Assorted chocolates arranged on a table
HealthNovember 10, 2020

Chocolates and tissues: Beginning to eliminate the stigma of mental illness

By: Lenore Cortez, MSN, RNC
Why is it that we still have a stigma attached to asking for help when we have a mental health problem? I live in a very conservative part of the United States and find that people here are not quite as open to mental health care as other areas of the country where I have previously lived.

I care for patients who don’t want to try a medication for their depression because they are worried about “what people will say when they find out.” My usual response is simply asking them, “If you had a heart problem and the doctor wanted to put you on medication would you take it?” They almost always say, “Yes.” I go on to explain that taking medication for a mental health problem is not a sign of weakness and for them to think of it as medicine for their brain.

I use this same tactic when students come to me saying they have never felt so stressed. In some cases, the student goes on to tell me about all the other stresses in their life, which can include several years of having anxiety or depression but never addressing it other than to put on a strong face. I have had students with paralyzing anxiety who have had a 180-degree improvement in their grades once they begin a small dose of an anxiolytic prescribed by their PCP or the university counseling center. These students come to realize that their decision to ask for help was the right one.

Ripples in a pond

In class, we talk about what we can do to decrease stigma. I go into detail about the following types of stigma:

  • Social Stigma is that which comes from the stereotypes and ignorance of the general public towards a person with severe mental illness (SMI).
  • Self-Stigma is the stigma that a person places on themselves making them feel less of a person due to their fear of people looking at them differently if they were to know the individual had a mental illness.
  • Label Avoidance happens when a person with mental illness does not seek medical care for fear of being labeled in a derogatory way.

I share the video “Grand Central Terminal” from Bring Change 2 Mind (2009). In this video, everyone is dressed in white t-shirts with either a mental health diagnosis emblazoned across their chests or their relationship to the person next to them. We see Bipolar Disorder/Sister and Post Traumatic Stress Disorder/Battle Buddy and Schizophrenia/Cousin. At the end of the video, the camera pans away and all the white t-shirts change to color with no words and everyone just blends into the crowd. The main point of this video? We each are fighting our own battles and most of the time no one else is the wiser.

I want my students to think about how they can make others feel important, despite that person having a mental health diagnosis. I tell them to think of the ripples that result from dropping a pebble into a pond. The pebble represents reducing the stigma for one person. The ripples are each person that is touched by the message of decreasing stigma. Each of us has a role in decreasing the stigma of mental illness.

Mental health in the classroom

When you became an educator did anyone tell you that you would also be responsible for monitoring your students’ mental health? Probably not. As the semesters pass, my experiences with this have increased. There are more and more students with anxiety and depression. In fact, I have had students have a panic attack during class. When that occurred, I left another student in charge of the class activity so that I could go be with the panicking student and assess their needs. Many times, in nursing education there are topics that will act as triggers to our students. We can’t possibly know what all those triggers are going to be. I will usually make a blanket statement before presentations that I know are difficult (i.e. talking about suicidality, death, trauma) so that students know it is safe to step out of class as long as they follow up with me later.

As nurse educators, how do we recognize that our students are having mental health problems? Well, beyond them coming to us saying they are having a problem, it is part of our responsibility to recognize subtle changes. Has the normally quiet student suddenly dropped off the grid, having absences and asking for extensions? Do you see grades dropping or absences in the student who has always pushed themselves to get good grades? Do you notice a mood change or poor ADL’s in a normally happy/well-groomed student? Our job is not to act as a counselor or mental health nurse, but to be able to notice when a student is slipping under the surface. We can reach out as a lifeline by simply sending that student an email saying we have noticed some changes and offering our help. We can reach out to our Title IX office and make a report if we suspect some kind of maltreatment is occurring to the student. We can invite the student to our office and then walk them to the on-campus health center. I cannot even count the number of times I have reached out only to have the student thank me for noticing.

Just as we have been taught to recognize our gut instincts when it comes to assessing our patients, the same is true when we notice something is out of character for one of our students. Even as it may feel uncomfortable to us to address these concerns imagine how it feels to the individual if no one notices. Sometimes the simple act of reaching out to them is exactly what they are missing in their lives outside of school.

I talk a lot to my students about learning how to use therapeutic communication. This is exactly the time we need to use silence and just listen to the student who agrees to meet to discuss what is going on in life. We are so quick to try to fix things by giving advice and filling silence. Notice what happens if we just sit with that student and listen. I have heard that some faculty will set up short appointments with each student at the beginning of the semester and use that time to get to know them. I admit that I have not done that. In all my courses I have about 120 students total. I do, however, constantly remind all my students that I am available to them at any time. Just today (a Sunday) I had two students reach out to me by text to ask questions. I took the time to answer their questions and ask how they were doing. It is little things like this that make the biggest impression on our students.

One good thing is that we have a counseling center on campus. In my previous blog, I mentioned that I have referred students to be seen at the counseling center. I have also had the director as a guest lecturer in my mental health course. This is a great way for the students to get to know one of the resources on campus and have a face to connect with that resource.

Mental health in the workplace

We need to also remember to be cognizant of changes we see in our peers. We live in a fast-paced world. The work environment is constantly changing, especially with Covid-19 social distancing procedures to keep everyone safe while we continue to teach our students. We are needing to adapt to these changes, while monitoring its effects on our students, but are we paying attention to the cues of our co-workers or even ourselves? Are we practicing Self-Stigma by hiding behind a mask of strength only to go home at night and collapse onto the couch due to the effort of not asking for help? Our students look to us as examples of how to act in the workplace and the world around us. If we are not practicing what we preach then how will we ever be able to decrease the stigma of mental illness? Don’t be afraid to ask for help. Don’t be afraid to ask a co-worker if they are okay. We are all in this together.

Some of the resources available:

  • Employee Assistance Programs (EAP) – These are great resources for connecting with mental health professionals. The service is free and will assist the employee in finding a therapist who can provide short-term help and refer them to another professional if longer treatment is necessary. Your Human Resources department will be able to provide information on how to access this benefit. This is a resource you might mention to a co-worker who needs some unbiased mental health care.
  • Mentalhealth.gov is a great website for information on different mental health problems, resources, and crisis lines.
  • SAMHSA Treatment Referral Helpline, 1-877-SAMHSA7 (1-877-726-4727) – Call for general mental health information & to find treatment in your area.
  • Apps are a great option for take-anywhere support. These are just a few of the many options:

Talk with your peers, offer praise, smile, share a good laugh, and ask questions about what is going on in their lives and really listen.

Perpetuating change

Be a change agent. Accept the challenge of stepping outside your comfort zone to advocate for positive changes in the world around you. Talk about mental health with your students, your peers, your family and your friends. Make this topic something that is just part of normal conversation. We can’t end the stigma of mental illness unless we talk about it and accept that it is part of life. It is not something to be swept under the rug hoping it goes away on its own. Who have you spent time talking with today? And, more importantly, who have you let talk while you listen? Together we can help to end stigma one person at a time.

Missed part 1 of chocolates and tissues? Read Chocolates and tissues: Overcoming faculty and student stress in nursing school now.

Lenore Cortez, MSN, RNC
Nursing Education Author, Wolters Kluwer Health
  1. Bring Change 2 Mind. (2009). Grand Central Terminal [Video] YouTube. https://bringchange2mind.org/learn/psas/grandcentralterminal.
  2. U.S. Department of Health & Human Services. (2020) Get Immediate Help. Mentalhealth.gov. https://www.mentalhealth.gov/get-help/immediate-help.
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