Stigma associated with seeking mental health treatment: do students think others are judging them more than they actually are?

Last year, I supervised Honors Thesis research by Morgan Rondinelli related to mental health in two introductory science courses at Michigan (Bio 171 and Physics 140). Morgan’s survey included two common screeners, one focused on symptoms of depression (the PHQ-8*) and one focused on anxiety symptoms (the GAD-7). The survey also asked about previous diagnoses, stress mindset, resource usage and knowledge, barriers to seeking help, and demographic information. Here, I will briefly summarize some of our findings, but I will especially focus in on the area that seemed the most novel: student views on stigma associated with seeking mental health care.

The tl;dr answer to the question in the post title is: it seems possible.

Before getting to the findings related to stigma, I’ll highlight a few other findings. But, before doing that, I want to emphasize that the response rate was low (5% of students across the two courses). That’s not surprising: survey fatigue is real and students didn’t receive any incentives for taking the survey (due to IRB concerns about coercion). There are some indications in the survey responses that the respondents were not a random sample of students**, which influences how we should interpret the results (a topic I’ve written about before in the context of grad student mental health). As one example, if X% of survey respondents indicate they have diagnosis Y, that does not mean that X% of all students in the classes have that diagnosis.

With that caveat, here are some of our most interesting findings:

  • ~23% of students reported a previous diagnosis of a depressive disorder and ~25% reported a previous diagnosis of an anxiety disorder. While our response rate was low and potentially biased, those are very similar to findings of a larger survey of UMich students (which found the following stats for previous diagnoses: 25% depression, 18% generalized anxiety disorder, 8% social anxiety, 7% ADHD, and 3% OCD).
  • First generation and LGBTQ+ students had significantly higher scores on the PHQ-8 (depression) and GAD-7 (anxiety) screeners.
  • Most students were aware of at least some on campus mental health resources.

Focusing on barriers to seeking treatment:

  • The most common barrier to seeking treatment was fear of how disclosing would affect student and faculty/staff perceptions. 37.7% of survey respondents identified this as a past barrier and 32.8% as a current barrier.
  • Something we didn’t think to ask about but that multiple students wrote in as a free response was that their mental health condition prevented them from seeking help (e.g., due to a lack of motivation associated with depression). In retrospect, we probably should have thought to include that as an option. It would be really interesting to know what percentage of students experience that as a barrier to seeking care.

The main motivation for me writing this post, though, was to discuss the results of two questions that we asked related to stigma. We asked the students:

  • I would think less of a person who has received mental health treatment, and
  • Most people think less of a person who has received mental health treatment

The difference in the responses to those questions was striking. There are a few ways of visualizing the data, and I think they each have different advantages, so I’ll include three different plots of the same data.

First, in the figure below, you can see that most students strongly disagreed with the statement that they themselves would think less of a person who has received mental health treatment (blue bars). In contrast, the most common response to the question about views of others (shown with black bars) was to “somewhat agree” that most people think less of a person who received mental health treatment:

Bar graph with Likert answers. There are two sets of bars, one for the answer to the question about their own views, one to the question about views of others. The key difference is given in the figure caption.

Most students strongly disagreed with the statement “I would think less of a person who has received mental health treatment”. Respondents were much more likely to agree with the statement “Most people think less of a person who has received mental health treatment”

We can use the very neat Likert package in R to plot those same data somewhat differently. Here’s that plot:

Note: on this figure “self” indicates the responses to the question “I would think less of a person who has received mental health treatment” and “others” indicates the responses to the question “Most people think less of a person who has received mental health treatment”. 61 students answered both questions; the percentages on the right indicate the percentage of students who chose one of the “agree” options for a question and the percentages on the left indicate the percentage of students who chose one of the “disagree” options.

The take home message that stood out to me was: students view others as more judgmental than they say they are themselves. I’ll discuss that more below, but first want to show one last plot of the same data. Perhaps because I am an evolutionary ecologist, it seemed like I should create a reaction norm-style plot that connects individual answers to the two questions:

Note: On the y-axis, 1 = strongly disagree whereas 6 = strongly agree. The lines are partially transparent and jittered, so that more common response combinations appear darker and thicker.

That paired response figure makes it really clear that no students viewed themselves as more judgmental of students who seek mental health care (as compared to how they think most people view people who seek mental health treatment).

Why is this?

At first, I thought “This is wonderful! Now we just need to tell students that their peers are much less judgmental than they think and then people will feel okay seeking care!” But there are (at least) two important caveats that warrant consideration. First, people do not always admit to holding unpopular views; our survey was anonymous which should reduce the impact of this social desirability bias, but it’s possible some students didn’t trust that we really wouldn’t be able to link their answers to them. Second, I wouldn’t want a student who has experienced negative reactions when someone found out they had received mental health care to feel like we were saying their real, lived experience of stigma had not really happened.

In the end, I find these results really interesting, but am not sure what to do next. I have a lot of ideas for projects related to student mental health and am moving ahead with several of them. But none of them directly involve exploring this issue of stigma. I think that would be really interesting to do, but also need to spend more time thinking about it and reading about it. (I also need more hours in the day so I can actually get that done!)

