Stigma in mental health care: A catalyst for change

Stigma in mental health care remains one of the most pervasive challenges in delivering equitable support to those who need it. It operates on multiple levels: within the individual, between caregivers and service-users, and throughout the mental health care system itself. Stigma is not just a societal inconvenience; it has real consequences on people's lives, affecting therapeutic relationships, reducing care quality, and discouraging people from seeking help. 

Here, I explore the impact of stigma in mental health care through the lens of cultural misunderstandings and biases. I reflect on how my experiences working in mental health hospitals have driven my commitment to addressing these challenges through both academic research and my business development, ConnectedCulture.   

Understanding stigma in mental health care

It's imperative to understand the scope of stigma in mental health care, often operating on three levels:

1. Self-Stigma: Service-users may internalise societal attitudes, feeling shame or inadequacy about their mental health struggles.
2. Interpersonal Stigma: Caregivers and practitioners may unconsciously (or consciously) judge or dismiss service-users based on their symptoms, behaviours, or cultural backgrounds.
3. Systemic Stigma: Policies, practices, and resource allocations may reflect broader societal biases, resulting in inequalities in care access and quality. 

These levels are deeply interconnected, and their impact can be devastating. When a service-user perceives judgement from their caregiver or senses that the system does not account for their unique needs, it reinforces self-stigma and reduces trust in the system. 

My journey into addressing these issues began during my time working in a mental health hospital, where I witnessed these dynamics play out firsthand.

My professional to academic transition

I worked at a mental health hospital from the age of 19, for four years (2020-2024). I experienced myriad service-users and mental illnesses, from working on acute wards, Child and Adolescent Mental Health Services (CAMHS) acute, CAMHS Psychiatric Intensive Care Unit (PICU), eating disorder units, drug and alcohol rehabilitation, and by the time I left I had been situated on a male PICU. One of the starkest observations during my time in these settings was the vast disparity in the quality of care. The contrast between general wards and private rehabilitation units was glaring. On private wards, money dictates care, service-users had access to better meals, living spaces, and even therapeutic environments. Whilst frustrating, this inequality was also a reflection of systemic injustice.

Beyond financial disparities, I also saw how stigma shaped interactions between staff and service-users. I took pride in my ability to go beyond the standard responsibilities of a healthcare assistant, often completing tasks that should have been handled by nurses or doctors. Yet, while I was encouraged to take on additional responsibilities, I faced resistance when I questioned systemic issues or advocated for changes. Over time, I became acutely aware of how mental health staff, despite their professional obligations, often distanced themselves from service-users who were perceived as 'difficult' or even 'treatment-resistant'. 

This phenomenon, malignant alienation (MA), became a focal point for my academic research. Eventually, I realised I wanted to address these issues beyond the constraint of the hospital setting. I decided to pursue a PhD in Psychology. 

Malignant Alienation and its impact on care

MA, originally conceptualised by Watts and Morgan (1979), describes the progressive deterioration in the relationship between service users and staff. This can lead to neglect, inadequate treatment, and increased suicide risk. Despite its significance, MA remains under-researched, particularly in relation to psychotic symptoms. 

Before I continue, I must define 'religious psychosis' and 'spiritual psychosis'. They have overlapping features but distinct characteristics. Religious psychosis typically involves delusions or hallucinations rooted in religious frameworks which the majority of the population seem to be well-educated on. Individuals may believe that they are prophets, are receiving messages from the divine, or have a special connection to a deity. These experiences often align with cultural or religious backgrounds but become pathological when they cause distress or impair daily functioning. In contrast, spiritual psychosis encompasses broader spiritual experiences, such as feelings of unity with the universe, encounters with spiritual entities, or altered states of consciousness. While these experiences can be transformative to someone who is not mentally ill, they can be disorienting or distressing to someone who is mentally ill, particularly if they disrupt daily life. 

I initially pitched a proposal focused on cultural insensitivities in service-user care, a topic I became acutely aware of during my clinical experience. I observed a concerning bias in how religious versus spiritual psychotic symptoms were perceived and treated. Those diagnosed with religious psychosis were often met with greater understanding, perhaps because religion is widely taught and socially familiar. Their beliefs were more readily excused or accommodated, even when their behaviours were indistinguishable from those with spiritual psychosis. 

