So far, in our month of Mental Health Awareness, we have been heavily evaluating the impact that self- and social stigma has on those who are or have loved ones who are afflicted with some sort of mental health issue (which is estimated to be the majority of society). The third type of stigma surrounding mental health is Institutional Stigma (a.k.a. professional and structural stigma).
According to the Mental Health Commission of Canada, “Institutional stigma, in terms of mental illness, refers to the rules, policies, and practices of social institutions that arbitrarily restrict the rights of, and opportunities for, people with mental illnesses”. Inequities and injustices resulting from this stigma cause people with mental illnesses to have unequal access to social, economic, and political resources and power. With time, stigmatizing institutional policies and practices has become the norm by which society operates.
Institutional stigma is more systemic and involves policies of the government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Intentional structural stigma requires a conscious and purposeful effort to restrict the rights and opportunities of people with mental illnesses. This can be overt, such as policies that disqualify people from health insurance coverage because of having a mental illness, or covert, in which case institutions deliberately use a criterion that is strongly correlated with mental illness to deny equal opportunities to people with mental illnesses.
Unintentional structural stigma produces inequities for people with mental illnesses through inadvertent means, usually occurring because people with mental illnesses are disproportionately represented in certain groups and find themselves the subject of a given social policy. For example, strict crime policies imposing harsher sentences for less serious offenses (e.g., drug offenses) will have disproportionate effects on people with mental illnesses because of the prevalence of co-occurring mental health and substance use problems.
How does Institutional Stigma play out in our society? Here are some examples:
Healthcare
- The healthcare system is consistently identified as a significant contributor to structural stigma related to mental illness as well as other stereotyped health conditions such as HIV/AIDS and addictions. The primary ways in which mental illness-related institutional stigma manifests in the healthcare system are through insufficient funding of mental health services and research, the coercive methods of hospitalization and acute care that lays the foundation for the delivery of mental health services, and the unprofessional practices of mental health professionals who marginalize the population with which they work.
Employment and Income
- People with mental illnesses routinely encounter barriers to obtaining and maintaining employment. Those who do find work tend to be siloed to jobs that offer lower levels of compensation and fewer opportunities for advancement. Three ways that institutional stigma surfaces in the employment and income realms are through refusal to hire, failure to accommodate needs presented because of a mental health issue, and a disincentive to work through caps in income related to the receipt of disability benefits.
Housing
- The closure of large psychiatric institutions, disparities in income and wealth, as well as other forms of institutional stigma have had a significant influence on housing choices for people with mental illness, resulting in more people with mental illnesses being displaced from adequate housing. There are several ways in which this type of stigma manifests and, as a result, a substantial number of people with mental illness find themselves living in unstable situations with family or friends, in deplorable and dangerous conditions, or systematically funneled into neighborhoods that place them at greater risk of social isolation, victimization, disease, and other stressful life situations. Examples of institutional stigma surrounding housing are:
o Landlords may refuse to rent to people with mental illnesses and/or those who are receiving disability benefits; or
o Housing may be unaffordable for a proportion of people with mental illnesses whose income is limited by the fact that they are unable to work because of their impairments; or
o Policies and practices of housing services may be unsuitable for people with mental illnesses (e.g., overly paternalistic, unpleasant, unsupportive); or
o Eligibility criteria for housing may require medication compliance, abstinence from alcohol or substance use, attendance in addiction treatment; or
o Housing designed for people with mental illnesses at times faces severe community opposition and discriminatory zoning laws.
Education
- While access to equitable education has been determined to be a basic human right, for people with mental illness, this isn’t necessarily the case. Research has found that poor mental health is associated with poor educational quality and a high dropout rate. This creates long-term, far-reaching disadvantages in employment, financial security, social functioning, and health and well-being. Ways that institutional stigma manifests in education are insufficient funding for services to support students with mental illnesses, failure to provide reasonable accommodations for their mental health needs, segregation from mainstream classrooms, or exclusion from activities/opportunities offered to students without mental illnesses.
- Students with mental illnesses who are applying to post-secondary school programs can also be questioned about, and subsequently denied opportunities because of gaps in their transcripts related to the time taken to recover from mental health issues. In some educational systems, access to mental health assessment and treatment services is excessively delayed, leading to extensive interruptions in student education. Another barrier to receiving adequate education is that behavioral issues or absences from school may be responded to with skepticism, scrutiny, and disciplinary action rather than support and accommodation.
Criminal Justice System
- People with mental illnesses are grossly over-represented in the criminal justice system, and all of the inequities outlined in the previous examples of institutional stigma culminate toward the propensity for those with mental illnesses to engage in crime and be incarcerated. The institutional stigma that materializes in the context of the criminal justice system includes deficiencies in the health and social service systems and disbelief and discreditation of those with mental illnesses who have been victimized and systematically denied protection by the justice system. Once they enter the criminal justice system, they get entrenched in structural stigma making it more difficult to be granted parole and to succeed in the community under correctional supervision. Inmates without access to appropriate mental health and substance use services in jail or prison may be more likely to be charged with breaking institutional rules or involved in a verbal or physical altercation, all of which reduce their chances of succeeding in requests for temporary absences and parole. Inmates with mental illnesses may also be denied parole because appropriate mental health and substance use services do not exist to support them in the community.
There are other forms of institutional stigma that affect those with mental illness – they are less likely to have their privacy and information protected, they are less likely to participate in public actions, votes, and organizations, and they face more barriers to travel and immigration due to screening procedures, and their rights to reproduction and parenting are often infringed upon due to systemic discriminatory practices that weaponize their mental health status as justification to limit custody or unsupervised time spent with their children.
Despite growing awareness of institutional stigma surrounding mental health, it is made clear that there is still a long road ahead to largely eliminate these barriers, as evidenced by a series of studies conducted by McKinsey & Company which found that while 80% of polled employees believed that an “anti-stigma” campaign would be helpful, whereas only 23% of employers actually implemented such a program. Also, while employers ranked reducing mental health stigma at the bottom of their concerns, 75% of employees recognized the presence of stigma at work. These results demonstrate a growing need to restructure our approach to de-stigmatization of mental illness in the policies at our workplaces, institutions, and government agencies.
Maybe awareness alone isn’t enough, and we need to take a hard look at our institutional policies which impact these various aspects of stigma for those with mental illness. This starts with a collective force involving those who make policies and enforce implementation. Everyone can do their part by voicing their observations and concerns to those at the ‘top’, creating staunch advocacy for mental illness to be institutionally protected just as cancer or other health-related life disruptors are treated. The former is no less organic than the latter, and to treat one vastly different than the other is evidence that we haven’t yet come to accept mental health as a common and natural affliction but instead, as a reason to scrutinize and judge those with mental illness who we see as deplorable, bizarre, or crazy, all labels resulting from social-stigma.