Is it "OK to not be OK" at school? Mental Illness Stigma

Statement of Issues
School pupils are in a key developmental period, often characterised by experimentation, impulsivity, curiosity and uncertainty, making it a time of heightened risk for the onset of mental illness. The average onset of a mental illness is around the age of 14, with half of all mental illnesses being diagnosed by the age of by the age of 18. Stigma in relation to mental illness has been identified as a barrier to young people seeking treatment and speaking out about their experiences. Young people's experiences suggest that they do not believe it is “OK to not be OK”. This is concerning, as experiencing untreated mental illness from a young age can have a long-lasting negative impact on life outcomes including poor academic achievement, reduced employment opportunities, increased likelihood of mental health challenges in later life, increased risk-taking behaviour, and poorly developed relationships. School represents a key time to target anti-stigma interventions, to prevent these pervasive negative impacts. In this article, we explain what stigma is and why we should be thinking about ways to effectively tackle it.

In 1963, Erving Goffman recognised the importance of defining and understanding the concept of stigma. Stigma occurs when someone has an attribute that is viewed as undesirable by others, meaning they define that individual by their "undesirable" characteristic rather than seeing them as a whole person. Discrediting an individual because of one attribute can be particularly harmful when an individual is stigmatised during childhood or adolescence and when they are experiencing mental illness.

While there are a variety of stigma definitions, one that aligns with the experiences of children and young people is the tripartite model described by Distinguished Professor Patrick Corrigan and Professor Amy Watson twenty years ago. In this model, stigma includes three components: stereotypes, prejudice, and discrimination.

• Stereotypes: negative expectations about an individual based on a defining feature (e.g., a mental illness).
• Prejudice: endorsing the stereotype and experiencing negative emotional responses based on those negative expectations (i.e., fear of an individual with mental illness).
• Discrimination: treating an individual differently based on the belief that the previous beliefs are true (i.e., refusing a job to someone with a mental illness, without just cause).

Stigma can manifest itself in several ways, including public stigma and self-stigma. Public stigma, which can act as a precursor to self-stigma, arises when a community holds negative stereotypical views towards an individual. Self-stigma subsequently results from internalising and agreeing with negative public views about oneself.

Developmental Issues
From a developmental perspective, the school years can be understood as a period of multiple and often profound changes, when young people renegotiate relationships with adults, peers, and the community. The many complex developmental tasks of school-age young people developing a sense of self as distinct from others, identity formation, learning how to develop close relationships, and gaining control over impulses. This is an important stage for establishing healthy behaviours, attitudes, and lifestyles that contribute towards current and future health. It can also be a turbulent period, with young people at risk of experiencing mental illness. Mental illness has been one of the most common focus of studies of this age group given it affects social, emotional, and educational development disproportionately, and may prevent the normal transitions and learning experiences typical of this period.

Stigma research tends to be carried out with adults and so has not adequately considered children and young people’s unique developmental contexts. The development of personal stereotypes and an awareness of societal stereotypes develops by middle childhood (around ages 6 to 8 years). This ability can emerge even earlier for children who belong to a stigmatised group. We don’t know exactly how children and young people experience stigma in relation to mental illness, but evidence of stigma experiences relating to young people who take anti-psychotic medication can give us a glimpse into young people's stigma experiences. These experiences are unique to children and young people and include: not having access to information about their illness; a shift in family dynamics and attitudes (the family unit is far more relevant and impactful for children and young people than adults, and stigma can originate within the home); and negative reactions in the school environment (the ways in which their peers, teachers, and school culture responds to their mental illness is a large source of stigma for many children and young people).

Why do Young People Avoid Seeking Help?
Mental illness self-stigma is known to prevent young people seeking help for fear of further stigmatisation and feelings of guilt and shame. This might account for why there is a high prevalence of mental illness in school-age individuals, but only a small percentage who are seeking treatment. Self-stigma is known to lead to the “why try” effect. The “why try” effect refers to decreased self-confidence where individuals begin to question whether it is worth pursuing their goals i.e., “why try to seek treatment? I’m not worthy”. It can also mean people question the validity and purpose of taking part in treatment and an overall belief that treatment will not be successful.

Implications for Wellbeing
A disproportionately high number of school pupils experiencing mental illness are bullied when compared to their peers. These students may be labelled by their peers as “different” and as violating social norms, making them common targets for stigma and bullying. Friendships play an important role in this scenario. Supportive friendships have been shown to act as a protective shield for those experiencing stigma at school. However, research highlights that fear of stigma can make it harder for young people to make and nurture friendships, which can worsen the impact of bullying. Efforts to reduce the stigma relating to mental illness can help supportive friendships to blossom, and these may protect against the harmful effects of bullying and stigmatisation.

Implications for Educational Outcomes
No published evidence exists evaluating whether stigma relating to mental illness is linked to educational outcomes; but it is likely to do so in two ways. First, we already know that poor mental health has a negative impact on young people’s educational outcomes. One of the most well-known findings relating to stigma in this area is that young people are less willing to try to get help with their difficulties if they experience stigma – meaning that stigma is likely to make their educational issues even worse. Second, self-stigma is likely to reduce the extent to which young people engage in educational activities. Indeed, evidence from young people who use mental health services shows that self-stigma is linked to poorer life outcomes in both employment and education. Self-stigma is also linked to less social activity. This is a concern if students choose to withdraw from group-based school activities since it may mean less engagement with extra-curricular activities, group-based school work and activities designed to foster resilience, such as the Duke of Edinburgh award scheme (see Education Today article “Children can develop resilience at school with the right challenges and support” < https://www.educationtoday.com.au/news-detail/Children-can-develop-resilience-at-school-with-the-right-challenges-and-support-5276 >).

Take-home Message
It is becoming increasingly clear that children and young people experience mental illness stigma and that this has serious implications. These students ask for help less often, have difficulties making friendships, report poorer social wellbeing and educational outcomes, and have poorer life chances. While a review in 2021 found that there were 61 stigma-reduction initiatives available in Australia, few were designed with schools in mind. This highlights an area for future work which involves young people in the development of fit-for-purpose anti-stigma initiatives. Initiatives designed with young people are more likely to focus on issues that are relevant and appropriate for them, which include educating young people in mental illness literacy, promoting help-seeking and creating support systems which ensure that young people know that it is “OK to not be OK”.

Photo by Elīna Arāja from Pexels