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Psychiatric-Mental Health Nursing

1.3 Mental Health Stigma

Psychiatric-Mental Health Nursing1.3 Mental Health Stigma

Learning Objectives

By the end of this section, you will be able to:

  • Discuss stigma surrounding psychiatric-mental health and illness
  • Explain the importance of representation and acceptance of mental health in the community
  • Describe the nurse’s role in stigma reduction

According to the National Alliance on Mental Illness (NAMI) (n.d.-a), “One in 5 Americans is affected by mental health conditions” (para 4). Due to the stigma surrounding mental illness, people delay getting treatment for an average of eight to ten years and less than half will ever seek help (NAMI, n.d.-a). Stigma affects the quality of life for the millions of people with mental illness. Nurses are in a position and have an obligation to educate the public about mental illness to reduce stigma, to help create positive change through engagement in public health advocacy efforts, and to model compassion for those affected by mental illness.

Stigma toward Mental Illness

Despite a recent focus on mental health in the United States, there are still many harmful attitudes and misunderstandings surrounding mental illnesses that lead people to ignore their mental health and make it more difficult for them to reach out for help (Centers for Disease Control and Prevention, 2021a; Corrigan & Watson, 2002). The term stigma refers to a cluster of negative attitudes and beliefs that motivates the general public to fear, reject, avoid, and discriminate (Figure 1.6). In this case, the discrimination is against people with mental health disorders (SAMHSA, n.d.-b).

A four column, two row table. The first row from left to right reads: "Self," "Public," "Institutional," "Affiliated." The second row from left to right reads: "Internalizing negative stereotypes related to mental illness," "Endorsing negative stereotypes about others with mental illness," "Maintaining policies that can lead to decreased access to services for people with mental illness," and "Being affected by stigma directed at another person with mental illness."
Figure 1.6 There are four main types of stigma surrounding mental health issues. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Estimates report that nearly two-thirds of people with diagnosable mental health disorders do not seek treatment due to the stigma of mental illness. The U.S. Surgeon General’s Report in 1999 was a milestone report that sought to dispel the stigma of mental illness and its impact on those seeking care (Hegner, 2000). This was the first surgeon general report to discuss mental health and mental illness, the first to put mental health in the spotlight. The National Alliance on Mental Illness (NAMI) seeks to improve the lives of those with mental illness and reduce stigma through education, support, and advocacy. NAMI encourages people to share their stories to discredit stereotypes, break the silence, and document discrimination (Abderholden, 2019).

Psychosocial Considerations


To fully understand the impact of stigma, it is important to understand several types: self-stigma, public stigma, and institutional stigma. There is also a fourth type of stigma relating to the caretakers of people with mental illness, internalized stigma or affiliated stigma (Kaggwa et al., 2023). Public stigma includes negative or discriminatory attitudes that individuals have about mental illness. Self-stigma involves negative attitudes, including internalized shame, that individuals with mental illness have about their own condition. Institutional stigma is more systemic, involving government and private organization policies that limit opportunities for individuals with mental illness.

Implicit and Explicit Bias

The term implicit bias refers to prejudice evidenced in attitudes beyond consciousness or control (Stull et al., 2013). Implicit bias may be automatic and unintentional. Bias against those with mental health disorders comes up in communities, within the health-care sector, and in those with mental illness themselves. Each person’s social conditioning affects their implicit bias (Cherry, 2023).

The term explicit bias refers to attitudes people are aware of, endorse, and communicate (Vela et al., 2022). Explicit bias interferes with inclusion, equity, and access in health care and negatively affects communication and teaching (Vela et al., 2022). Researchers examining bias in health care call for systemic change to address both implicit and explicit bias (Vela et al., 2022). It is important to work with and advocate for people who have mental illness toward more support and better outcomes for this population. Positive attitudes increase the desire to help and influence behaviors, which is especially important in those who are caring for people with mental illness.


The term prejudice refers to the beliefs, thoughts, feelings, and attitudes someone holds about a group. A prejudice is not based on personal experience; instead, it is a prejudgment, originating outside actual experience. While prejudice is based in beliefs outside of experience, experience can lead people to feel that their prejudice is confirmed or justified. This is a type of confirmation bias. For example, if someone is taught to believe that a certain ethnic group has negative attributes, every negative act committed by someone in that group can be seen as confirming the prejudice. Even a minor social offense committed by a member of the group, like crossing the street outside the crosswalk or talking too loudly on a bus, could confirm the prejudice.

Prejudice—as well as the stereotypes that lead to it and the discrimination that stems from it—is most often taught and learned. The teaching arrives in many forms, from direct instruction or indoctrination, to observation and socialization. Movies, books, charismatic speakers, and even a desire to impress others can all support the development of prejudices.


