Stigma in school-based mental health: perceptions of young people and service providers
Mental health affects one in five young people, with the majority avoiding help due to stigma. In this study, young people's (n = 49) perception of stigma as a barrier to accessing school-based mental health services was compared with that of service providers (n = 63), along with the perceived extent of mental health problems and availability of school-based mental health resources.
Participants completed a survey or interview. EBSCO and PubMed databases were used for the duration of this study, from August 2010 to September 2011.
A greater proportion of young people versus providers reported stigma as the largest barrier to accessing mental health services. In addition, most young people reported that school-based mental health resources were scarce.
These results emphasize the need for young people's involvement in mental health initiatives.
Key Practitioner Message
- Stigma is perceived as a significant barrier to young people accessing school-based mental health and substance abuse programmes by both young people and service providers, with this perception being greater in young people
- There appears to be limited mental health literacy in schools exemplified by (a) young people's perception of teachers as inadequately equipped to deal with and address mental health and substance abuse problems (b) young people's limited knowledge about existing mental health and substance abuse resources available at their schools
- Engaging young people in the planning and development of mental health and substance abuse programmes could help decrease the extent of the disparity between these two groups
Researchers estimate that one in five adolescents will suffer from a mental disorder (Kataoka, Zhang, & Wells, 2002; Offord, Boyle, Flemming, Munroe-Blum, & Grant, 1989). Half of adult disorders will emerge before the age of 14% and 70% before the age of 18 (Kessler, Berglund, Demler, Jin, & Walters, 2005) making adolescence a critical period for the identification and remediation of disorders. Without appropriate help, such disorders are detrimental to a young person's relationships, school and future life trajectory. Many barriers are associated with seeking mental health services. Three of the most common ones reported by young people are stigma associated with seeking help, not recognizing one has an illness and not knowing where to go for help (Davidson & Manion, 1996). Stigma has been defined in various ways by researchers in different fields; however, for the purpose of this article we will use the Mental Health Commission of Canada's definition of stigma: ‘beliefs and attitudes about mental health and mental illness that lead to the negative stereotyping of people and to prejudice against them and their families’ (2009). Young people may be more susceptible to stigma and less willing to access mental health services according to Kranke, Floersch, Townsend, and Munson (2010) as they are concerned with social interaction and peer acceptance while in school. This is particularly relevant for boys, as adolescent males are significantly less likely to seek professional help than females (Chandra & Minkovitz, 2006). The primary objective of this project is to examine young people's experience of stigma at school and the extent to which this creates a barrier to accessing mental health services in this environment. This was contrasted with school-based service providers' perceptions of stigma as a barrier to young people accessing mental health services.
The rate of unmet mental health needs is alarmingly high. Some estimate it to be as high as 70% of young people who have a mental health need do not access mental health services (U.S. Surgeon General, 1999). To gain insight into the barriers young people associate with accessing mental health services, Chandra and Minkovitz (2007) conducted a study and found that many participants rated issues pertaining to stigma as the biggest barrier for accessing mental health services. Results from this study showed an increase in stigmatized views when students had less knowledge of mental health. Another common barrier was the belief that their parents would deny the issue or peers would react negatively and reject the idea of accessing mental health services. Participants felt teachers should be more aware of mental health, its effects on school performance and how to help students who may have a mental health concern or illness (Chandra & Minkovitz, 2007). Results from Short, Ferguson, and Santor (2009) support these findings as teachers in their study self-reported being unprepared to deal with or identify mental health problems.
Stigma tends to be a barrier to treatment due to the fear of being labelled negatively (Kadison & Digeronimo, 2004). The prevalence of stigma as a barrier to young people accessing mental health services was researched by Kranke et al. (2010). Two themes emerged in their study: family perception and school environment. If there was a negative perception towards mental health in the family, young people tended to feel more shame related to their illness. In terms of school, young people were often concerned with the behaviours of peers and teachers. If these behaviours were perceived as stigmatizing or discriminatory, young people became more secretive, feeling more shame about their illness and withdrawing from social contact more frequently. Kranke et al. believed young people's emphasis on peer approval and social interactions were partially responsible for these findings. They found that a supportive family and communication with peers could reduce the self-stigma associated with mental illness (2010).
