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Stigma: Barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing, 26(10), 979-999


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This paper explicates the stigma of mental illness as it is experienced by four ethnic minority groups in the United States. Concerns about prejudice and discrimination among individuals who suffer burdens related to mental illness are delineated. It is proposed that ethnic minority groups, who already confront prejudice and discrimination because of their group affiliation, suffer double stigma when faced with the burdens of mental illness. The potency of the stigma of mental illness is one reason why some ethnic minority group members who would benefit from mental health services elect not to seek or adequately participate in treatment. The combination of stigma and membership in an ethnic minority group can impede treatment and well-being, creating preventable and treatable mortalities and morbidities. The article concludes with recommendations for research and health policy implications.
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Issues in Mental Health Nursing, 26:979–999, 2005
Taylor & Francis Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.1080/01612840500280638
Faye A. Gary, EdD, RN, FAAN
Medical Mutual of Ohio Professor of Nursing for
Vulnerable and At-Risk Persons, Frances Payne Bolton
School of Nursing, Case Western Reserve University,
Cleveland, Ohio, USA
This paper explicates the stigma of mental illness as it is
experienced by four ethnic minority groups in the United
States. Concerns about prejudice and discrimination among
individuals who suffer burdens related to mental illness are
delineated. It is proposed that ethnic minority groups, who
already confront prejudice and discrimination because of
their group affiliation, suffer double stigma when faced with
the burdens of mental illness. The potency of the stigma of
mental illness is one reason why some ethnic minority group
members who would benefit from mental health services
elect not to seek or adequately participate in treatment. The
combination of stigma and membership in an ethnic
minority group can impede treatment and well-being,
creating preventable and treatable mortalities and
morbidities. The article concludes with recommendations
for research and health policy implications.
Much like leprosy in earlier centuries, mental illness remains em-
bedded with connotations that serve as barriers to help seeking and
treatment compliance (Corrigan, 2004a, 2004c). Remnants of this real-
ity continue despite the phenomenal scientific advancements that have
been made with regard to treatment modalities and subsequent evidence-
based outcomes (Corrigan, Watson, Warpinski, & Gracia, 2004b). Even
when individuals elect to seek treatment, many of them neglect the pre-
scribed regimen, while others abort treatment and terminate mental
Address correspondence to Faye A. Gary, Frances Payne Bolton School of Nursing, Case
Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106. E-mail:
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980 F. A. Gary
health services (Corrigan, 2004a; Gary, Baker, & Grandbois, 2005;
Szasz, 2003). Stigma is one of the major reasons. In this paper, stigma
refers to a collection of negative attitudes, beliefs, thoughts, and behav-
iors that influences the individual, or the general public, to fear, reject,
avoid, be prejudiced, and discriminate against people with mental disor-
ders. Stigma is manifest in language, disrespect in interpersonal relation-
ships, and behaviors. It is a barrier to those individuals who need mental
health services, but who are reluctant or refuse to seek help because
of the potential for discrimination and rejection by others (Corrigan,
2004b; Corrigan, Green, Lundin, Kubiak, & Penn, 2001; Corrigan &
Penn, 1999). It is considered “the most formidable obstacle to future
progress in the area of mental illness and health” (U.S. Department of
Health and Human Services, 1999, p. 29).
This paper presents a discussion about stigma, and highlights some
of constructs that can be employed to understand stigma among any one
of the four minority groups.
Reasons why many people avoid needed psychiatric treatment are not
yet fully understood, even though it is an enduring, though troubling,
theme throughout the mental health system. The concept of Double
Stigma is hypothesized to be an additional burden that confronts ethnic
minority groups in America, but may affect different cultural groups
in special ways. Related constructs that are useful in understanding the
dynamics that set up and reinforce stigma in mental health as expressed
by ethnic minorities are embedded in the following discussion.
Individuals who are prejudiced tend to embrace negative stereotypes
about people. Statements such as, All people with PTSD are danger-
ous and incompetent, are likely to generate negative emotional reac-
tions from others . . . including comments such as “Yes ...they frighten
me . . . I stay away from them” (Corrigan, 2004b). Prejudice is a cog-
nitive and affective response, serving as an antecedent to discrimina-
tion, which has behavioral dimensions (Bettelheim & Janowitz, 1964;
Corrigan, 2004b; Gary, 1991; Kramer, 1949; Link, Phelan, Bresnahan,
Stueve, & Pescosolido, 1999; Pinel, 1999). Prejudice denotes thoughts
and feelings that members of one group have about individuals in an-
other group that are frequently based on stereotypes and unsubstantiated
information (Gary, 1991; Nicholson, 1998). In the United States, preju-
dice continues to negatively impact the lives of ethnic minority people
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Stigma: A Barrier among Ethnic Minorities 981
at all levels of their existence (Byrd & Clayton, 2002; Myrdal, 1996).
It also looms over individuals who are in need of psychiatric treatment
(Corrigan, 2004b; Pinel, 1999).
When dominant group members express certain stereotypes and neg-
ativisms about minority groups and then act in ways that are not in
the best interest of these groups, discrimination is in action. Discrim-
ination is expressed through decision-making and behaviors that are
observable, measurable, and reportable. Through this process, domi-
nant groups afford themselves advantages and privileges that they deny
minority groups (Byrd & Clayton, 1992, 2000, 2002; Myrdal, 1996).
Double Stigma is obvious: Until recently, individuals with psychiatric
disorders were placed in large state hospitals located in rural areas with
huge fences around them; many of the patients were confined until
death (Lamb & Weinberger, 1998). In communities, property owners
were and continue to be reluctant to lease dwellings to persons with
mental illnesses. Employers often will not extend opportunities to for-
merly hospitalized individuals. Changes in federal laws have helped to
relieve some of these discriminating actions, but constant monitoring
is still required (see, for example, the Americans with Disabilities Act,
Today, individuals with mental illness are often inappropriately placed
in jails and prisons, a practice that has extended over more than two
centuries (Buchanan & Leese, 2001; Corrigan, Watson, Warpinski, &
Gracia, 2004a; Lamb & Weinberger, 1998; Szasz, 1971). When dis-
crimination is examined from the perspective of ethnic minority group
membership and mental illness, the problem becomes more complicated.
