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Stigma surrounding mental health treatment among American college-aged students who are considered “at-risk” is a serious problem that results in premature termination of treatment, treatment avoidance, and even suicide. This paper addresses the perceived stigma associated with getting treatment for high-risk mental illness problems and reviews relevant literature related to the root cause of treatment avoidance. I selected this topic because I have several close friends who struggled with serious depression while in college.
Mental health stigma research and treatment relates closely with counseling psychology via most of the unifying themes: personal strength and optional functioning (as a whole person), social justice, and dedication to the scientist-practitioner model. The themes of strengths emphasis and focus on the whole person relate to the belief that college students have the power, resources, and coping mechanisms to positively deal with mental health problems within the context of their entire environment. Mental health research and counseling also relates to the important theme of social justice and advocacy. As we will realize in the literature review that follows, historically marginalized populations suffer far worse when dealing with mental health problems. Consequently, counseling psychologists have both a duty and responsibility to address injustice by paying attention to the contextual reasons marginalized people require remedial counseling (Vasquez, 2012). The scientist-practitioner model is also tightly integrated with this topic because the research and treatment dynamic upholds the feedback loop of research informing practice, and practice informing future research (Mallinckrodt, Miles, & Levy, 2014). Finally, this segmented topic is differentiated from clinical psychology because it focuses on mental health stigma from a holistic and environmental standpoint rather than solely a diagnostic (psychopathological) one.
College students in the United States are a high-risk population for serious mental health problems. Schulze (2012) highlighted that the Center for Disease Control reported suicide as being one of the top three causes of death among 18-24 year old people. College is a stressful environment for young people because it may be the first time they are away from their friends and family. Additionally, the stress of choosing a career and executing against high expectations causes further duress. While exact statistics are largely unknown, Research by Schulze (2012) and Goldblum, Testa, Pflum, Hendricks, Bradford, & Bongar (2012) found that members of the LGBTQ community were particularly susceptible to higher rates of depression, mental illness, and suicide because of their sexual identity. Empirical research by D’Amico, Mechling, Kemppainen, Ahern, & Lee (2016) had similar findings on the basis of college students struggling with a transition to adulthood that is often times rocky and uncertain. One fundamental problem with the serious issue of mental health on college campuses is the taboo nature of the subject, and the inherent impact on acquiring accurate, objective, and empirical research.
While college aged students are likely to go to their friends for advice and counsel, fewer people turn to on-campus counseling services or other formal treatment options. Research by Stanley, Hom, & Joiner (2018) found that at-risk youths—those with DSM-V psychiatric disorders—were highly unlikely to start treatment (or continue it) because of help-seeking stigma. Current research suggests that this stigma comes from two major factors: internal self-stigma and fear of external social consequences. According to Hansson, Lexen, & Holmen (2017), self-stigma refers to “internalization of negative stereotypes among people with severe mental illness” (p. 1415). Self-stigma manifests as the media, peers, and society paint a negative stereotype of mental illness; as a result, people suffering often times try to avoid admitting the need for treatment.
Moreover, stigma stemming from external factors like peers, family, and colleagues results in fear of rejection, alienation, and social distance. A study conducted by Yang, Anglin, Wonpat-Borja, Opler, Greenspoon, & Corcoran (2013) found that associating labels with certain psychiatric conditions resulted in enforcement of negative stereotypes and affinity towards creating social distance from such people. Terms like schizophrenia, major depression, and psychosis were found to result in severe status loss for the individual in question (Yang et al, 2013). These findings suggest that at-risk college students may be aware of their condition but choose not to seek treatment in order to preserve their sense of identity and pride. We also have to consider other compounding factors that contribute to avoiding treatment. People of color, ethnic minorities, or members of the LGBTQ community very likely face the additional burden of individual level oppression in the form of microaggressions. Moreover, internet-based data breaches and personal data misuse among major technology companies has made the public wary of who has their personal information, how it’s being used, and whether it will be exposed—especially in a HIPAA-compliance context (Davenport, 2017). Taking these additional discrimination and societal factors into account, the higher rate of tragic suicide attempts among transgender people becomes more understandable.
The good news about this unsettling research is that educational initiatives, intervention programs, and campus services work effectively in remedying the root-cause of avoiding treatment. Studies by Morrison and colleagues (2013) found that cognitive therapy sessions for college students with at-risk mental states resulted in statistically significant reductions in perceived stigma and more treatment-seeking behavioral outcomes. These results align with findings by D’Amico et al (2016) regarding how education reduces stigma and positively impacts a person’s affinity for getting help.
