Keywords

Introduction

Mental health stigma, also known as mental illness stigma, is the social judgement or devaluation of a person with mental illness or of mental health treatment. Because those with mental illness may experience discrimination such as denial of housing and employment, there are real-life consequences for those who face stigma. Often, such stigma beliefs are driven by lack of knowledge about mental health, but among Latinx communities, mental health stigma may have a particularly profound impact as a result of their cultural values and norms as well as experience with racial discrimination. This chapter examines mental health stigma in the Latinx community by highlighting the various types of stigma, the potential negative outcomes of stigma, factors that influence rates of stigma, and how practitioners can address mental health stigma.

Types of mental health stigma:

Mental health stigma is complex in its conceptualization, but for the purposes of this chapter, the focus will be on perceived- and self-stigma. Perceived (public) stigma concerns beliefs that others have negative views about those with mental illness or about mental health treatment. Public stigma is often assessed using measures of social distance or by asking stigma-related questions about vignettes concerning individuals with mental health problems. Perceived stigma beliefs can cause people to fear being labeled as a person with mental illness because of concerns about being judged negatively. Latinx parents have reported concerns that their family, friends, and community members would stigmatize them if they sought treatment for their children who suffered from worry and sadness [1]. Not only can perceived stigma beliefs impact treatment seeking, they can also impact mental health. For example, youth, including Latinxs, with higher rates of perceived stigma had greater odds of suicidal ideation and attempts [2]. Perceptions that others harbor stigma about mental illness and treatment impair treatment seeking and mental health overall.

Self-stigma, which is also known as personal stigma, is when public stigma becomes internalized such that individuals with mental health problems have negative beliefs about themselves due to their illness. Such beliefs can result in lower self-esteem and are related to feelings of shame [3]. In a predominantly Latinx sample of youth under psychiatric treatment, all but one of them reported feelings of shame related to their diagnosis that led to feelings of low self-worth [4]. Perceived stigma and self-stigma are related such that believing that others have mental health stigma beliefs is related to greater self-stigma [5]. Perceived- and self-stigma, both have deleterious impacts on mental health care.

Other types of mental health stigma are also important to consider, though they have been less widely researched. Structural stigma focuses on the institutional consequences of mental health stigma. An example of this would be that Latinx Americans are more likely to believe that those with mental illness are dangerous than European Americans [6] and such beliefs can have institutional consequences such that a person with mental illness would potentially be denied housing and jobs because of this false belief about dangerousness. Another structural stigma issue is that Latinx parents are concerned about such matters for their children, noting worry about whether their children will be placed in special education or have difficulty obtaining employment as a result of seeking treatment [7]. They also have concerns about losing their parental rights [1]. Another type of stigma is intersectional stigma which involves the combination of multiple stigma identities within a person or group and is sometimes known as double stigma. The term double stigma can be misleading however, as it suggests that the effects of stigma are merely added together when in truth they interact in a much more complicated, multiplicative manner [8]. Intersectional stigma is affected by how severely each of the identities differs from the social norm and how much victim blaming is associated with each identity. Therefore a gay Latinx man with a substance abuse problem would likely experience more severe stigma than a heterosexual Latinx woman with an anxiety disorder. It is important to remember that mental health stigma is found among all ethnic/racial groups within the United States. This is not a problem that is unique to the Latinx community, but understandings of mental health stigma that consider culture are important to addressing this problem.

Levels of Mental Health Stigma in the Latinx Community:

Various studies have been conducted comparing rates of mental health stigma between sectors of the Latinx community and other ethnic/racial groups with mixed results (Table 3.1). Some have found Latinxs to have higher rates of mental health stigma than other groups such as European Americans [7, 9, 10]. Others have found them to exhibit lower rates of mental health stigma than African Americans [11, 12] and Asian Americans [5]. In contrast, studies have found that the stigma beliefs of Latinx populations are similar to European Americans [12] and African Americans [13]. Comparison studies present an unclear picture and may not be most helpful in developing understanding of the impact of mental health stigma in the Latinx population.