In an effort to explain some of the deleterious outcomes associated
with discrimination based on minority group status and the burden of
having to live with a mental disorder, I propose the concept of Double
Stigma. Hence, minority group members with mental illnesses endure
discriminatory practices as manifest by numerous segments of this so-
ciety, including politicians, researchers, and clinicians. Centuries-old
practices of discrimination against the mentally ill (Abreu, 1999; Balsa
& McGuire, 2003; Corrigan, 2004b; Szasz, 2003) are inculcated into
American society, and can have a deleterious impact on individuals and
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982 F. A. Gary
families. Szasz (2003) posits that one of the enduring social obligations
that psychiatrists have to society is to control the “harm to self [suicide]
and to others [crime], which creates an ethical dilemma for the med-
ical profession” and for psychiatric nurses who have acquired similar
societal obligations (Szasz, 1971).
From the other side of the discrimination paradigm, America’s history
abounds with prejudice and discrimination against African Americans,
American Indians and Alaska Natives, Asian Americans, and Hispanic
Americans. Unfortunately, prejudice and discrimination continue to ex-
ist and affect all aspects of these people’s lives (Abreu, 1999; Balsa &
McGuire, 2003; Byrd & Clayton, 2001; Hamilton & Sherman, 1994).
Overlaps can occur in Double Stigma when race/ethnicity and health
care are cross-cutting phenomena. The United States Public Health Ser-
vice’s infamous four-decades-old Tuskegee Syphilis Study serves as a
powerful example of the deleterious effects of prejudice and discrim-
ination. This one study helps to clarify the harm that health profes-
sionals, in collusion with the federal government, can perpetuate upon
ethnic minority individuals in the name of the advancement of science
and protection of the public (Gary, Yarandi, & Scruggs, 2003; Jones,
1998; U.S. Department of Health and Human Services, 1999). Ethnic
minorities who have symptoms or histories of mental disorders expe-
rience vastly different access and outcome histories when compared
to their more socially accepted Caucasian counterparts (Pescosolido,
Gardner, & Lubell, 1998; Poussaint & Anderson, 2000; Rogler, Cortes,
& Malgady, 1991). Figure 1 depicts the factors that help to influence
the individual’s decision to seek, delay, or avoid treatment for mental
Double Stigma is created by ethnic minority group membership, and
membership in one of these groups confronts the individual with sig-
nificant barriers. Moreover, too few nurses or other mental health pro-
fessionals who are members of these four ethnic minority groups have
been able to join the ranks of mental health professionals. This fact
helps to continue to perpetuate health disparities, and the lack of cul-
turally competent care in mental healthcare delivery systems (Smedley,
Stith, & Nelson, 2003; U.S. Department of Health and Human Services,
1999). The Sullivan Commission Report suggests that the missing per-
sons in healthcare systems are ethnic minority professionals; it calls for
new and novel approaches to diversifying nursing’s workforce (See the
Sullivan Commission Report, 2004, for a more detailed discussion). A
discussion of the model in Figure 1 will help the reader to integrate the
numerous factors that interact to produce and sustain stigma related to
mental disorders among ethnic minority groups.
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Stigma: A Barrier among Ethnic Minorities 983
FIGURE 1. Sources: Corrigan, 2004b; Corrigan, River Lundin, Penn, Uphoff-
Wasowski, Campion et al., 2001; Gary, 1991; Lefley, 1989; Rowe, 2005;
Smedley, Stith, & Nelson, 2003; U.S. Department of Health and Human
Services, 1999.
Race Applied as a Biological Concept
It is essential that readers become aware that the biological con-
struct of race has no scientific evidence. Nevertheless, for more than a
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984 F. A. Gary
century, health professionals and other powerful societal entities per-
petuated the concept of race and linked it to biological constructs,
based on superficial differences such as the light-skinned Europeans,
the dark-skinned people of African descent, the brownish-red-skinned
Native Americans and Alaska Natives, or the almond-shaped eyes of
Asians. Informed biology can now document the fact that these dif-
ferences are more related to environmental adaptations, and have lit-
tle significance to a biological phenomenon (Anderson & Nickerson,
2005). Advances in human genetics suggest that all human beings have
about 99.9% identical DNA (Rowe, 2005). (See Rowe, 2005; Sternberg,
Grigorenko, & Kidd, 2005 for a more detailed discussion.) However,
race is a social concept that has powerful and sometimes devastat-
ing consequences. Its presence has dominated American culture and
helped to create legal and formal mechanisms used as rationales for
prejudice, discrimination, social stigma, health disparities, and pat-
terns of questionable forensic outcomes (Anderson & Nickerson, 2005;
Cooper, 2005; Myrdal, 1996; Ossorio & Duster, 2005; Shields et al.,
Labeling as Stigma Inducing
Stigma is a term that is used to convey prejudice or negative stereo-
typing. It emits poorly justified and often false information about
people that helps to create discriminatory acts against them (Corrigan,
Green, Lundin, Kubiak, & Penn, 2001; Corrigan et al., 2004b; Dinges
& Duong-Tran, 1993; Jones, 1998; Jorm, 2000). Numerous types of
stereotypical labeling of minority groups have endured for centuries
(Corrigan, Thompson, Lambert, Sangster, Noel, & Campbell, 2003;
Harris, Gorelick, Samuels, & Bempong, 1996; Johnson & Cameron,
2001; Jones, 2003). Researchers and clinicians, including mental health
professionals, endeavored to document the inferiority of certain ethnic
minority groups in the service of justifying prejudice and discrimination
(Anderson & Nickerson, 2005; Helms, Jernigan, & Mascher, 2005;
Smedley, & Smedley, 2005; Yee, Fairchild, Weizmann, & Wyatt, 1993).
