By Ashley Habig
Stigma is a very prevalent problem in mental health care that does not get talked about often enough. Stigma is often rooted in experiences and cultures people are surrounded by growing up, but can be broken down with the proper education. Stigma around mental health patients can be very isolating for them, meaning love and a support system are crucial for their treatment and healing. Not all types of stigma are the same though, as some can be more severe or more targeted at specific people or illnesses than others. Specifically, I will be focusing on the differences in the stigma surrounding mental health in rural vs urban areas, and evaluating why these differences may occur and exactly what makes the stigma in these areas so different.
Not one group in particular is affected by mental health; it is a common illness that many humans face at some point during their lives. Denise Williams, a NC native case manager, discussed one of her first jobs in a group home working with mental health patients specifically in her interview. She stated,
“I have learned that mental health is an issue across all races, socio-economic incomes, it doesn’t matter where you are from, you can experience a mental health issue.”
She later says she learned this from her early experiences working in a group home, which inspired her to continue to work in the mental health field and normalize mental health support and drop the stigma around it (Williams, 2019). Miss William’s interview clip helps us understand the prevalence of mental health in our society, and the importance of breaking this stigma coming from someone who sees firsthand how prevalent and normal a mental health issue is in our society and healthcare system.
Now that it’s established that mental health issues are a widespread issue, it is beneficial to analyze the overarching differences between stigma towards mental health patients in rural and urban areas. A study accomplished this by using a telephone interview method to examine the differences in stigma around depression in both rural and urban areas. The results showed that people living in rural areas have a higher perception of stigma around them than urban areas, and this difference was noticed in greater amounts between men than women in the two different living environments. The study also provides theoretical explanations for both of these differences. The researchers hypothesize that the difference solely on living areas may be due to the greater variance of people with higher education in rural areas, as education level is a factor that plays into stigma. The other conclusion they offered for the difference in women and men is that women are more susceptible to having depression than men are, so the researchers believe that men are more likely to judge others regarding an illness that has less of a chance of affecting them. This study also analyzed the differences in participant’s reactions to the doctor’s treatment plan for their depression. The results showed that urban participants were more likely to agree with providers about their proposed treatment plan (Jones, 2011). This may be due to the fact that rural participants can often be more skeptical about modern medical care and not trust seemingly “new” treatments and diagnoses, whereas urban participants are more likely to be educated and have more trust for their medical doctor. Also supporting this idea is the fact that there are more people living in an urban area, so there is a higher chance that the participant knows somebody that deals with depression, and therefore would be less likely to hold a stigma against people with the illness.
Taking a closer look at the roots and effects of mental health stigma in urban areas can provide a further explanation for the perception of stigma in these areas. A longitudinal study completed in urban Canadian cities focused on homeless people who suffer a mental disorder or addiction problem over the course of several years to determine their perception on if people have a stigma against them. The research showed that participants showing severe signs of depression in the beginning of the study were more likely to have lower levels of stigma perception, and that people who have been diagnosed with severe mental illnesses such as psychosis or symptoms of self harm ideology were more likely to have moderate to high levels of stigma perception. The thought of outsiders having stigma towards them was also shown in the study to cause an increase in depression symptoms, as it creates negative feelings of being disliked and judged (Mejia-Lancheros, 2020). A main cause for this is believed to be that homeless people feel as if they are unwelcome or mistreated when receiving mental health care support. This idea and trend can be applicable to any urban area residing homeless people, as these feelings are similar no matter where the location of the city may be.
Rural areas also have high levels of perceived stigma, but with slightly different reasoning and implications in society. Marie Flynn-Vargo discussed her time working in a rural group home in North Carolina as a nurse in their ER in her interview with the Southern Oral History Program at UNC. She talked about the unfair and rude treatment that the other nurses gave to the mental health patients by saying,
“she agreed with me, and she said ‘Yes, a lot of our staff are very disrespectful to mental health patients.’ Or um, oh and when it got cold, oh my god all the homeless people are going to come now to the ER, cause they’re cold, and they want something to eat. I know, they say stuff like that.”
This shows the stigma that the mental health patients’ own staff and caregivers had towards them. She expressed that she was disappointed and sometimes even angry at this treatment and the stigma the staff had about their mental health patients (Flynn-Vargo, 2018). This shows how even when trying to seek support in rural areas, sometimes the stigma is rooted so deeply in people’s minds that even the caregivers can be the ones discriminating against mental health patients, sadly. More evidence for the stigma of rural mental health patients comes from a study using interviews from hispanics living in rural areas of the US looked at different aspects of mental health including the stigma those with mental health believe others have towards them. The research found that a main effect of this stigma is that it discouraged mental health patients from seeking care out of fear of providers judging them as well as being called “crazy” (Moyce, 2022). This matters more in these rural communities with lower population sizes across the US, as providers and staff are more likely to personally know mental health patients which may make them feel more judged compared to being judged by a complete stranger, making them less likely to seek care.
Overall, stigma surrounding mental health illnesses are present in both rural and urban areas, with people living in rural areas facing more stigma than others due to the smaller, tight-knit community and a lack of consistent higher education among residents. This stigma has also proved to increase depressive symptoms in urban communities, as it increases their perception of being isolated and judged by society. Although these stigmas are similar in both areas, we see the main differences in the root of the misjudgment rather than how it is implicated in society. As Denise Williams said in her interview, everyone experiences mental health and it is not just one subpopulation being affected by this illness (Williams, 2019). With this idea in mind and with the right education, mental health stigma can be broken and we can work towards more inclusion and acceptance in society. One important way of reducing the stigma is increasing the support system and resources in both rural and urban areas for these mental health patients so they are more likely to reach out for treatment. This way mental health patients in all locations can get the help they deserve and not have to worry about being judged or not taken seriously by providers and others in society.
Flynn-Vargo, Marie. “Y-0133 Interview with Marie Flynn-Vargo.” Southern Oral History Program, 24 Oct. 2018, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28444/rec/1. Accessed 5 Mar. 2022.
Jones, Arden R et al. “Rural-urban differences in stigma against depression and agreement with health professionals about treatment.” Journal of affective disorders vol. 134,1-3 (2011): 145-50. doi:10.1016/j.jad.2011.05.013
Mejia-Lancheros, Cilia et al. “Trajectories and mental health-related predictors of perceived discrimination and stigma among homeless adults with mental illness.” PloS one vol. 15,2 e0229385. 27 Feb. 2020, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229385
Moyce, Sally, et al. “Rural Hispanic Perceptions of Mental Health: A Qualitative Study.” Journal of Transcultural Nursing, Jan. 2022, https://journals.sagepub.com/doi/10.1177/10436596211070592
Williams, Denise. “Y-0138 Interview with Denise Williams.” Southern Oral History Program, 16 July 2019, https://dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28717/rec/1. Accessed 5 Mar. 2022.