Table 3.1 Ethnic comparisons of mental health stigma
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Perhaps more important are studies that only focus on Latino populations when examining rates of mental health stigma (Table 3.2). Studies that examine the levels of mental health stigma in the Latinx community find that it is typically present in the majority of the sample. For example, among depressed, Spanish speaking Latinxs, 83% endorsed at least one mental health stigma belief [14]. When examining adolescents, 86.4% of a diverse students sample reported that stigma was a barrier to seeking treatment [13]. It is important to note that mental health stigma rates may be even higher than is suggested by research due to factors such as social desirability. Though individuals may endorse low rates of stigma on a survey, they may really have greater stigma beliefs. This is suggested by a study conducted with a primarily Dominican sample using a method called Preguntas con Cartas (Questions with Cards) [15]. Participants were presented with questions about mental health stigma, then permitted to respond using cards that were placed face down and compiled anonymously in the group. The anonymous group score indicated higher levels of stigma when compared with survey responses about stigma. This discrepancy suggests that the ability to respond anonymously reduced pressure to answer in the socially desirable manner. These findings indicate that mental health stigma is a concern in the Latinx community that should be combatted.

Table 3.2 Rates of mental health stigma in Latinx samples
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Impact of Mental Health Stigma on Treatment

Mental health is particularly important because of its impact on treatment. For those who harbor self-stigma, they may be reluctant to even seek the knowledge that they need in order to address their mental health needs. The shame and fear of someone finding out about their issues and being labeled as mentally ill may be too great. Latinx individuals are less likely than European Americans to seek mental health treatment [9]. Though there are a variety of external barriers to treatment such as less access to mental health insurance, even when studies control for these factors, the discrepancy remains. For example, Benuto and colleagues [9] found that even when controlling for age, gender, income, and education among a community sample, 70.3% of European Americans and 34.6% of Latinxs reported using mental health treatment. Mental health stigma likely plays a significant role in this difference.

Mental health stigma beliefs are likely related to a lower desire to seek treatment among Latinx populations (Table 3.3). This appears to be the case in community samples [9, 16], among parents [12], and within college samples [17]. Perceived stigma beliefs were related to being more likely to miss scheduled mental health meetings and being less likely to take antidepressants among a community sample [16]. In line with this finding, having lower rates of public stigma is related to more positive attitudes about help-seeking [18]. When Latinx parents have concerns about mental health stigma, they are less likely to seek treatment for their children who suffer from anxiety [7]. Specifically, concerns that their child’s teacher will find out about their mental health treatment, that this knowledge would reflect poorly on them as parents, that the child would be teased, and that the parent would be embarrassed were all related to avoiding seeking treatment or delaying seeking treatment for their children [19]. Similar results are also found in college students. Mexican American college students with higher stigma concerning mental illness being incurable and beliefs that those with them were dangerous and untrustworthy were more like to have a preference for no treatment or for religious treatment as opposed to conventional treatment [20]. Further, among Latinx women with a history of eating disorders, having stigma about eating disorders was related to a lower likelihood of them seeking or participating in treatment [21]. Despite this collection of findings, it is important to note that mental health stigma does not always predict service use for those in the Latinx community. A meta-analysis, that included two studies, found that among Latino, Cuban, and Puerto Rican samples, mental health stigma was not related to help-seeking [22]. Further, Sánchez and colleagues’ [23] examination of a Puerto Rican, immigrant Latino, and Brazilian sample also found no relationship between stigma and help-seeking; however, it is important to note that their stigma measure focused on beliefs about whether people with mental illness are discriminated against. Despite these few findings that do not demonstrate a relationship, there is significant evidence to suggest that among Latinx communities, having mental health stigma reduces the likelihood that individuals are willing to seek mental health treatment.

Table 3.3 Relationships between mental health stigma to treatment and mental health outcomes
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Factors that May Increase Mental Health Stigma

In order to challenge the impact of mental health stigma in the Latinx community, factors that potentially foster it must be examined (Table 3.4). Many mediators of the relationship between mental health stigma and treatment outcomes have been examined, but those that seem to have the most profound impact include past treatment experiences, perceived racial discrimination, mental health knowledge, and cultural values.

Table 3.4 Factors related to higher mental health stigma
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Treatment can have a positive or negative impact on mental health stigma. Latinx clients, particularly immigrants, often have problems with dropping out of treatment early or with receiving care that is of lower quality. When treatment experiences are negative, such experiences are likely to increase mental health stigma and may in turn reduce further mental health service use [24]. However, when experiences are positive, they may reduce mental health stigma. For example among depressed, Spanish speaking clients receiving supportive counseling in which they were permitted to vent their concerns, mental health stigma decreased over time and more so than those in behavioral activation treatment [14]. The authors suggested that the venting process may be compatible with clients’ perceptions of what therapy is and therefore reduce stigma. They suggest allowing clients to vent even within therapy formats that do not typically allow for that process. Positive therapy experiences reduce negative beliefs that individuals have about therapy, allowing them to reap the benefits of therapy.