One of the most provocative but least discussed labeling phenomena
that have negatively impacted minority populations is intelligence test-
ing based on the bogus use of race. In this twenty-first century, clar-
ity through a better understanding of the genome, and DNA, could
help bring science to a more socially responsible debate (Anderson &
Nickerson, 2005; International HapMap Consortium, 2003; Interna-
tional Human Genome Sequencing Consortium, 2001). A more educa-
tionally sophisticated group of ethnic minority researchers and clinicians
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Stigma: A Barrier among Ethnic Minorities 985
will participate in this debate, which will no longer be in the exclu-
sive domain of Caucasians (Anderson & Nickerson, 2005; Thomas,
Labels that are generated by others, though without malice, never-
theless can produce stigma. When mental health professionals provide
psychiatric diagnoses such as schizophrenia or paranoia, stigma is a pos-
sible outcome (American Psychological Association, 1993; American
Psychiatric Association, 2000). The potency associated with labeling is
such that a certain symbol, or the association with a certain professional,
can lead to the person being labeled and subsequently stigmatized. For
example, a sign on a door saying “Mental Health Clinic” can provoke
stigmatizing thoughts and feelings among casual passersby, with impli-
cations that the persons who enter the clinic are not “playing with a full
deck. Similarly, the professionals who provide care there can some-
times not be immediately identifiable from among the patient group at
the clinic. Goffman (1963), Birenbaum (1970), and Gray (1993) refer to
this process as “courtesy stigma” suggesting that family members might
also share some of the stigmatization because of their affiliation and
kinship with the mentally ill person. Some family members try to avoid
the stigma, while others appear not to be concerned about its impact
(MacRae, 1999).
Stereotypes are not necessarily pernicious (Corrigan & Penn, 1999).
They are knowledge structures that are learned and practiced by indi-
viduals in society. Stereotypes can be efficient but potentially dangerous
beliefs associated with categorizing information about certain ethnic
minority people and other populations such as individuals with men-
tal illnesses (Balsa & McGuire, 2003; Byrd & Clayton, 2001; Corrigan
et al., 2003; Corrigan, Green, Lundin, Kubiak, & Penn, 2001; Macrae
et al., 1994). Stereotyping includes categorizing information about cer-
tain groups of people and their behaviors (Corrigan & Penn, 1999; Gary,
1991; Hamilton & Sherman, 1994). Consider the stereotype that Asian
Americans are the “model minority. This stereotype creates some ad-
vantages for this minority group, but it also produces blind spots and false
negatives. Societal constructs follow: Asians do not have social or sub-
stance abuse problems, or do not experience poverty. Such stereotypes
could serve as a deterrent to mental health care for Asian Americans, and
place extreme ambivalence at the center of their need to seek help for
preventable and treatable mental health disorders (Bach, Pham, Schrag,
Tate, & Hargraves, 2004; Shields et al., 2005).
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Public Stigma
Stereotypes can negatively influence the lives of individuals with
mental illness through the public’s thoughts about violence (Penn
& Corrigan, 2002), incompetence in self-care and independent liv-
ing (Corrigan et al., 2001; Okazaki, 2000), and self-blame (Corrigan,
2004b), including the insinuation that individuals with mental illnesses
are responsible for their own disorders (Lefley, 1989). As a rule, stereo-
types are difficult to eradicate (Balsa & McGuire, 2003; Byrd & Clayton,
2001) and can endure for years and years. One can glean from this dis-
cussion that stereotypes, prejudice, labels, and discrimination can help
to interrupt the lives of thousands of individuals—and thwart their op-
portunities to become productive citizens (Corrigan et al., 2004a, 2004b;
Gary, 1991; Wahl & Harman, 1989).
The negative impact of stigma also is observable in the general health
system. Individuals with mental illnesses are less likely to obtain the
necessary health assessments and subsequent care when compared with
individuals without these mental illnesses. A variety of factors interact to
create these disparities, including muddled approaches to attaining care
(Pescosolido, Gardner, & Lubell, 1998) or the behavior of the illness,
which includes denial, as found in mood disorders, Bipolar, or Type II
Depression (American Psychiatric Association, 2000). Individuals with
mental illnesses receive fewer medical services than persons with similar
conditions who do not have mental illnesses (U.S. Department of Health
and Human Services, 1999, 2001; U.S. Department of Health and Human
Services & Health Resources and Services Administration, 2003). The
nature of the illness can act as a barrier to receiving appropriate mental
health care (Brown, Schulberg, & Prigerson, 2000; Kessler et al., 2003;
Roy-Byrne et al., 2000). Public policy issues regarding parity of mental
health insurance coverage with general health insurance coverage con-
tinue to be debated among politicians, economists, providers, and the
public, while limits to access to care remain a major concern among pa-
tients and providers (Goffman, 1963; LaFromboise & Howard-Pitney,
1995; Pescosolido et al., 1998; Pillay & Sargent, 1999; Rodriguez, Allen,
Frongillo, & Chandra, 1999; Schneider, Zaslavsky, & Epstein, 2002).
Hence, mental illness can be a barrier to receiving appropriate health
With regard to the criminal justice system, there is a crossing point
between mental health and criminal justice systems. Briefly, the men-
tally ill are frequently criminalized, and are “housed” in confinement
facilities such as jails and prisons where they may or may not receive
the necessary treatment. This tendency is observed across the lifespan
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Stigma: A Barrier among Ethnic Minorities 987
(Corrigan, Lickey, Campion, & Rashid, 2000; Lamb, Weinberger, &
DeCuir, 2002; Shelder, Mayman, & Manis, 1993; Wolff, 2002).