In the meantime, as the project wraps up and the nears its end, I thought it would be useful to share these results more broadly, in the hopes that they inspire discussion (and maybe even follow up research). I’d love to hear thoughts from others!

 

*The PHQ-9 is more common, but includes a question related to self-harm. Based on the IRB review process, we removed that question, which yields the PHQ-8. Scores on the PHQ-9 and PHQ-8 are very highly correlated.

**Two things in particular stand out as suggesting respondents were not a random sample of students:

  • 36% of our respondents identified as members of the LGBTQ+ community; we don’t know of a survey of Michigan students that asked the exact same question, but in the UMAY survey of the campus community, 14% of students identified their sexual orientation as something other than heterosexual. That’s not a direct comparison, but the difference is sufficiently large that it seems likely that LGBTQ+ students may have been more likely to respond to our survey.
  • 20% of our respondents identified as first generation students; in 2013, ~10% of students reported having parents who did not attend college or who attended some college.

10 thoughts on “Stigma associated with seeking mental health treatment: do students think others are judging them more than they actually are?

  1. Very interesting and a really important topic. The results seem so strongly different between perceptions of self and other that to me it argues against some of the simpler and more artefactual explanations like sample bias or social desirability bias as the full explanation (although I’m sure they’re both real and in the direction of the results). I wonder how much of the fact is that “other” represents many people the student will interact with and this is a case where they are sensitive to the worst reaction out of the group instead of the average reaction out of the group? IE it only takes one judgmental jerk amidst dozens of nice people to make me feel unsafe about disclosing. I suppose you could get at that by asking questions about their perceptions of what they think most other people would think or the typical other person would think vs the worst reactions. In mathematical terms max(x_i) behaves very differently than mean(x_i).

    If this explanation is (partly) true, I don’t know what it solves on a practical level as the concern is a rational and realistic one.

    Maybe helping students see that seeking help does not result in automatic disclosure and that disclosure is not an all or nothing thing. I expect that they already know that though. But I suspect young adults are more prone to all or nothing thinking. But by now I am really going out on a limb of speculation just because I want there to be easy solutions.

    • Agree with Brian on the consequences of differences between mean(x_i) and max(x_i). I’ve also seen the effect of groupthink on such issues–one person in a group who voices the stigma they hold can have others nodding along, even if they wouldn’t espouse the same view on their own. I would like to hope that the groupthink can go the other way too, when someone voices their objections to the stigma/ensuing bias, but in that instance, it didn’t. I’d love to see one of those randomized, controlled studies where the only difference between applications is, say, a note in a recommendation letter indicating a leave of absence due to mental illness, to actually quantify the stigma.

      • I agree that it would be really interesting to have data on that! If it was a CV statement, I think it would be interesting to have a treatment indicating a leave of absence due to mental illness vs. a more subtle indicator, such as leadership in a mental health-related organization.

      • How people respond to a person who speaks up depends on how they assess the cost of opposing the nasty person vs the benefits of supporting the nice person.

    • Excellent point that our perception of stigma might be driven more by the maximum than the average. I’ve certainly had conversations with students who received a strong negative reaction from a professor after they disclosed a mental health concern, and you’re absolutely right that it’s a rational and realistic concern for students to worry about a similar reaction in the future.

      It would be interesting to know what students think in terms of the likelihood of others (including faculty) finding out if they seek mental health care. Do they trust that their privacy will be protected if they seek care? I don’t know of data on that.

      I also like the idea of emphasizing that there is not automatic disclosure and that they can be in charge of when and how and how much they disclose.

      And, finally, your “it only takes one judgmental jerk” comment makes me wonder if we need a messaging campaign for faculty: “Don’t be the judgmental jerk”.

  2. Thanks for this important discussion. We do need to try to find some solutions to this complex situation. Would it be helpful for professors and/or grad students who have lived through some of these challenges to offer a space for discussion within a faculty or department. Does anyone have any experience of this? We have a university-level counselling service or suicide line, but both of these are more remote. Is it better to try something locally (OR not)?

    • One idea I’ve been discussing with folks at Michigan is to have a formal service position within departments, where someone is designated as a mental health point person. The idea would not be for them to be a mental health professional, but for them to be someone who is aware of campus resources (a challenge at large, decentralized universities like Michigan!) and who has received mental health first aid training. I think it would also be important for the person NOT to be a mandatory reporter, since that would probably dissuade people from going to them.

      I wasn’t sure if this was a feasible idea at all, but then I spoke to someone whose been at Michigan a while who said that, before Title IX, the university had a very similar position related to sexual misconduct. So, there might be a precedent for the general idea.

  3. Late to the comments but I’m in the field escaping the Minnesota winter! Anyway, interesting post, and the disconnect between what people themselves think and what they say others believe is exactly in keeping with what’s called social norms research. I found out about this because at the U of Minnesota they are using this approach to work on preventing sexual misconduct and other behaviors. Alan Berkowitz has written a ton about it, and I got to hear him speak, which was really interesting. He has a website (alanberkowitz.com) with tons of links and articles, and it is very compelling. Apparently it is helpful to use in campaigns about, for example, underage or binge drinking, too.

  4. Pingback: Paired line plots (a.k.a. “reaction norms”) to visualize Likert data | Dynamic Ecology

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