Stigma becomes dangerous when it interferes with individuals seeking help. A common consequence of not accessing professional help for a mental illness is suicide. Approximately 90% of adolescents who die by suicide had an unmet mental health need (Brent, Perper, & Moritz, 1993; Shaffer et al., 1996). After examining 151 cases of adolescent suicide Moskos, Olson, Halbern, and Gray (2007) found that the six top barriers parents, siblings and friends perceived for their loved ones accessing mental health services were: the belief that nothing could help, the belief that seeking help was a sign of weakness, reluctance to admit having a problem, denying having a problem, embarrassment towards seeking help and not knowing where to go for help (Moskos et al., 2007).
Another barrier related to young people accessing mental health services is the perception that stigma exists within the mental health service sector. Star et al. (2005) suggest that stigma can and does exist among service providers. Service providers in his study reported three main reasons behind the existence of stigma in the service sector; a lack of value for clients by professionals, a high staff turnover rate and a lack of support for staff from their organizations. Other researchers suggest there may also be a misconception of service providers as biased individuals. These perceptions are often attributed to all professionals in the field after one poor experience (Star et al., 2005). The perception of service providers towards their clients is important as it influences the likelihood that individuals will continue to seek help and the likelihood of recovery from a mental illness (Charbonneau, 2007).
Regardless of the source of stigma, one can assume that a reduction in it would lead to an increase in adolescents accessing mental health services. Consequently, programmes have been designed to reduce stigma in school settings (Pinfold et al., 2003). Successful programmes have common components: they provide positive brief contact with someone with a disorder, include education regarding disorders and provide an opportunity to protest. Positive brief contact is usually with someone who has overcome their illness (Heeney & Watters, 2009). Although a combination of these factors has lead to successful programmes, young people are still reluctant to access mental health services. For the purpose of this study, programmes were categorized under one of four types: curriculum-based, school-based, school-linked and other. Curriculum-based programmes are embedded into the curriculum and target all students in the designated school or classroom(s). School-based programmes are programmes that are run in the school but not included in the curriculum. They often target some, but not all students. School-linked programmes are programmes that have a link to the school, such as a referral source, but are run externally. Programmes listed as other are training programmes, alternative schools or programmes that exist as a pilot study.
In spite of a great deal of research on stigma and mental health services in general, there is less information on these factors within a school context. An examination of the relationship between young people's and service providers' perceptions of stigma as a barrier to accessing school-based mental health services will better inform programmes targeting young people in Canadian high schools. It was hypothesized that young people will report that stigma is prevalent within the school environment and represents a significant barrier to accessing mental health services. It was also hypothesized that school-based service providers will describe stigma as a significant barrier; however, this will be to a lesser extent than young people report.
Two groups of respondents were recruited for this study, young people in high school and school-based mental health service providers. The sample of young people used in this study consisted of 13–20 years of age, currently attending a Canadian high school. They presented an array of personal experiences including some with self-reported mental health concerns. As young people voluntarily accessed the survey online from an outside source, the resulting sample was one of convenience. Forty-nine young people with and without a mental health concern or illness completed the survey, the majority of which were female (82.2%) and white (80.4%). The majority of participants were from Ontario (74%) and had a mental health concern (57.5%). Of those who self-reported having a mental health concern or illness, the majority had been diagnosed by a doctor (68%) and had received treatment (64%).
The data from service providers came from the School-Based Mental Health and Substance Abuse (SBMHSA) project. A subset of 63 programme leaders associated with school-based mental health and/or substance abuse programmes in secondary schools across Canada were included as participants for this study. Service providers participated from the following Canadian provinces and territories: Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland, Nova Scotia, Ontario, Prince Edward Island, Saskatchewan, Nunavut, Quebec and the Yukon. Programmes were nominated by members of the SBMHSA consortium and associated networks. In the overarching project, service providers had to be involved in programmes that were currently being implemented in schools from grades 1–12 and had a focus on mental health or substance abuse. For this study, only those service providers affiliated with programmes implemented in grades 9–12 were included. Out of the 63 programme leaders interviewed, 17 were from curriculum-based programmes, 23 were from school-based programmes, 13 were from school-linked programmes and 10 were from other programmes that did not fit into one of these categories.