Conversely, those presenting with spiritual psychosis, a phenomenon emerging in psychological literature as a potential coping mechanism for childhood trauma, were more likely to be dismissed as delusional, 'crazy', or excessively medicated. The dissociative aspects of spiritual practices can serve as a means of emotional regulation for individuals with trauma histories. However, because this is less culturally recognised, service users exhibiting spiritual psychotic symptoms often faced greater stigmatisation and harsher treatment. This disparity is rooted in a lack of cultural education within the mental health system. As a person of colour, I often found myself explaining these nuances to Caucasian colleagues, who made ignorant or judgemental remarks about service users from different cultural backgrounds. Such systemic biases that affect diagnosis and treatment. A key distinction lies in cultural context and personal impact, beliefs deemed normative in one culture may be pathologised in another. Clinical challenges arise when distinguishing between a profound spiritual awakening and a psychotic episode, as no clear guidelines exist. Research suggests that positive outcomes may indicate a spiritually transformative experience, while distressing outcomes could signal psychosis (O'Connor & Vandenberg, 2005; Greyson, 2006). Understanding these differences is crucial for developing more nuanced and culturally competent mental health care, preventing misdiagnosis, and reducing stigma. 

While my initial focus was on cultural bias in psychiatric care, my secondary supervisor introduced me to the concept of MA, primarily explored in borderline personality disorder (BPD) literature. MA describes not just stigma but the active breakdown of therapeutic relationships, a process influenced by multiple factors (Watts & Morgan, 1979):

• Patient-related factors (e.g. behaviour, diagnosis, level of engagement)
• Staff-related factors (e.g. burnout, personal biases, training level)
• Staff-patient interactions (e.g. communication, trust, history of conflict)
• Hospital environment (e.g. institutional policies, overcrowding, staff levels)

Upon reviewing the literature, I found that while there is widespread recognition of the need to expand MA research, little has been done to address it. There are suggestions on how to measure it, but no standardised tool currently exists. Hence, I am dedicating my PhD to developing a measure of MA, which will allow for a structured way to assess MA in clinical settings, a clearer understanding of its causes and consequences, and potential interventions to mitigate its impact on service users.

Once developed, this measure will be piloted, validated, and implemented with the hope that MA will become a more widely recognised concept in mental health research and practice.

Although MA and stigma are closely related, they are different concepts:

• Stigma refers to attitudes, stereotypes, and biases that lead to discrimination against individuals with mental illness. It can be internalised (self-stigma), interpersonal (between service users and staff), or systemic (within policies and structures)
• MA is a dynamic process, a worsening breakdown in trust and therapeutic rapport between service users and staff. It is not just about perception but about tangible shifts in care quality and how a service users' distress is increasingly dismissed over time.

By developing a validated measure, I aim to bring greater awareness to how and why these relationships deteriorate, ensuring that interventions can be put in place before alienation leads to neglect, over-medication, or increased risk of harm.

A practical response: My business, ConnectedCulture

While my PhD focuses on the critical dimensions of stigma, my business, ConnectedCulture, addresses the practical challenges of delivering culturally competent mental health support.  

My professional experiences made it impossible to ignore the system's failure to meet the needs of service users from diverse cultural backgrounds. Cultural beliefs and traditions were often dismissed as irrelevant to mental health care, or worse, misunderstood as pathological. Service users frequently report feeling unseen and unheard, further exacerbating their distress.

Following my resignation as a healthcare assistant, I spent time in Australia, where I discussed these issues with my aunt, a mental health practitioner. We reflected on how similar patterns of cultural insensitivity appeared in her workplace. Despite the organisations stated commitment to represent indigenous communities, they had employed only one person of colour (her), and their only acknowledgement of cultural diversity was Aboriginal artwork. 

This realisation led to the creation of ConnectedCulture, a platform designed to connect individual with therapists who understand the importance of cultural and religious contexts in mental health care. We aim to:

• Provide culturally sensitive therapy tailored to diverse backgrounds
• Educate professionals on the impact of cultural misunderstandings in mental health care
• Advocate for systemic changes to ensure mental health services are inclusive and equitable

A shared mission: addressing stigma through research and practice

Although my PhD research and my business address the issues I've observed from different standpoints, they share a common goal: creating a mental health care system that is equal, inclusive, and safe for all.

Whilst MA and cultural sensitivity are separate issues, they are also deeply interconnected. Both stem from a failure to see service-users as whole individuals, shaped by their unique experiences, identities, and contexts. Both also highlight the desperate need for systemic change, whether that's through better tools for practitioners, more inclusive training programs, or policies that prioritise equality in care delivery.

Stigma thrives in the spaces where misunderstanding and bias go unchallenged. By addressing these issues head-on, through both academic research and practical initiatives, I hope to contribute to a mental health care system where no one feels alienated, dismissed, or stigmatised.

A call to action

The fight for inclusive practices in mental health care is far from over, and requires ongoing reflection, education, and advocacy to ensure success, respect, and support. Whether through research or my business, I am committed to playing my part in this journey. Together, we can create a mental health care system that truly lives up to its promise of healing and support for all. 

If you'd like to get in touch about any of the above please contact me for academic enquiries at: [email protected], or business enquiries at: [email protected].