Consider, too, the disproportionate numbers of African Americans,
American Indians and Alaska Natives, and Hispanics who are in the na-
tion’s prisons. Being of ethnic minority status increases the chances of
incarceration and a long-term sentence with the criminal justice system
(Braithwaite & Arriola, 2003; Dressel & Barnhill, 1994; Freudenberg,
2002; Hartwell, 2001). This fact reflects another example of “double
Together, these realities support the hypothesis that in American soci-
ety, persons with mental illnesses are at risk for experiencing substantial
stigma related to mental illnesses, and that ethnic minority populations
endure the greater burdens (Corrigan, 2004b; Goffman, 1963; Lefley,
1989; MacRae, 1999; Pinel, 1999). Higher rates of mortality and mor-
bidity, and diminished well-being (Cooper, Corrigan, & Watson, 2003;
Corrigan, 2004b; Marmot & Wilkinson, 1999) are unfortunate natural
Family and Courtesy Stigma
In addition to the public’s stigma about mental illness, patients’ fam-
ilies also might encounter stigma that is generalized to them, as in the
case of “courtesy stigma” (see MacRae, 1999). Social barriers can be
erected against the patients, their families, and sometimes their friends
(Caldwell, 1996; Corrigan, 2004a, 2004b; Corrigan et al., 2003; Lefley,
1989). Symptom severity as manifested by patients who carry the burden
of chronic mental illness also might help to further isolate and alien-
ate patients and their families. It can diminish their reputations and
status in the community, and jeopardize their relationships with neigh-
bors and the public (Lefley, 1989; Pescosolido et al., 1998; Pescosolido,
Wright, & Kikuzawa, 1999). Kafkaesque nightmares sometimes emerge
within families as they ponder how, when, why, and under what cir-
cumstances these horrific illnesses occurred in their family members
(Adshead, 2003; Anderson & Nickerson, 2005; Lefley, 1989; Nemeroff,
2003; Pinel, 1999; Szasz, 2003). Residual and sometimes overwhelming
familial guilt accompanies the illness; parents and families struggle with
providing care for their loved ones as they try to unravel the complex
and costly nature of treatment that is required to maintain the individ-
ual (Adshead, 2003; Corrigan, Lickey et al., 2000; Lefley, 1989; Szasz,
2003). In many instances, family resources are depleted and individuals
only have access to care within the public domain (Hudson, 2005). That
is to say, given the severity of the illness and its chronic nature, families
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988 F. A. Gary
cannot afford the necessary treatment for their loved ones. Limited sci-
entific evidence and the lack of knowledge and skills among mental
health professionals sometimes add to family stigmatization (Lefley,
1989; Vaughn, Snyder, Jones, Freeman, & Falloon, 1984).
Until recently, mental health professionals focused their scholarly ef-
forts on understanding mental illness from the conceptual frameworks
of family theories that delineated the family as the pathogenesis of the
individual’s mental illness. Based on this conceptualization, treatment
modalities were developed (Lefly, 1989; Lidz, 1968; Vaughn & Leff,
1976). The implicit and sometimes explicit message promulgated by
mental health professionals was that “the patient’s illness was their [the
family’s] fault and they should go away, shrouded in guilt, and leave the
professional to undo the damage” (Goldstein, 1981, p. 2). Inherent in this
framework is the possibility of iatrogenic damage expressed through a
variety of pathways. Included are the avoidant or recriminate responses
to familial requests for information and support for their efforts. Other
areas of tension linked to the prevailing schools of thought during that
era included double-bind communications, and the selection of interven-
tions that, by their nature, would alienate the family and other supporters.
Self-filling prophesies served to motivate particular types of behaviors
within the family and provider structures (Goldstein, 1981; Lefly, 1989;
Lidz, 1968; Vaughn & Leff, 1976). Other researchers such as Grunebaum
(1984) have suggested that family members are placed in untenable po-
sitions of having to endure the pain of the ill member’s disorder, tolerate
the stigma related to having caused the disorder, and the responsibil-
ity of having to oversee and monitor compliance with a treatment plan
that is often poorly understood. At the same time, the family struggles
with patient-related issues such as housing, medication compliance, and
conflicting advice from mental health professionals (Ahshead, 2003;
Corrigan, 2004b; Grunebaum, 1984; Lefley, 1989; Szasz, 2003).
The discussion is in no way complete without acknowledging the
impact of self-stigma, which can be an inhibiting factor that impedes
help-seeking behaviors and the quality of treatment and life experienced
by individuals with the illness (Corrigan, 2004b; Corrigan, Edwards,
Green, Diwan, & Penn, 2001; Jost & Banaji, 1994). Many individuals
with mental illnesses experience lowered self-esteem (Link, Struening,
Neese-Todd, Asmussen, & Phelan, 2001). Over time, they exhibit dimin-
ished self-efficacy, and continual lowering of self-esteem (Link et al.,
1999). They are at risk for a blighted future embedded with hopelessness
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Stigma: A Barrier among Ethnic Minorities 989
and sometimes despair (American Indian Policy Center, n.d.; Borowsky,
Resnick, Ireland, & Blum, 1999; Edmonson, 2000; Ferry, 2000; Gary,
Yarandi, & Scruggs, 2003). Numerous aspects of these mental states
are antecedents to suicide, one of the most devastating outcomes asso-
ciated with this malady. Mentally ill persons can internalize the stigma
that is prevalent within society. In this sense, they come to believe and
act as if the stigma is a real and legitimate phenomenon (Corrigan,
2004b; Corrigan et al., 2003; Link et al., 2001; Miller & Kaiser, 2001;
Okazaki, 2000; Snowden, 2001; Snowden & Cheung, 1990; Stevens &
Hall, 1988). That is to say, some come to believe that they are less val-
ued than others in society, and literally devalue themselves and their real
or potential contributions to the society (Hudson, 2005). As a result,
individuals with mental illness might avoid employment, and elect not
to be successful at some task or in a job, because of fear of failure, or
internalized self-stigma, which can translate into self-abhorrence (Balsa
& McGuire, 2003; Cool & Garrido, 2000; Cooper-Patrick et al., 2002;
Flores & Vega, 1998; Jones, 2003; LaVeist, Nickerson, & Bowie, 2000).
Importantly, a similar dynamic can occur among ethnic minority
persons who have fears and doubts about their own abilities or who
depend on reflected appraisal from others to attain and maintain their
self-worth and sense of self-efficacy (Corrigan, McCracken, & Holmes,
2001; Corrigan et al., 2004a; Costello, Compton, Keeler, & Angold,
2003; Gary, Baker, & Grandbois, 2005; Gary et al., 2003; Poussaint &
Anderson, 2000).