Though prejudice refers to biased thinking, discrimination consists of actions against a group of people. Discrimination can be based on race, ethnicity, age, religion, health, sexual orientation, gender identity, or disability. For example, discrimination based on race or ethnicity can take many forms, from unfair housing practices, such as redlining, to biased hiring systems. Overt discrimination has long been part of U.S. history. In the late nineteenth century, it was not uncommon for business owners to hang signs that read, “Help Wanted: No Irish Need Apply.” And Southern Jim Crow laws, with their “Whites Only” signs, exemplified overt discrimination that is not tolerated today.

Discrimination can be intentional in the way that someone else makes a derogatory comment about another’s mental illness or treatment, or it can be unintentional when someone is afraid to be close to a person with mental illness due to their lack of understanding about the disease (Mayo Clinic, 2023). This type of discrimination extends to primary caretakers of people with mental illness who may feel judged and unsupported by society (Kaggwa, 2023). Discrimination presents barriers for people with mental health conditions obtaining “good jobs, safe housing, satisfactory health care, and diverse social interactions” (Stull et al., 2013, para 1).

Representation and Acceptance of Mental Health in the Community

Despite the number of people who experience mental illness in any given year, stigma continues to be a social problem in the United States (Ma & Nan, 2018). People with mental illness have ongoing problems finding jobs and affordable and safe housing and are faced with the public’s fear of being in close contact with them. Media campaigns can have a positive effect on changing public attitudes. One such campaign is Bring Change 2 Mind hosted by Glenn Close. This program has provided educational public service announcements about mental health/illness since 2009 (Bring Change 2 Mind, 2023).

Gender differences play a role in acceptance of mental illness. In 2018, Ma and Nan found that females are more likely to have positive attitudes toward and empathy for stigmatized groups than their male counterparts. Males have more often been found to want to deal with mental health issues on their own due to fear of stigma (Coveney, 2023).

Culture and Mental Health

Cultural and ethnic considerations are paramount in perceptions of mental health. Culture and ethnicity not only influence the way the disease develops, but also the way it is expressed, accepted, and understood (Mizock & Russinova, 2013). “The explanatory model a culture has for mental illness can both enhance and reduce stigma faced by people with serious mental illness” (p. 231). Cultural values and beliefs affect how a person views certain ideas or behaviors. In the case of mental health, it can determine whether or not the individual seeks help, the type of help sought, and the support available. Every individual has different cultural beliefs and faces a unique journey to recovery. In general, historically marginalized communities in the United States are less likely to access mental health treatment, or they wait until symptoms are severe before seeking assistance (Mental Health First Aid USA, 2019).

Four ways that culture can impact mental well-being are (Mental Health First Aid USA, 2019):

  • Cultural stigma: Every culture has a different perspective on mental health, and many cultures have a stigma surrounding mental illness. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help.
  • Describing symptoms: Culture can influence how people describe or feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. For example, members of the Amish community are typically stoic and endure physical and emotional pain without complaining.
  • Community support: Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Because of existing stigma, it can be challenging for individuals to find mental health treatment and support. Globally, there are different beliefs and practices related to the care of mental health problems. Some communities offer support to those with mental illness and others shun or ignore its presence. The treatment received by those defined as mentally ill or disabled varies greatly from country to country.
  • Resources: When looking for mental health treatment, it can be difficult to find resources and treatment options that take into account a specific culture's concerns and needs.

Communication problems interfere with the spread of mental health knowledge from culture to culture when specific descriptors of diagnoses are not expressed the same ways in different cultures. A solution to this is the use of Transnational and Inclusive Mental Health De-stigmatizing Education (TIMHDE). This concept involves people from all different continents, cultures, and lived experience working together to establish a mutual way to present educational content about mental health (Illingworth, 2021).

Barriers to Mental Health Care

Barriers to mental health care vary. There can be barriers that the client places on themselves by not wanting to admit that they need help. Barriers can also be connected to fear of stigma from friends and family, cultural biases, not having health insurance to cover the costs of treatment, and not having adequate information about the mental health resources available in their community (Heath, 2017).

For those who live in rural areas, finding treatment sources is also not always easy. There may be limited options, especially in rural areas and low-income urban areas; waiting lists; poor quality of care available for indigent clients; and financial obstacles, such as co-pays, deductibles, and time off from work. There is also the consideration that in small rural communities where everybody knows everyone, people may fear getting the help they need because of the stigma associated with mental health care.

Availability, accessibility, and acceptability (the stigma attached to mental illness) are all problems in rural areas. Approximately two-thirds of those with symptoms receive no care at all (U.S. Department of Health and Human Services, 2005; Wagenfeld, Murray, Mohatt, & DeBruiynb, 1994). At the end of 2013, the U.S. Department of Agriculture announced an investment of $50 million to help improve access and treatment for mental health problems as part of the Obama administration’s effort to strengthen rural communities.