When individuals have experiences with racism, these negative interactions can also impact their levels of mental health stigma. For example, among a diverse sample of college students, the more discrimination that they experienced, the more likely they were to anticipate greater perceived stigma concerning mental health help-seeking and in turn had greater self-stigma [5]. Quinn and colleagues [25] suggest that when a person has experiences with racial discrimination, then this increases their belief in the likelihood that they would be discriminated against as a result of a concealed stigmatized identity such as having a mental illness or substance abuse problem. Further, racist stereotypes such as Latinx individuals being prone to drug abuse, may be related to increased stigma for psychotropic medications such as antidepressants when compared to psychotherapy [26]. Beliefs that antidepressants are addictive [27] create hesitancy in the Latinx community in which they do not want to associate with drugs, even medications to treat mental illness. Experience with racism may foster greater stigma towards medication to treat mental illness and make individuals more likely to expect discrimination due to having a mental illness.

Another factor that impacts mental health stigma is knowledge about mental health or mental health literacy. For example, some Latinx immigrants harbor stigma beliefs about depression because they believe that it is caused by evil forces and sinfulness [28]. A similar conclusion was found from a study among Mexican American college women who were more likely to harbor self-stigma beliefs if they believed that the causes of mental illness were spiritual in nature (i.e., punishment for sins) [29]. When individuals have better understanding about the biological etiology of mental health disorders, they have fewer stigma views [30]. Knowledge may also be important because increasing knowledge is likely to reduce the level of anxiety someone has about interacting with someone with a disorder as they will have a better understanding of what to expect. Having less anxiety about social interactions with mentally ill individuals is related to less mental health stigma [11]. With psychoeducation about how mental illnesses present and treatment options, mental health literacy can be increased and stigma, in turn, reduced.

One of the most important factors that one must consider when examining mental health stigma in the Latinx community is the influence of cultural values and norms. One compelling study found that a preference for consuming media in Spanish versus English is related to higher levels of mental health stigma among youth [31]. The assumption is that Spanish media (film, television, radio, or music) is less likely to include anti-stigma messages and information about mental health help-seeking, perhaps as a result of cultural beliefs. Further evidence that connects Latinx culture to stigma was found in a study of Mexican American college students in which those with greater enculturation—connection to Mexican culture as opposed to mainstream American culture—was related to higher levels of mental health stigma as well as a greater preference for no treatment or religious treatment as opposed to conventional treatment [20]. One’s level of acculturation may also impact mental health stigma, but research has been mixed. Studies of Mexican American female college students found no relationship between acculturation and mental health stigma [29] while acculturation was related to less stigma about mental illness and treatment among Latinx college students and their parents [17]. Overall, these examinations of connection to Latinx culture in general suggest that there may be some aspects of the culture that foster mental health stigma.

Considerations of more specific aspects of Latinx culture also demonstrate a connection to mental health stigma. Family or courtesy stigma refers to the belief that family and friends may experience discrimination as a result of their relationship to a person with a mental illness [3]. Though not examined well, family stigma is likely important for Latinos due to familismo beliefs. Familismo refers to the high value in family connection within many Latinx groups. Family members may be blamed for their kin’s mental illness or others might perceive that they could be “infected” by it. Because of stigma beliefs, despite their strong connection to family, many members of the Latinx community are hesitant to share their mental health concerns with their family members. Among Latinx at risk for depression, greater perceived stigma was related to less likelihood that they would disclose their depression diagnosis to family or friends [16]. Research has also connected familismo to treatment use finding that those with high familismo behaviors were more likely to utilize informal or religious mental health treatment than medical or specialty psychological interventions [32]. These findings indicate that valuing family may complicate the treatment process of members of Latinx communities because of stigma beliefs.

The hesitancy to disclose mental health problems to others is likely due to the judgement that individuals anticipate from sharing that they are having mental health difficulties. This may be particularly problematic among Latinx youth who report greater desire for social distance from those who have mental health problems than European American youth [10]. Latinx adolescents, particularly males and those with higher rates of public stigma, likely expect that disclosure will result in social isolation. When such isolation includes the family, this may worsen mental health outcomes, so many choose to remain silent.