Revisiting the Overlap between Stigma and Ethnic Minorities
The long history of discrimination and maltreatment of ethnic minor-
ity groups in America has left its seemingly indelible stain on this society
(Byrd & Clayton, 2001; Smedley & Smedley, 2005; U.S. Department of
Health and Human Services, 1999, 2001). Statistical data suggest that
there are mortality and morbidity differentials among ethnic minorities
and Caucasians. Health differentials between the two groups cannot be
entirely explained by race and ethnicity: Socioeconomic status and envi-
ronmental factors also must be considered, and are sometimes a proxy for
race and ethnicity. Research that differentiates among the three and their
outcomes is just beginning to emerge (Anderson & Nickerson, 2005;
Shields et al., 2005). The importance of social class is evidenced through
facts that suggest that people live, die, and get sick depending on their
race and ethnicity, gender, age, and socioeconomic group status (Hudson,
2005; Rowe, 2005; Smedley & Smedley, 2005). Social class determina-
tion consists of level of education, income, and occupation. Individuals
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990 F. A. Gary
with less education and who belong to the working class (laborers) are
more likely to die of heart disease than are people with higher levels
of education and who work as professionals (Navarro, 1997; Smedley
et al., 2003). Those with less education and/or of the working class re-
ceive mental health care that is substantially compromised; stigma is
a dynamic force that brings this hypothesis to fruition. Psychiatric ser-
vices are more often sought by Caucasians than by African American,
American Indian and Alaska Native, Asian American, and Hispanic
American groups (Byrd & Clayton, 2001; Jones, 2003; Smedley et al.,
2003; Smedley & Smedley, 2005; U.S. Department of Health and Hu-
man Services, 1999). Given the lower socioeconomic status (limited
capacity to purchase goods and services), the public and private stigma
influences, and the distrust of the mental health system, ethnic minority
people are at risk for not receiving adequate mental health care. Hence,
their chances for experiencing higher mortality and morbidity rates will
continue to increase exponentially, unless new and novel approaches are
implemented to forestall and reverse this trend (Marmot & Wilkinson,
1999; Mayberry, Mili, & Ofili, 2002; McDonnell, 2000). These are some
of the factors that are the pathogeneses of health disparities among eth-
nic minority groups in America (Byrd & Clayton, 2002; LaVeist, 2002;
LaVeist, Bowie, & Cooley-Quille, 2000; Shields et al., 2005; Smedley
et al., 2003; U.S. Department of Health and Human Services, 1999,
Based on the ubiquitous nature of stigma, an aggressive approach to
its eradication is a major public health objective, in service to the larger
goal of reducing mental health disparities that currently exist among the
four ethnic groups (see Healthy People 2010, U.S. Department of Health
and Human Services, 2000). This discussion concludes with particular
recommendations that address stigma.
Nurse researchers and others need to move beyond the lofty goal
of assuring equal access to research and broaden its scope. Research
about stigma should be a major focus for nurses and other mental health
professionals. It should address cogent issues such as public stigma,
self-stigma, family stigmatizing, help-seeking and delaying behaviors,
quality indicators for mental health care among ethnic minority groups,
and others. Decisions to abort, or not comply with, treatment also should
be robustly examined among the four groups. Of equal importance is
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Stigma: A Barrier among Ethnic Minorities 991
the impact of public and courtesy (proxy) stigma on decision making
related to help-seeking and treatment-seeking behaviors. Culturally rel-
evant research studies are needed from the perspective of self-stigma,
self-esteem, self-worth, and self-depreciating attitudes and behaviors
(Lefley, 1989; Macrae et al., 1994; MacRae, 1999; Rowe, 2005; Shields
et al., 2005; Smedley et al., 2003; Szasz, 2003; U.S. Department of
Health & Human Services 1999, 2001).
The roles and influences of support systems or reference groups in
helping to facilitate or delay help seeking is essential information that
needs to be further examined. What are the key elements that maintain
consumer-driven groups? Would initiatives that explore stigma from the
perspective of care settings be informative from the policy perspective?
At the systems level, with regard to insurance, how do the insurance
disparities for mental health disorders affect each of the ethnic minor-
ity groups (Lee & Estes, 2001)? Are there differences within the four
groups? And, if there are differences, how do these differences manifest
themselves? What are the diverse methods and techniques of addressing
these differences?
Interpretation and Dissemination of Research Results
Nurse researchers and others must become more cognizant of how
their research findings will potentially be interpreted and used to trans-
late science to service. Scientists should become more sensitive to the
levels of mental health literacy that exist among its own groups and the
public. Given the increased interest in and intersection with genetics and
race—within the context and interpretation of behavior—a finely tuned
intellect embedded in ethically and socially responsible critical think-
ing is required. In addition, research practices and how research results
could be framed and/or exploited, interpreted, and understood must be
added to the basic research process (Geller, Barnhardt, & Holtzman,
2002; Lefley, 1989; Macrae et al., 1994; MacRae, 1999; Rowe, 2005;
Shields et al., 2005).
Health Literacy
Nurse researchers and practitioners must provide health literacy in-
formation for the public and for individuals and families who endure the
burden of mental illness. They must strengthen the premise that individ-
uals with mental illness and their families can benefit from the science
that is being promulgated about the prevention and treatment of mental
disorders. Researchers ought to produce summary abstracts that clearly
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992 F. A. Gary
and specifically highlight their findings, including sensible statements
about implications for disease and acuity-level prevention and self-care
(Corrigan et al., 2004a; Jones, 1998; Jorm, 2000; Smedley et al., 2003;
U.S. Department of Health and Human Services, 1999, 2001).