The previously discussed studies share common strengths regarding empirical consistency and method repeatability; however, almost all of these studies use relatively small sample sizes (N < 150) and don’t consider the impact of volunteer bias. The studies summarized in the literature review consistently showed similar findings: intervention and education programs dramatically reduce perceived stigma of mental illness and increase likelihood of seeking treatment. The methods listed also seemed objective and easily reputable by other researchers looking to test the same hypothesis among different populations. One caveat to point out is that the literature showed how better outcomes were approach-agnostic; that is, no single therapeutic approach was necessarily more effective than the other (example cognitive versus psychodynamic).
Despite these strengths, the sample sizes were relatively small and most likely not representative of the entire population on campuses (especially people of color and LGBTQ community members). Most studies had less than 150 participants, while some like Stanley et al (2018) only had 32. Lastly, a consistent weakness among the studies was the problem of volunteer bias. Mental illness stigma research is in itself a catch-22 in the sense that the stigma likely causes significant discouragement from participation among some populations. This volunteer bias likely excludes people that may drastically impact the data and findings.
Important and potentially fruitful directions for counseling psychologists in the field of mental-health among at-risk college students may focus on: (1) extra sample size considerations during research; (2) increased attention to social relations in counseling sessions. Lots of further work needs to be done in these areas, and that work should extend to populations that face higher risks of suicide and suffering: people of color; LGBTQ community members; sexual assault victims; and people that were historically oppressed. To accomplish this, extra care and consideration should be placed on recruiting participants to ensure that sample sizes are in line with principles of social justice and advocacy. The research collected from these studies should also inform future practice (in adherence with the scientist-practitioner model) by placing a higher emphasis on social relations during the counseling process. In dealing with the pressure to fit in and transition to adulthood, it’s clear that this population is more sensitive towards the attitudes, perceptions, and judgments of family and friends. Counseling psychologists would likely benefit from being acutely sensitive towards these relationships as a realistic impediment to continuing or starting treatment.
Davenport, R. G. (2017). The Integration of Health and Counseling Services on College Campuses: Is There a Risk in Maintaining Student Patients’ Privacy? Journal of College Student Psychotherapy,31(4), 268-280. doi:10.1080/87568225.2017.1364147
D’Amico, N., Mechling, B., Kemppainen, J., Ahern, N. R., & Lee, J. (2016). American College Students’ Views of Depression and Utilization of On-Campus Counseling Services. Journal of the American Psychiatric Nurses Association,22(4), 302-311. doi:10.1177/1078390316648777
Goldblum, P., Testa, R. J., Pflum, S., Hendricks, M. L., Bradford, J., & Bongar, B. (2012). The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice,43(5), 468-475. doi:10.1037/a0029605
Hansson, L., Lexén, A., & Holmén, J. (2017). The effectiveness of narrative enhancement and cognitive therapy: A randomized controlled study of a self-stigma intervention. Social Psychiatry and Psychiatric Epidemiology,52(11), 1415-1423. doi:10.1007/s00127-017-1385-x
Mallinckrodt, B., Miles, J. R., & Levy, J. J. (2014). The scientist-practitioner-advocate model: Addressing contemporary training needs for social justice advocacy. Training and Education in Professional Psychology,8(4), 303-311. doi:10.1037/tep0000045
Morrison, A. P., Birchwood, M., Pyle, M., Flach, C., Stewart, S. L., Byrne, R., . . . French, P. (2013). Impact of cognitive therapy on internalised stigma in people with at-risk mental states. British Journal of Psychiatry,203(02), 140-145. doi:10.1192/bjp.bp.112.123703
Schulze, F. R. (2012). Suicide prevention on a college campus: an in-depth look at students' experiences in a peer education program (Published doctoral thesis). Boston University, Boston, MA.
Stanley, I. H., Hom, M. A., & Joiner, T. E. (2018). Modifying mental health help-seeking stigma among undergraduates with untreated psychiatric disorders: A pilot randomized trial of a novel cognitive bias modification intervention. Behaviour Research and Therapy,103, 33-42. doi:10.1016/j.brat.2018.01.008
Vasquez, M. J. (2012). Psychology and Social Justice: Why We Do What We Do. PsycEXTRA Dataset. doi:10.1037/e692142011-001
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Yang, L. H., Anglin, D. M., Wonpat-Borja, A. J., Opler, M. G., Greenspoon, M., & Corcoran, C. M. (2013). Public Stigma Associated With Psychosis Risk Syndrome in a College Population: Implications for Peer Intervention. Psychiatric Services,64(3), 284-288. doi:10.1176/appi.ps.003782011