Other Latinx cultural ideas such as machismo and marianismo may also impact mental health stigma. Marianismo suggests that Latinx women should be dignified and always self-sacrifice even during suffering while machismo values state that Latinx men should be strong and the protectors of their families. These cultural beliefs may influence mental health stigma because having a mental illness would be seen as a sign of being weak (débil) as it goes against these cultural views. Further some members of the Latinx community feel as if they are not worthy of respect if they must seek treatment [33]. The belief that one is not fulfilling cultural norms and expectations if they seek treatment can have a profound impact on one’s judgement of mental health and treatment. These beliefs can influence feelings of self-worth making denial that one has a problem and avoidance of treatment a likely outcome.

Interventions to Reduce Mental Health Stigma

Due to the profound impact that mental health stigma can have on the lives of those with mental illness, various intervention programs have been developed to reduce such beliefs. Unfortunately, many of these programs fail to consider culture or even include Latinx participants [34]. Contact programs are interventions in which individuals are exposed to people who have mental health disorders. These interventions can be done in person, using video, or online, but in vivo approaches have a more significant impact on reducing mental health stigma [3]. Among adults, contact programs typically lead to reductions in mental health stigma and the willingness to seek treatment in turn [34]. However, among adolescents, such programs do not have this effect. One study of adolescents in which 40% of the sample was Latinx found that contact with college students who had a history of bipolar disorder did not result in reductions of mental health stigma [35]. This was similar to Corrigan and colleagues’ [34] finding from their meta-analysis that contact interventions are ineffective with adolescent populations. Contact programs may reduce mental health stigma among Latinx adults, but are likely not useful for adolescents; however, little has been done to examine whether culture is an important consideration for such interventions.

One culturally adapted intervention method that has been used to reduce mental health stigma among Latinxs is the use of an educational fotonovela. A fotonovela is an entertainment-education strategy that uses a popular media form to increase knowledge, shift social norms, and induce individuals to engage in socially responsible action. Typically they include cultural norms, popular images, simple language, and colorful, entertaining drawings that are designed to be engaging. Ideally the characters are perceived as similar to the reader, likeable and real. One such tool is “Secret Feelings.” Cabassa and colleagues [36] developed this depression focused fotonovela with input from primarily Mexican and Central American individuals. It was designed to help readers know that depression is a common disorder that, though it is serious, can be treated. “Secret Feelings” challenges common misperceptions about the addictiveness of depression medications and that depression is related to weakness, as well as encourages speaking to a doctor about symptoms.

“Secret Feelings” has been used to reduce mental health stigma in a variety of Latinx samples (Table 3.5). A randomized clinical trial using a convenience sample of adult night school students found that the use of the fotonovela did not reduce desires for social distancing or perceptions of dangerous more than the control group, though it did result in greater knowledge about depression treatment [37]. The authors did note that overall the sample had very low social distancing scores and this floor effect could account for the lack of findings. Another study demonstrated that “Secret Feelings” can reduce social distancing desires from pre- to post-test among a mostly Spanish speaking sample of Latinx women with depression [38]. Among a sample of immigrant Latinx women, those who read “Secret Feelings” had greater decreases in antidepressant stigma, but no change in general mental health stigma when compared to a control group [39]. Their exposure to the fotonovela also increased their depression knowledge and intent to seek treatment. One important aspect of the fotonovela is that it is designed to be shared with family and friends as it is entertaining and generates conversation. Among Latinx participants from a community adult school, 55% of those who received the fotonovela reported passing it on to someone else compared to 36% of those who were given a depression pamphlet [40]. This finding suggests that the fotonovela may be a good tool to spread information about mental illness throughout the Latinx community. Overall, “Secret Feelings” appears to be a culturally appropriate tool for some Latinx individuals and is a good resource for primary care and mental health care providers.

Table 3.5 Summary of fotonovela, “Secret Feelings,” and mental health stigma studies
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Ways to Address Mental Health Stigma in Treatment

Mental health care providers should strive to assess stigma beliefs and address them within the therapy process (Table 3.6). Basic tasks such as psychoeducation and focusing on building rapport that are typical to the therapy process are critical to reducing mental health stigma in current patients; however, it is critical to assess the individual needs of each client and consider culture when treating Latinx clients.

