It is difficult for many of us to start psychotherapy or other forms of psychological intervention and stick with it. For example, more than one in three people who could benefit from treatment are not getting it [1]. Many things account for the underutilization of health care services, such as cost and problems with insurance coverage. This article, however, seeks to address a significant (and often invisible) reason I believe people do not begin or stick with treatment: the stigmatization of psychotherapy and other mental health care treatments (hereafter referred to inclusively as “therapy”).

What is stigmatization, in general? The existence of stigmatization in social groups may be simply understood as a fear-driven process, in which the feared object is marked with disgrace and thereby less accepted within the group. In the scope of this article, the feared object is therapy.

The stigmatization of psychotherapy is influenced by any combination of factors, outlined in the table below:

Factors of Therapy Stigma

Factor	Explanation
Associative link between therapy and mental illness	Research consistently finds that mental health difficulties are generally stigmatized by the public (even in spite of an increase in mental health literacy) as one meta-analysis found [2]. The public may then unconsciously associate mental illness with therapy. The degree of mental illness, however, of people in therapy varies widely from very mild to severe. Also, different types of therapy may be more or less stigmatized due to associations with the stereotypical clientele they serve (e.g. a person labeled “ex-convict” may be judged differently than a person labeled “college student”).
Culture	I use culture broadly to include, for example, the culture of a country, ethnic group, family, online discussion board, workplace, church, school, sports team, or club. In some families or geographic areas, a person would seek the counsel of a religious preacher for mental health support, whereas another person who is similar in all other ways would seek the help of a psychotherapist. In some countries, therapy is more common, such as Argentina [3], where the number of psychologists per capita soars above other countries and sessions are more affordable than in other countries.
Impact of diagnostic labels	The impact of diagnostic labels can be powerful and vary by type (e.g. physical or mental) [4] and specificity (e.g., the label “antisocial” is more stigmatized than “adjustment disorder”). Labels can be a quick way to categorize a person, but can never capture a person’s unique human character. Some people are relieved to receive a psychiatric diagnosis that explains their symptoms. However, individuals usually fear and avoid unfavorable labels, as the associated stigma may rob them of social opportunities [5]. If the power of labeling interests you, search the web for “Labeling Theory.”
Internalized stigma/self-stigma and other beliefs about therapy or therapists	We are influenced by personal experience, stories, and other sources of information (e.g. “All my friends say…” or even, “research shows…”). For example, hearing a respected friend say things like, “Medication is a sign of weakness,” “Psychologists are just trying to work out their own stuff,” or “Shrinks are just paid friends” can influence one’s beliefs and make the mere idea of therapy seem more disgraceful to the person. These messages we take in, which could also be called social scripts, reflect the cultural beliefs but are not necessarily to the benefit of our well-being. Viewed a slightly different way, the thought of being in therapy can take on certain meanings for an individual. For example, he or she may worry about being regarded by others as unstable, weak, or having serious problems. Individuals may rest their opinion of therapy on a very small amount of data, such as the treatment success (or lack thereof) of just one family member.
Psychological makeup	An individual’s unique psychology impacts the degree to which stigma may be a barrier to treatment. My experience suggests that the following characteristics can impact help-seeking and treatment adherence: stress level [6], shame-proneness, self-destructive tendencies, amount of hope, orientation to self-examination, readiness for change, ability to take responsibility, conscientiousness, orientation towards self-growth and healthy living practices, and openness to receiving and adhering to treatment. For example, an open-minded and hopeful person will have a relatively easy time initiating and adhering to therapy. Some people who are not mentally healthy may be fortunate enough to have a friend or family member suggest they receive professional help: sometimes problems are so severe that a person loses perspective on their own level of suffering (e.g. problematic drinking).
Gender	Research supports that women are more likely to seek help than men. Click here [7] for a 2005 literature review, and here [8] for a 2002 review.
Geography	Being in talk therapy may be more common and accepted in large cities than small towns. For example, urban centers in the US such as New York City and the Bay Area of California seem to have relatively less therapy stigma, although research would be needed to identify these patterns.

 

There are many factors that influence the degree to which therapy is stigmatized. Some individuals would never open up to a therapist about their feelings (e.g. due to fears around being labeled unfavorably by their peers), while others view therapy as healthy and normal.