Health policymakers must support research that informs health pro-
fessionals about the social determinants of health, including mortality
and morbidity. In order to approach this dimension with rigor and sci-
entific accuracy, the use of race and or ethnicity as “proxies” for so-
cioeconomic status, environmental and situational life experiences that
are known to disproportionately impact minority groups should not be
continued. The alternative is to measure these constructs directly. A set
of measures, defined by consensus, that more accurately addresses these
variables should be developed at the national level (by the National Insti-
tutes for Health). When unraveling the numerous complexities related
to health disparities, federal and local initiatives that build consensus
around core measures that address inequity and social determinants of
health status and their impact on disaggregated populations should be
constructed (Anderson & Nickerson, 2005; Shields et al., 2005). That is,
research should move beyond the current “racial and ethnic” categories
that are typically used in research, and begin to focus more on local
groupings/variables for the purpose of better understanding health be-
liefs and behaviors. Then the development of specific interventions for
the given population designed to alleviate the disparities would be more
relevant and perhaps produce better outcomes (see National Academy
of Sciences report, Ver Ploeg & Perrin, 2004, for a more detailed dis-
Health policymakers should also support interdisciplinary learning
across all health professionals with an emphasis on research and health
policy. As the proliferation of research continues to grow exponentially,
it is imperative that all disciplines recognize the complexities that are
inherent in human behaviors and mental disorders among all human
groups. Importantly, the need for sophisticated and complex configu-
rations related to constructs, design options, measures, recruitment ap-
proaches, human subject issues, and data analyses should be incorpo-
rated into the standards for all research. The future of research should be
embellished with the best thinking for addressing complex issues related
to mental disorders and ethnic minority groups—with carefully con-
structed findings and implications for research and practice (Anderson
& Nickerson, 2005; Balsa & McGuire, 2003; Byrd, & Clayton, 2001;
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Stigma: A Barrier among Ethnic Minorities 993
Rowe, 2005; Shields et al., 2005; Smedley et al., 2003). To prevent and
treat mental disorders, and relieve the burden of disease for all peo-
ple, psychiatric nurses must commit to addressing issues of intricate
magnitudes—many with callous and heinous histories.
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... Moving from passive to active representation, managers leverage their employees' lived experience to augment trust between the organization and its clients. Improved trust represents an important pathway for better client outcomes, particularly when distrust in government (Jones, 2016;Pew Research Center, 2015;Whetten et al., 2006) and stigma surrounding mental health issues and addiction (Barry, McGinty, Pescosolido, & Goldman, 2014;Gary, 2005;Luoma et al., 2007) remain high. For socially marginalized populations, particularly in the healthcare domain, that distrust and fear of stigma is often magnified (Gary, 2005;Whetten et al., 2006). ...
... Improved trust represents an important pathway for better client outcomes, particularly when distrust in government (Jones, 2016;Pew Research Center, 2015;Whetten et al., 2006) and stigma surrounding mental health issues and addiction (Barry, McGinty, Pescosolido, & Goldman, 2014;Gary, 2005;Luoma et al., 2007) remain high. For socially marginalized populations, particularly in the healthcare domain, that distrust and fear of stigma is often magnified (Gary, 2005;Whetten et al., 2006). Agencies whose workforce includes persons whose experiences mirror that of the population being served may be uniquely suited to ameliorate these barriers to successful recovery. ...
This study draws on the insights of managers in the behavioral health treatment system to explore the value of persons who bring lived experience to their organizational positions. Within these organizations, persons with relevant lived experience occupy various nonclinical and clinical positions. When facilities incorporate workers with lived experience, managers observe increased levels of trust between clients and service providers, an enhanced client-centered perspective among service providers, and higher quality in the services provided. This study may guide managers in considering how (or whether) human service organizations might institutionalize lived experience as a mechanism to help create a representative bureaucracy.
... EDs. There are likely multiple factors that contribute to screening and treatment disparities between WOC and non-Hispanic, White women with EDs, such as mental health stigma (Gary, 2005), clinician bias leading to lower rates of ED identification in WOC (Becker et al., 2003;Goel et al., 2020a), and lack of culturally-sensitive assessments (Belon et al., 2015). Findings from this study could inform future ED screening to reduce disparities in underrepresented populations, especially with regards to the high endorsements of binge eating in Asian/South Asian women and laxative use and insomnia symptoms in Hispanic women. ...
Objective: To examine eating disorder (ED) symptomatology, related clinical impairment, and comorbid psychopathology in college women with EDs across five racial and two ethnic groups. Method: Participants were 690 women from 28 US universities who screened positive for an ED. Thirteen variables assessing ED symptoms, related clinical impairment, and comorbid psychopathology were compared across racial and ethnic groups using analyses of variance (ANOVAs) and independent samples t-tests. Results: Across racial groups, significant differences emerged in binge eating and laxative use. Asian women reported significantly more binge eating than White women (p < .01). Individuals self-identified as the "Other" racial group reported greater laxative use than Asian and White women (ps ≤ .01). No other significant differences emerged across all other variables (ps ≥ .13). Across ethnic groups, Hispanic women reported significantly more laxative use (p < .01), and more comorbid insomnia symptoms (p = .03) than non-Hispanic women. No other significant differences were observed (ps ≥ .24). Discussion: Findings suggest that binge eating, laxative use, and insomnia symptoms differ across racial and ethnic groups in US college women who screened positive for EDs. Findings can inform tailoring of ED screening to reduce current disparities in these underrepresented populations.
... For many ethnoracial minority participants, these barriers might mean the difference between continuing in treatment or dropping out, or even refusing to begin treatment altogether (Gary, 2005). Therefore, the need for culturally responsive strategies to circumvent these barriers becomes ever more urgent, as trials for MDMA-assisted psychotherapy for PTSD move into Phase 3 prior to eventual submission for FDA approval (Burge, 2017). ...
MDMA-assisted psychotherapy was shown in previous clinical trials to be efficacious and safe for alleviating treatment-resistant posttraumatic stress disorder (PTSD). However, due to low ethnoracial diversity, the question remains as to whether ethnoracial minority participants would benefit similarly. Thus, in Study 1, ethnoracial differences in PTSD symptoms, secondary outcomes (emotion regulation, alexithymia, self-compassion), and suicidality were examined for a recent multisite, open-label trial of MDMA-assisted psychotherapy. In Study 2, a mixed-methods case study was conducted on an ethnoracial minority participant from the same open-label trial, to provide a culturally informed lens on recovery from PTSD in a participant of color. Lastly, recommendations for diversifying ongoing MDMA-assisted psychotherapy trials were provided. [Dissertation defended; portions of abstract not shown]
... It will also be important for future studies to identify if size of schools, proportion of Indigenous or racially diverse students and income levels or socio-economic rating of the school area impacts on actions the school takes in responding to selfharm and suicidal behaviour. As families with low socioeconomic status and people in ethnic minorities are at higher risk of developing mental health disorders (Gary, 2005;Reiss, 2013) and schools with higher proportions of these students may respond differently to mental health issues. Further studies could also seek to understand the prevalence of self-harm or suicidal behaviour throughout the school year, and understand how this may impact on the role of school staff in responding to incidents. ...