The Youth Online Survey consisted of 35 questions that evaluated young people's perceptions of the extent of mental health problems in schools, resources available for young people and the impact of stigma on young people and their use of services. Some of the questions for this survey were taken from the Survey of Educators (Short et al., 2009) or based on the findings of Moses (2010). Questions specifically targeting young people's perceptions of stigma in the survey asked participants the barriers they associate with seeking mental health services, their belief if stigma is a problem for young people in their school, if individuals with a mental health concern or illness believe they are treated differently due to their illness and if they have had difficulties making new friends or keeping old ones. The majority of the questions were ranked on a 5-point Likert scale, with one open-ended question, and one question where young people were asked to select the prevalence of different mental health issues in their school. The survey was posted on Mind your Mind, a leader in web-based information and survey techniques. It was also posted on the Kids Help Line website and Facebook page. The online survey was posted for a month on both sites with no additional marketing by e-mail or other forms of communication. However, the use of a web-based survey has the potential to increase sample sizes due to its anonymity, extension to remote communities and access for those who may feel stigmatized (Carlbring & Andersson, 2006; Griffiths & Christensen, 2007). The extent that these benefits are seen is dependent on the length of time a survey is available online and the amount of marketing conducted to promote the survey.
The School-Based Mental Health and Substance Abuse Interview was designed by the School-Based Mental Health and Substance Abuse Consortium for their national programme scan. The Consortium is made up of a set of 40 diverse leaders in research, policy and practice across Canada. The interview was designed to describe programmes across the country, including any challenges and enablers associated with implementing programmes, and barriers the programme leader has faced in implementing the programme. A probe was present in the barriers section that specifically pertained to stigma. The interview lasted approximately 1 hr and consisted of 32 open-ended questions.
Young people voluntarily completed the online survey by accessing a link on Mind your Mind's website (www.mindyourmind.ca) or the Kids Help Line website (www.kidshelpphone.ca). Once the participant had read through the content page they were instructed that continuing to the survey acted as consent to participating in the survey. The content page explained the purpose of the survey, the participant's rights and provided resources for participants to access once the survey was complete. Survey completion took approximately 15–20 min. The participants were provided with links to helpline resources, and support (e.g. Kids Help Line) throughout the survey. The participants were also given the option to exit the survey at any point in time. The survey was completely anonymous and once completed was stored in the Survey Monkey account assigned to the project.
Service providers who participated in the School-Based Mental Health and Substance Abuse Interview were associated with programmes nominated and selected based on the criteria laid out by the School-Based Mental Health and Substance Abuse Consortium project. Nominations could be made by other programme leaders or members of the Consortium. Nominees were sent an email with a nomination link on it instructing them to fill out a basic information form regarding the nominated programme. An email was then sent to the participant to arrange an interview time. The participants provided verbal consent after receiving a description of the project and their participation prior to the interview. Interviewers were undergraduates from the University of Ottawa who had been trained in the interview protocol and who received ongoing supervision by Consortium staff. The semistructured interview was then conducted (average length was 1 hr). The interview was recorded so it could be transcribed after the interview was completed. At the end of the interview, the participant was given the opportunity to request a copy of the transcribed script to validate what was discussed before the script was finalized.
Both the Youth Online Survey and the School-Based Mental Health and Substance Abuse Interview were reviewed by the Children's Hospital of Eastern Ontario's Ethics Review Board. The Youth Online Survey was also reviewed by the University of Ottawa Research Ethics Review Board.
Qualitative and quantitative data were available from both the Youth Online Survey and the School-Based Mental Health and Substance Abuse Interview. Data were analysed to assess two main constructs: the prevalence of perceived stigma, and to what extent it is seen as a barrier to accessing mental health services. All analyses were run on SPSS Version 18 and a standard alpha of .05 was used. Sample size differs by analysis as participants did not complete all questions in the survey. Data from the national scan and the online survey were first categorized into nominal variables before being analysed. Two by two contingency tables were used to analyse the between-group results on dichotomized data. The categorical data analysed in these tests were used to compare service providers and young people's views. Categorical data were also used to evaluate the responses of service providers' to the open-ended questions on the SBMHSA interview. Recurring themes were examined in the qualitative analysis. Descriptive analyses were also conducted on data gathered from both tools.