People come to therapy for a variety of reasons. Some are in couples therapy for constant arguments with their partner. Some were raped at a college party and have disturbing flashbacks about it years later. Some have been teased as a child and now struggle with self-esteem. Some are having a hard time coping with the daily stressors of life. Some are trying to lose weight. Some were physically and psychologically abused by their parents. Some have just moved to a new area and feel isolated and lonely. Some feel it would be easier to just not exist. Some are college students going through a difficult breakup. Some know they were born into the wrong gender. Some begin to feel a panicked if they merely think of driving over a bridge. Some seek therapy for prophylactic purposes, or simply as a means of ongoing personal growth and development.

No matter your reasons for seeking care, each reason is valid, and change awaits those who are motivated and open to therapy. Beginning treatment and sticking with it in the face of real or perceived fear can feel unnerving, but is a crucial step. Whether you are seeking care for depression or a broken bone, neither problem indicates that you are defective; neither condition should be stigmatized. Whatever brings you to treatment, take a moment to thank yourself. You are doing good by taking responsibility for your holistic health.

Although therapy may be stigmatized in the majority of places and social settings, perhaps the best thing you can do to neutralize this is to be mindful about ways in which you may stigmatize yourself. This can be achieved through the process of self-acceptance, and is usually much easier with the support of trusted others. Trusted others can be anyone, paid or not. The therapeutic relationship, however, is unique because it allows the client to talk about a broad range of things in a safe environment in which the taboos of ordinary social discourse are greatly diminished. Ideally, therapy should be a stigma-free experience.

I am in talk therapy myself, and have been for years. Therapy helps me grow as a person, feel good about myself, better connect with others around me, and live a richer life. As both a client and a clinician, I hope that therapy continues to become more mainstream, affordable, and accepted in the US. Perhaps some day, the yearly mental health check-up will be just as common as the yearly physical!

For Further Reading

http://apt.rcpsych.org/content/6/1/65.Full

http://www.psychologytoday.com/blog/occupational-hazards/200806/the-stigma-therapy

https://wesfiles.wesleyan.edu/courses/PSYC-309-clwilkins/week2/Kurzban.Leary.2001.pdf

References

[1] Therapy in America 2004 Polls Shows: Mental Health Treatment Goes Mainstream. Retrieved from http://www.camft.org/ScriptContent/CAMFTarticles/Misc/TherapyInAmerica.htm on August 14, 2014.

[2] Schomerus, G. et al. (June 2012). Evolution of public attitudes about mental illness: a systematic review and meta-analysis:Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2012.01826.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false on August 14, 2014.

[3] Romero, Simon (August 18, 2012). Do Argentines need therapy? Pull up a couch. Retrieved from http://www.nytimes.com/2012/08/19/world/americas/do-argentines-need-therapy-pull-up-a-couch.html?pagewanted=all&_r=2& on August 12, 2014.

[4] Ben-Porath, D. (August 2002) Stigmatization of individuals who receive psychotherapy: An interaction between help-seeking behavior and the presence of depression. Retrieved from http://guilfordjournals.com/doi/abs/10.1521/jscp.21.4.400.22594 on August 12, 2014.

[5] Corrigan, P. (2004). How stigmas interferes with mental health care. Retrieved from http://und.edu/health-wellness/healthy-und/how-stigma-interferes-with-mental-health-care-kay.pdf on August 12, 2014.

[6] Pratt, K. (March 29, 2014) Stress management 101. Retrieved from https://healthypsych.com/?s=stress on August 14, 2014.

[7] Galda P.M. et al. (March 2005). Men and health help-seeking behaviour: literature review.http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2004.03331.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

[8] Möller-Leimkühler, A.M. (September 2002) Barriers to help-seeking by men: a review of sociocultural and clinical literature with particular reference to depression. Retrieved from http://www.jad-journal.com/article/S0165-0327(01)00379-2/pdf on August 12, 2014.

About this Contributor: Clark Rector studied wildlife biology and psychology at the University of Montana, Missoula, before moving home to California where he received a B.A. in psychology from Sonoma State University. At Sonoma State he volunteered for the Outdoor Pursuits program as a trip leader. Sonoma State also offered the opportunity to learn about the mind-body connection in the biofeedback lab as a participant and technician. Clark has worked in various outdoor education, teambuilding, and summer camp venues in Northern and Southern California. He has also volunteered for Project Healing Waters, where he taught wounded veterans various skills in fly fishing at the Long Beach VA. He currently attends the Wright Institute in Berkeley, CA in pursuit of a clinical doctorate degree in psychology (PsyD). His future interests include play therapy and nature-based psychological treatments.