Table 3.6 Mental health practitioner strategies to address stigma concerns
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Increasing the Number of Culturally Matched Providers

Though Latinx Americans account for almost 20% of the population in the United States, only 4% of the mental health psychologists are Latinx [41]. A greater number of Latinx mental health providers are needed to assist in the struggle to reduce mental health stigma and provide effective therapy in the Latinx community. Latinx mental health providers typically have the cultural knowledge to develop treatments and interventions that can address stigma concerns and reduce mental illness symptoms. However, this does not mean that members of other ethnic groups cannot provide effective treatment to Latinx individuals. With cultural competence, appropriate and efficacious treatment can be produced.

Mental health practitioners have a responsibility to address issues of culture in the therapy process. Principle E of the APA Ethics code states that psychologists must consider and respect cultural differences [42]. There are a variety of cultural factors that should be considered when treating members of the Latinx community including personalismo. The cultural value of personalismo—valuing warm and emotional connections—suggests that the relationship between the client and the mental health provider may be even more important than the provider’s expertise. Building a strong, trusting relationship should be the first priority of the therapist.

A key idea noted by Abdullah and Brown [33] is that interventions should not be designed to change cultural values, but instead to emphasize values that support less stigma or shifting the client’s views of mental illness or treatment so that it fits better with their cultural values. For example, instead of trying to change machismo values, demonstrate how engaging in therapy will allow a severely depressed father to be the protector that he desires because he will be mentally well and better able to fulfill those duties. Culturally competent mental health providers would be able to assess the cultural value of caballerismo—a positive male image that focuses on the man as the nurturing provider that defends the weak, is chivalrous and respects others—and utilize it to encourage fathers to seek treatment for their mental health issues so that they can continue to provide for their families instead of trying to stifle machismo beliefs. Therapists must be adept enough to demonstrate that they respect their client’s cultural beliefs while getting them to consider other values that might be more supportive of good mental health.

Increasing Mental Health Knowledge

Most mental health providers, without hesitation, would suggest that increasing mental health knowledge is a clear way to reduce stigma. Research demonstrates that when people learn about the biological etiology of psychological disorders, this tends to result in reduced stigma for them [3]. Yet, this may be more complicated for Latinx community members. Lopez and colleagues [43] found that among college students though greater depression knowledge was related to lower levels of stigma about mental health and reduced desire for social distance from someone with a disorder, it was also related to greater stigma about antidepressant medications. A similar finding was attained among a Latinx sample of depression clients in which their stigma for antidepressants increased with knowledge, purportedly as a result of learning about side effects [23]. Because of the strong cultural view that antidepressants are addictive, which may be increased with knowledge about side effects, this may be an area in which mental health providers must be very cautious when providing education. Antidepressants may be a last resort reserved only for those with severe depression and discussions of them must be handled carefully. However, in general, increasing knowledge about mental health can lead to reduced stigma with Latinx clients; therefore, psychoeducation should be a key aspect of all treatment.

Inclusion of Family in Treatment

Due to cultural values such as familismo and the interdependent nature of many in the Latinx community, support from family and friends may be a critical aspect of the treatment process for those with mental health stigma. Latinxs are more likely to disclose their mental health problems to family than friends [44], therefore the inclusion of family in the therapy process may be even more critical than including friends. Despite the likely cultural appropriateness of including family, this can be complicated due to stigma. A group of predominantly Puerto Ricans who utilized mental health treatment wanted their family members to participate in a psychoeducation program, but were fearful that they would not participate due to stigma [30]. But the inclusion of family in treatment or anti-stigma interventions programs could allow for conversations about mental illness which could lead to more positive family interactions. Psychoeducation or interventions may be an important first step before including family in the therapy process. Latinx clients will likely suffer additional distress if they feel they must hide their therapy from family members. It is critical that clinicians assist clients in navigating the process of disclosing their mental health treatment and inviting their family to join in their process.

Conclusion

There is much diversity within the American Latinx population that includes English language fluency, nationality, immigration status, acculturation, experiences with discrimination, and socioeconomic status among others. These factors must be considered by practitioners as they consider mental health stigma. There is no one size fits all approach. There is still much that we do not know about mental health stigma in the Latinx community, therefore researchers should strive to fill these gaps. Concerns that still need to be addressed more fully include a better understanding of heterogeneity among Latinxs, closer examination of the role of cultural values in understanding mental health stigma, issues within the measurement of mental health stigma, and examination of outcomes and concerns for disorders other than depression. Better knowledge about mental health stigma will assist mental health providers in offering more efficacious treatment to members of the Latinx community.