Significant results were found for the between-groups analysis comparing young people and service providers' perceptions of stigma as a barrier to young people accessing school-based mental health services [χ2 (1, N = 79) = 4.712, p = .03]. Specifically, there was a significantly greater proportion of young people (69.5%) who perceived stigma as a significant barrier to accessing school-based mental health services than did school-based service providers (51%). Within-groups analysis revealed that young people with and without a self-reported mental health concern or illness did not differ significantly as to whether they perceived stigma as a barrier [χ2 (6, N = 10) = 8.472, p = .206].
Overall, young people perceived stigma as the number one barrier to young people accessing mental health services (47.8%). However, young people with a mental health concern or illness ranked ‘not knowing where to go for help’ as the second most common barrier to accessing school-based mental health services (23.1%), whereas those without a mental health concern or illness ranked ‘peer pressure’ and ‘not knowing you have a problem’ as the second most common barriers (20%). The list of barriers young people perceived as preventing someone from accessing school-based mental health services is presented in Table 1.
Table 1. Young people's perceptions of barriers to accessing mental health services
|Stigma (47.8%)a ||Stigma (53.8%)||Stigma (40%)|
|Not knowing where to get help (17.4%)||Not knowing where to get help (23.1%)||Peer pressure (20%)|
|Not knowing they have a problem (13%)||Family influence (15.4%)||Not knowing they have a problem (20%)|
|Family influence (13%)||Not knowing they have a problem (7.7%)||Family influence (10%)|
|Peer pressure (8.7%)||Peer pressure (0%)||Not knowing where to get help (10%)|
|Cost (0%)||Cost (0%)||Cost (0%)|
|Other (0%)||Other (0%)||Other (0%)|
| N = 23|| N = 13|| N = 10|
Overall, young people reported being ‘very concerned’ or ‘concerned’ about students' mental health and substance abuse problems at their school (68%). The majority of young people reported that ‘very few’ or ‘none’ of their friends had a mental health concern or illness (71%). Young people (overall) also ‘strongly disagreed’ or ‘disagreed’ that there were resources available at their school to answer questions they had regarding mental health concerns or illness (64%). A minority of the young people overall reported that teachers were ‘well prepared’ or ‘prepared’ to deal with and identify mental health needs (31.5%).
Insignificant results were found when the perception of stigma as a barrier by service providers was compared to the type of programme they represented (i.e. curriculum-based, school-linked) [χ2 (8, N = 60) = 13.72, p = .089]. Insignificant results were also found when the type of programme was compared to the involvement of young people in the implementation [χ2 (8, N = 63) = 13.36, p = .10]. When the perception of stigma by service providers was compared to the involvement of young people in the implementation and design of the programme, insignificant results were found as well [χ2 (2, N = 60) = 0.332, p = .847].
The results support the primary hypotheses suggesting that, overall, young people perceive stigma as present within the school environment and as a significant barrier to accessing school-based mental health services. School-based service providers also perceive stigma as a significant barrier for young people, but to a lesser extent than young people report. These findings suggest that young people's and service providers' perceptions of the prevalence of stigma may well differ.
The results of young people's perceptions of stigma are consistent with the literature. Davidson and Manion (1996) found that fear, embarrassment and stigma were the most common barriers reported by young people to seeking mental health services. Young people's perceptions of stigma will influence their help-seeking behaviour. Their perception of its prevalence could help to explain why 70% of young people who have a mental health need do not access mental health services (U.S. Surgeon General, 1999). The literature has found that help-seeking behaviour is also influenced by gender whereby boys are less likely to seek help (Chandra & Minkovitz, 2006). The limited number of male participants in the current study (17.8%) suggests that young men are reluctant to discuss such issues even in a research context. The sample size for the male population was so small for this study that no analysis by gender could be conducted on the data.
Service providers' perceptions of the existence of stigma was significant (51%), suggesting that service providers recognize the prevalence of stigma and its importance as a limitation to service access by young people. These results are consistent with the literature as Star et al. (2005) found that service providers recognized stigma as a barrier in the mental health field.