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School staff have a unique opportunity to detect and respond to mental health issues including self-harm and suicidal behaviour in adolescents. There is limited knowledge about how these incidents are managed in schools. This study aims to understand the incidence rates, perceived severity and management of self-harm and suicidal behaviour incidents by schools. A total of 1525 school incidents were analysed for rate, severity and response. Pearson’s χ2 test was used to understand incident rates of self-harm and suicidal behaviours compared to all other incidents, and if incident category was related to emergency service involvement. A Kruskal–Wallis ANOVA analysed differences in severity ratings for incidents, and relative risk ratios determined the probability that first responder services will be engaged in self-harm and suicidal behaviour incidents. Self-harm and suicidal behaviour incidents (n = 77) accounted for 5.05% of all incidents and were more likely to be rated highly severe compared to other incidents. Incidents of self-harm and suicidal behaviours were 1.43 times more likely to have police involvement and 8.37 times more likely to have ambulance involvement compared to other incidents that caused harm to students, staff or property including welfare and violence incidents. The findings highlight the severity of reportable self-harm and suicidal behaviour incidents as they required an emergency response. We discuss the potential missed opportunity for early intervention by school staff and services, which may hinder future disclosure or help-seeking by at-risk young people. Training of school staff may provide knowledge and confidence to respond appropriately to self-harm and suicidal behaviour incidents and prevent escalation requiring emergency intervention.
... Providing information and having verbal discussions early in the recruitment process may address concerns about psychological screening, fear of stigma and increase the likelihood of participation (Brintnall-Karabelas et al. 2012, NICE 2014).Minority ethnic groups are often under-represented in health research, which could limit the generalisability of research ndings(Sheikh et al. 2009). Cultural barriers to research participation can have an impact on ethnic minority groups due to the stigma associated with mental health(Gary 2005). Future studies should consider the cultural appropriateness of the intervention and develop appropriate recruitment strategies. ...
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Aim: The aim of the study was to determine the acceptability and feasibility of an intervention to support women with mild to moderate anxiety in pregnancy. Design: The intervention development and feasibility testing followed the MRC guidelines for complex interventions. A feasibility study was conducted between April - May 2016. Methods: Qualitative and quantitative data were collected to assess the acceptability and feasibility of the intervention. The intervention was delivered in three components: pre-group individual meeting with the midwife; group sessions; guided self-help resources. The intervention was facilitated by midwives and co-facilitated by midwifery support workers Results: Eight women with self-reported symptoms of mild to moderate anxiety participated in the study. Women reported an improvement in anxiety symptoms and felt they had benefitted from participation. Accessing social support from other women in similar circumstances had helped women to feel less isolated and facilitated open and honest discussions. Women valued the involvement of the midwife facilitator to support their wellbeing and provide specific advice about their pregnancies. Conclusions: The intervention design appeared to be acceptable and beneficial for this group of women. This study highlights the potential for midwives to facilitate supportive interventions to enhance the current provision of emotional support for women with anxiety symptoms in pregnancy and address the current gap in services. The intervention is potentially feasible for introduction into current clinical practice with minimal additional resources.
... In addition, while the sample was racially representative of the study region, our data nevertheless fail to capture the experiences of people of color (POC). Gary (2005) has noted that POC experiencing mental illness are subject to a double stigma, facing prejudice due to both racial/ethnic identity and mental health status. Kulesza et al. (2016) likewise demonstrated stronger stigma-related implicit beliefs toward Latino/a people who inject drugs (PWIDs) than toward White PWIDs. ...
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The aim of this article is to address how conceptualizations of addiction shape the lived experiences of people who use drugs (PWUDs) during the current opioid epidemic. Using a discourse analytic approach, we examine interview transcripts from 27 PWUDs in rural Appalachian Ohio. We investigate the ways in which participants talk about their substance use, what these linguistic choices reveal about their conceptions of self and other PWUDs, and how participants’ discursive caches might be constrained by or defined within broader social discourses. We highlight three subject positions enacted by participants during the interviews: addict as victim of circumstance, addict as good Samaritan, and addict as motivated for change. We argue participants leverage these positions to contrast themselves with a reified addict-other whose identity carries socially ascribed characteristics of being blameworthy, immoral, callous, and complicit. We implicate these processes in the perpetuation of intragroup stigma and discuss implications for intervention.
... The present study extends this research to include initial help-seeking tendencies of adolescents. Peer and family norms may contribute to reduced tendencies to seek out initial information about mental health concerns for racial/ethnic minority adolescents (Clement, et al., 2015;Gary, 2005). It is also possible that reduced access to treatment may be a salient factor that influences interest in mental health treatment (Mojtabai et al., 2011). ...
Many adolescents avoid seeking psychological help despite the increasing prevalence of mental disorders. The current study investigated whether distress and stigma exhibit differential relationships to decisions to seek online mental health information among a sample of predominantly racial/ethnic minority U.S. adolescents. In this investigation, 174 adolescents (Age: M = 15.90, SD = 0.85, Range = 14−19) completed assessments of help-seeking stigma, psychological distress, and a question asking if they would like to view a website with mental health information. Distress was a statistically significant predictor of decisions to seek online mental health information, but stigma was not. Severely distressed boys were more likely to seek online information than severely distressed girls. Evidence-based online resources may be particularly effective ways to support distressed adolescents.
... İnsanlık tarihi kadar eski bir geçmişe sahip olan ve ilk damgalanan hastalıklardan olan cüzzam, tanrının insana verdiği bir "kötülük" olarak nitelendirilmiştir (Gary, 2005). 1300'lü yıllarda kara ölüm olarak da bilinen veba, tanrının insanlara günahkâr davranışları yüzünden gönderilen bir ceza olarak görülmüş, tanrının öfkesini yatıştırmak için toplumun normlarına aykırı yaşayan grupları günah keçisi ilan etmişlerdir. ...
