1640 - Villani, J., & Barry, M. M. (2021). A qualitative study of the perceptions of mental health among the Traveller community in Ireland. Health Promotion International, 36(5), 1450-1462. https://doi.org/10.1093/heapro/daab009