On the basis of the within-groups results, young people (with and without a mental health concern or illness) reported stigma as the most significant barrier to accessing school-based mental health services. These results are consistent with the literature. Moskos et al. (2007) interviewed parents and close others of recent suicide victims, and both groups ranked stigma as the number one barrier that prevented their family member or friend from accessing help.
The second most common barrier identified by young people to accessing school-based mental health services varied across subgroups. Young people with a mental health concern reported ‘not knowing where to go for help’ as the second most prevalent barrier (23%), whereas those without a mental health concern or illness reported ‘peer pressure’ and ‘not knowing they have a problem’ as the second most prevalent barriers (20%). On the basis of the inconsistency of these findings, one could question the level of mental health literacy among young people. There is a general lack of knowledge of the barriers associated to seeking mental health services. The level of mental health literacy found within schools can influence young people's ability to identify a mental health issue and access support for such an issue. This can also propagate the impact of stigma, as it is supported by ignorance. Chandra and Minkovitz (2007) found an increase in stigmatized views with a lack of mental health knowledge in their study. Young people commonly attributed personal blame to the individual suffering from an illness without proper mental health education. Furthermore, the inconsistent responses reported by young people (with and without a mental health concern or illness) suggest there is a lack of communication between young people about such issues. Alternatively, this could be the result of a difference in individual experiences.
Overall, young people are concerned with student mental health and substance abuse at their school (68%). Despite their concern with such problems, there is a general lack of understanding of the extent of the problem. The majority of participants reported having ‘none’ or ‘very few’ friends with a mental illness (71%). This finding contradicts the literature, which states that one in five adolescents will suffer from a mental disorder and that half of adult mental disorders will emerge before the age of 14 (Kataoka et al., 2002; Kessler et al., 2005; Offord et al., 1989). This contradiction may reflect a general lack of knowledge among young people regarding the prevalence of mental health problems or may be the result of young people being less willing to self-identify themselves as having such issues to peers. Chandra and Minkovitz (2007) found that few young people reported talking to their friends or family about mental health and those that did discuss it with their families felt it was a topic that should be kept secretive.
Overall, young people (with and without a mental health concern or illness) reported there was a lack of resources available at their school to answer any questions they had regarding a mental health concern or illness (64%). These results suggest there is a perceived general lack of services addressing mental health and substance abuse in high schools across Canada. However, work by Short et al. (2009) would suggest that there are pockets of important work being carried out in schools across Canada. These efforts, however, remain fragmented and poorly communicated. Another possible explanation for the present findings is that services are available but young people are not accessing them, as found in Santor, Kususmakar, Poulin, and Leblanc's (2006) study.
A minority of young people (with and without a mental health concern or illness) reported their teachers were ‘well prepared’ or ‘prepared’ to deal with and identify a mental health concern or illness (31%). These findings may be influenced by a lack of communication between teachers and students. However, research by Chandra and Minkovitz (2007) found results consistent with the present findings. In their study, young people reported teachers should be more aware of mental health, its effects on school performance and how to help students who may have a mental health concern or illness. Another study by Short et al. (2009) found that teachers self-reported being generally unprepared to deal with and identify mental health concerns or illness.
There was no relationship found between the extent to which service providers perceived stigma as a barrier to young people accessing their programme and the involvement of young people in their programme. There was also no significant correlation between the type of programme that was being implemented (i.e. curriculum-based, school-linked) and service providers' perception of stigma as a barrier to young people accessing their programme. These results contradict the literature, as Peterson, Pere, Sheehan, and Surgenor (2004) reported that one-third of people who access mental health services feel stigmatized, and as a result one can assume young people would become significantly less involved in these programmes if they felt discriminated against.
There was also no evidence of a relationship between the type of programme that was implemented and the amount of involvement of young people in the design and implementation of the programme. Depending on the type of programme, the involvement of young people would presumably differ; however, our results do not support this. This could be the result of a lack of awareness of existing school-based programmes or a reluctance to become involved due to the perceived existence of stigma. Santor et al. (2006) found that youth were more likely to use resources only if they had difficulties and that the majority of students who accessed these resources were consistently doing so. Of course, the lack of significant findings may also be attributed to the small sample size and limited power to detect meaningful differences in these comparisons.