African Americans are the second largest minority population in the United States. They are at greater risk for many diseases, especially those associated with low-income, stressful life conditions, lack of access to primary health care, and negating health behaviors such as violence, poor dietary habits, lack of exercise, and lack of importance placed on seeking primary health care early. In addition, African Americans carry the burden of several diseases, which is reflected in higher rates of diabetes, obesity, hypertension, stroke, hepatitis, cancer, asthma, and human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). This chapter provides insight and knowledge regarding the health status, traditions, values, beliefs, and practices of African Americans and implications for culturally specific patient care.
Demographic factors may be associated with youth psychopathology due to social-contextual factors that may also pose barriers to intervention. Further, in line with intersectionality theory, youth with multiple non-dominant identities may be most likely to experience psychopathology and face barriers to care. This study examined rates of parent-reported psychopathology and mental health treatment utilization as a function of several demographic characteristics (in isolation and in concert) in a population-based, demographically diverse sample of 11,875 9- to 10-year-old youth. Results indicated most consistently that lower SES was associated with greater rates of psychopathology and greater likelihood of treatment utilization; that Asian American youth (relative to all other racial groups) and Hispanic/Latinx (relative to non-Hispanic/Latinx) youth were less likely to have a history of psychopathology or to have utilized treatment; and that male youth had greater rates of lifetime Obsessive Compulsive Disorder (OCD) and Oppositional Defiant Disorder (ODD) and were more likely to have utilized treatment. There was more modest support for interactive effects between demographic factors on psychopathology, which are discussed. The present study provides some support for differential rates of parent-reported psychopathology and treatment utilization as a function of demographic identities in youth. Potential explanations for these differences (e.g., cultural differences in symptom presentation; underreporting of symptoms) are discussed.
Literature Review
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The biological concept of race has long been controversial in psychology. Although many psychologists have challenged the concept of race, others have espoused it as a deductive premise and applied it as an inferential and research factor and variable, especially regarding Black-White IQ differences. Although race and its use have been polemically disputed for decades, no discipllne-wide, concerted action within psychology has been taken to ascertain the scientific meaning of race and to determine its proper application. Psychology's inaction contrasts with deliberate steps taken by other national and international scientific groups. This article examines a variety of problems concerning race in psychology: (a) definition, (b) application, (c) invoking authority and references for genetic knowledge, and (d) passive inaction by psychologists and professional associations.
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The human genome holds an extraordinary trove of information about human development, physiology, medicine and evolution. Here we report the results of an international collaboration to produce and make freely available a draft sequence of the human genome. We also present an initial analysis of the data, describing some of the insights that can be gleaned from the sequence.
The authors examine determinants of satisfaction with medical care among 1,784 (781 African American and 1,003 white) cardiac patients. Patient satisfaction was modeled as a function of predisposing factors (gender, age, medical mistrust, and perception of racism) and enabling factors (medical insurance). African Americans reported less satisfaction with care. Although both black and white patients tended not to endorse the existence of racism in the medical care system, African American patients were more likely to perceive racism. African American patients were significantly more likely to report mistrust. Multivariate analysis found that the perception of racism and mistrust of the medical care system led to less satisfaction with care. When perceived racism and medical mistrust were controlled, race was no longer a significant predictor of satisfaction.
Context: American Indians and Alaska Natives have the highest suicide rates of all ethnic groups in the United States, and suicide is the second leading cause of death for American Indian and Alaska Native youth. Objective: To identify risk and protective factors associated with suicide attempts among native male and female adolescents. Design: The 1990 National American Indian Adolescent Health Survey. Setting: Schools of reservation communities in 8 Indian Health Service areas. Participants: Eleven thousand six hundred sixty-six 7th-through 12th-grade American Indian and Alaska native youth. Main Outcome Measures: Responses were compared among adolescents with and without a self-reported history of attempted suicide. Independent variables included measures of community, family, and individual characteristics. Separate analyses were conducted for boys and girls. Results: Ever attempting suicide was reported by 21.8% of girls and 11.8% of boys. By logistic regression done on boys and girls separately, suicide attempts were associated with friends or family members attempting or completing suicide; somatic symptoms; physical or sexual abuse; health concerns; using alcohol, marijuana, or other drugs; a history of being in a special education class; treatment for emotional problems; gang involvement; and gun availability. For male and female youth, discussing problems with friends or family, emotional health, and connectedness to family were protective against suicide attempts. The estimated probability of attempting suicide increased dramatically as the number of risk factors to which an adolescent was exposed increased; however, increasing protective factors was more effective at reducing the probability of a suicide attempt than was decreasing risk factors. Conclusions: A history of attempted suicide was associated with several risk and protective factors. In addition to targeting youth at increased risk, preventive efforts should include promotion of protective factors in the lives of all youth in this population.
The history and definition of minority status in this country is a central consideration in our analysis of the conditions that affect the etiology, identification, assessment, incidence, and treatment of developmental psychopathology in these populations. As history clearly illustrates, the status of a minority in a country is not a function of numerical representation. In South Africa, the “minority” population created by the system of apartheid was actually the numerical majority of its habitants. Minority status is not a matter of numbers: It is a matter of access to resources and the power to determine their allocation and distribution.
National data on psychiatric hospitalization point to marked ethnic-related differences. Blacks and Native Americans are considerably more likely than Whites to be hospitalized; Blacks are more likely than Whites to be admitted as schizophrenic and less likely to be diagnosed as having an affective disorder; Asian Americans/Pacific Islanders are less likely than Whites to be admitted, but remain for a lengthier stay, at least in state and county mental hospitals. These differences are clear-cut, but they ignore a major source of care: psychiatric hospitalization in placements other than psychiatric units and hospitals. Explanations for observed minority - White differences in hospitalization can be evaluated only partially or not at all: Such explanations include ethnic-related differences in socioeconomic standing and in the prevalence of major psychopathology; differential stigma, or capacity to tolerate or support a dysfunctional significant other; access and use of alternative services; and bias in the behavior of gatekeepers, especially practitioners assinging diagnostic labels and making involuntary commitment decisions. More research is needed to help explain these striking differences in utilization.