Veterans and military personnel make up a large portion of those who encounter barriers to receiving mental health care. Despite the implementation of post deployment screening to help identify signs and symptoms of mental health problems in veterans returning from Iraq and Afghanistan, stigma is still present in the military community (Warner et al., 2011; Brown & Hardey, 2023). Many veterans remain hesitant to disclose their symptoms for fear of it negatively affecting their reputation. Those in the military are trained to be tough, so they fear that “members of my unit might view me differently,” and “It would hurt my career” (para 13).

Nursing Implications

Stigma and negative attitudes toward mental illness can still be found among nurses. Several studies from a variety of countries indicated that health-care professionals can be classified in three categories in relation to stigma, including “stigmatizers,” “the stigmatized,” and “de-stigmatizers.” Stigmatizers refer to nurses in medical settings with stereotypical attitudes toward clients with mental illnesses, psychiatric-mental health nurses, and/or psychiatry. Nurses classified as the stigmatized have mental health disorders or perceive stigma regarding their roles as psychiatric-mental health nurses. De-stigmatizers actively work to reduce stigma surrounding mental health disorders. The authors of the studies found that many nurses share commonly held stereotypical beliefs portrayed in the media. For example, clients with mental health disorders have been portrayed in the media as dangerous, unpredictable, violent, or bizarre, and these portrayals can cause fearful attitudes. Nurses in the studies were concerned about inadvertently saying or doing “the wrong thing” or “setting off” uncontrollable behavior. Many nurses in general medical settings felt they lacked the skills to manage behavioral symptoms of clients with mental health disorders. The authors of the review reported that their findings support additional mental health education for entry-level nurses and practicing nurses to enhance their knowledge base on mental health (Ross & Goldner, 2009).

Real RN Stories

Nurse: Lenore, MSN, RN-BC
Years in Practice: 20 years
Clinical Setting: Psychiatric-mental health nurse
Geographic Location: Texas

As a board-certified psychiatric-mental health nurse and university-level instructor, I find it important to teach my nursing students the importance of accepting all people despite what some might think is a derogatory aspect of their being (i.e., diagnosed with a mental illness). In my first class of the semester, I always talk about stigma and show two videos available through Bring Change 2 Mind. The first video “Grand Central Terminal” lets the viewer meet people talking about the diagnosis printed on their white t-shirt. The second video features Ron Howard, who directed “Grand Central Terminal,” sharing why he felt this story was important to tell. After we watch these videos together, I open up the floor for conversation. I ask if seeing visual representation of stigma helps them to better understand this concept. I ask if anyone in class would like to share about a time they may have felt stigmatized. I explain that what happens in class is akin to what happens in Vegas—what happens in the classroom stays in the classroom; it is a safe space for sharing. I also tell my students to compare educating others about stigma to dropping a pebble into a body of water and watching the ripples extend. Much like the ripples in the water, each person they educate has the potential to share that knowledge with others, in effect decreasing the stigma toward mental illness one person at a time.

Nursing Interventions for Client Care

Nurses can reduce stigma and advocate for a client’s needs and dignity by establishing a therapeutic nurse-client relationship. A therapeutic nurse-client relationship is essential in all settings, but it is especially important in mental health care where the therapeutic relationship is considered the foundation of client care and healing. Although nurse generalists are not expected to perform advanced psychiatric-mental health nursing interventions, all nurses are expected to engage in compassionate, supportive relationships with their clients (Ross & Goldner, 2009). This is even supported in the Nursing: Scope and Standards of Practice (American Nurses Association, 2021).

Nurses’ Self-Care

Nurses spend a lot of time and energy caring for others. Regis College’s 2023 article about self-care tips for nurses highlights five problems that nurses face: “Stress, burnout, bullying, exhaustion, and inadequate sense of support from employers” (para 4). Self-care is an important part of being able to take care of others. If you do not take time to take care of yourself, you will have nothing left to give your clients. Some ideas for self-care include maintaining a sleep schedule as a way to recharge the body, recognizing when to talk to someone about your feelings, making time for exercise, maintaining a healthy diet, and practicing mindfulness (Regis College, 2023). When at work, nurses should make a point of taking breaks, eating lunch, mentoring other nurses (this provides an environment of support), and sharing a laugh with coworkers. In the psychiatric-mental health environment, it is especially important to practice self-care as the clients are often at their most acute level, staffing ratios can be low, and there is the constant need to be vigilant in maintaining a safe environment. These factors increase the stress level of the nurses.

The psychiatric-mental health nurse is taught to be self-aware of their own attitudes toward others and triggers that may occur with certain clients. This self-awareness can help decrease possible stigmatization. For example, there may be a client who reminds the nurse of an abusive family member. In this case, the nurse recognizes the trigger and utilizes reflection and possibly seeks peer or mentor support. By admitting that there are preexisting thoughts about a certain type of client, the nurse is acknowledging that they may not be able to provide nonjudgmental care and reach optimum treatment goals for that client. The role of being a nurse is very rewarding and exhausting all in one. Taking care of self is just as important as the care provided to clients.


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