In this study, the sample size was relatively small (49 young people and 63 service providers). This limits the generalizability of these findings and limits statistical power for the analyses conducted. There is less opportunity for within-group comparisons (e.g. gender) due to this small sample size as well. It should be noted that the small sample size is due primarily to limited time and resources associated with this small subproject. As a result, participants only accessed the survey based on convenience and no additional sampling was carried out to purposefully collect data based on stratified demographic characteristics.
This study's sample of convenience may also not be representative of young people in the general population, as the majority of participants were white (80.4%), and from Ontario (74%). As a result, sampling bias may be present in this study. There is also a strong reliance on self-report, which brings its own limitations to the findings. With self-report, there is potential for social desirability bias. This effect may be mitigated in this study by the use of the internet. One of the benefits of using the internet is its anonymity, which increases the likelihood of disclosure (Amichai-Hamburger & Furnham, 2007) and presumably decreases the effect of social desirability. However, the benefits associated with online measures were not maximized in this study due to the length of time and way the tools were advertised and accessible online.
Furthermore, there was a lack of consistency in the method for accessing the major constructs of interest in this study (i.e. online survey vs. semistructured interview). Young people were asked if they believe stigma was a significant problem for students with a mental health problem, whereas service providers were asked if they believe stigma is a barrier to the implementation of their programme. This lack of consistency makes it hard to compare the two groups.
An important note to make when evaluating the results is that the primary experimenter was responsible for coding the qualitative data into categorical data. The potential for experimenter bias must be acknowledged.
Finally, the psychometric properties of the tools used to measure young people's and service providers' perceptions have yet to be established. However, we can be confident on the measures' content validity as questions were created and vetted based on the consensus of a National panel of experts in this area.
Conclusion and implications
In spite of its limitations, this study reinforces our understanding of stigma as a barrier to service access by young people and extends this to the school context. The study highlights the similarities and differences in the perceptions of students and school-based mental health service providers. It suggests that there is value in the inclusion of both young people and educators when identifying, developing or refining school-based mental health programmes. This is a viable way to reduce the gap between school-based service providers' and young peoples' perceptions.
School boards should also encourage schools and educators to build their capacity in the area of mental health literacy. This is easier said than done. Twenty-two of the 63 programmes used in this study involved increasing the knowledge and awareness of educators, yet this is still limited according to these findings.
Mental health professionals, service providers, young people and educators should start to view stigma differently. Currently, programmes approach stigma from the perspective that it needs to be eliminated. Stigma is attached to many other illnesses and aspects of society. Cancer, diabetes and many other medical conditions historically had stigma attached to it, but now people openly share their stories, assisting in the reduction of stigma. Interestingly, the same type of stigma is attached to mental illness, but many individuals with mental health concerns keep their problems secretive.
It is evident from this study that young people have strong opinions pertaining to their own mental health and well-being as well as to the services that are meant to meet their needs. What is less clear is to what extent their opinions are supported by accurate knowledge. A commitment to mental health literacy across stakeholders including young people can influence opinions and impact stigma. Young people need to have their views influence mental health policy and practice, especially within the school context.
Future studies should examine this same concept using a monomethod approach to collating and analysing the comparative data. The relative merit of universal mental health programming is an emerging area of research as well. Research into the efficacy of different vehicles for knowledge exchange among young people (e.g. social media, peer-led discussion and support groups) as well as between young people and service providers (e.g. joint focus groups) should be examined. Furthermore, research into the relationship between personal factors (i.e. suffering from a mental illness) and the perception of stigma should be assessed and compared in service providers and young people. A gender difference in the perceptions of young people and service providers is a final area we feel merits further exploration with an eye to developing gender-specific stigma reduction efforts.
We would like to acknowledge and thank the Mental Health Commission of Canada for funding the Canadian School-Based Mental Health and Substance Abuse Consortium. This funding set the parameters of the initial contract with the Consortium, from which the scanning data were produced. We would also like to thank Laura Conroy, Julia Gandy and Mind your Mind for their involvement and support of this study. The authors of this publication have declared that they have no competing or potential conflicts of interest.