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Listening to Low-Income Patients: Mental Health Stigma Is a Barrier to Care

By Shanoor Seervai and Corinne Lewis

Sonia Martin* was living away from home and working two jobs to pay for college when she crashed emotionally. “I had a breakdown. . . . I needed to just have that moment. I needed that break away from life,” she says.

Martin was rushed to hospital, and then to a rehabilitation center, where she was treated with antidepressants. When she got out, she went to see a psychiatrist, who described her condition in one word: overwhelmed.

I had a breakdown… I needed to just have that moment. I needed that break away from life.

Financial Stress and Feeling Unsafe Contribute to Mental Health Issues

“Imagine at 20, with two jobs and trying to keep up my G.P.A. — that’s a lot for somebody that age,” she says. The biggest source of stress that contributed to Martin’s breakdown was money — without support from her family or financial aid, she couldn’t earn enough to get through college. She dropped out, and finally received an undergraduate degree online a decade later.

Martin hasn’t needed medicine to take care of her mental health since her breakdown in 2001, but she sees a therapist as regularly as possible. The most important lesson she learned, Martin says, is the importance of being able to talk to someone who can listen without judgment, outside her circle of family and friends.

Martin’s experience mirrors what we heard from others in recent focus groups with over 100 low-income patients: mental and emotional health issues are common, and exacerbated by stress from financial difficulties or feeling unsafe in one’s home or community. As a focus group participant explained, “My house was broken into. It’s a mental health stressor big time. I’m worried all the time.”

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Reluctance to Seek Help

Martin lives in Norcross, Georgia, where the median household income in 2016 was $44,000 — two-thirds of the national household income. She has observed a reluctance among her predominantly African American and Hispanic community to seek mental health care, and as a result has become a strong advocate for getting help. After a colleague expressed hesitation about seeing a therapist because she didn’t “want to do drugs,” Martin told her how talking to a mental health professional helped her get through troubled times.

Our focus groups, as well as studies of people with Medicaid and low-income women, reveal that while mental health is a common concern, low-income adults are often hesitant to get help because of misconceptions about care and stigma. Like Martin’s colleague, some of the low-income people we spoke with said they are reluctant to seek care because they don’t think it will help them, or because they are afraid of what others will think if they find out.

Many have come up with ways other than therapy or medication to cope with stressors and mental health issues. Martin, for example, has built religious and spiritual coping strategies into her life: meditation, prayer, “even just lighting a candle and closing my eyes for a few minutes,” she says. But she believes these practices should not undermine the need for therapy in her community.

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A Need for Mental Health Education

Many of the low-income patients we spoke with said people in their communities with mental and emotional difficulties often don’t recognize that they have a mental health problem that could benefit from treatment. “Most people are walking around with PTSD and don’t know it,” said one participant, referring to the stress he sees in his community from financial issues, crime, and police brutality. And another participant worried that some people with mental health problems, for example schizophrenia, might be perceived as being drunk or high among those who do not know about mental disorders.

Most people are walking around with PTSD and don’t know it.

The reasons symptoms are sometimes not recognized or understood are complicated. Many of the low-income patients we talked to expressed concern about the stigma of mental health issues or addiction problems, which has led them or others they know to sweep their symptoms under the rug, or refuse to seek help.

“Drug and alcohol addiction are both serious dilemmas that people in our community seem to neglect. Spouses rather hide or shut up because they don’t want any gossip and want to protect their community,” one participant said.

Another response is shame. “People feel uncomfortable talking about it. And if it runs in your family, they think something is wrong with your family,” said one participant.

Some low-income patients explained how cultural stigma and shame can lead people to hide their difficulties from others, which contributes to the lack of understanding and recognition of mental health issues. Many patients feel their community or culture shapes the conversation around mental health.

“It’s the culture. . . . People are afraid of going to the psychologist. If they go, they keep it a secret. They don’t tell anybody. You’re not going to go and tell your neighbor that you went to a psychologist,” explained one participant. This stigma is strong enough that some of the people we spoke with said they avoid getting help for their mental health or addiction issues because they fear that their employer will find out and they will be fired.

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Cost Remains a Barrier to Care

Along with stigma, cost is a huge barrier to seeking mental health care. Dawn Dixon is a 28-year-old single mother with diabetes. She doesn’t have a job or health insurance — so she often fails to take the insulin she needs to stay healthy. “Especially being a parent, when you’re talking about paying rent, transportation, day care, [health care is] not affordable at all,” she said.

She works hard not to project her financial and other stresses onto her daughter. “She doesn’t need to worry about what I’m worried about. She doesn’t need to see mommy having a breakdown,” she says.

To manage her stress, Dixon relies on a string of home remedies, from using cinnamon and nutmeg to sweeten foods, to prayer. She’d like to see a therapist, but without insurance, that isn’t possible.

In her largely African American community in Lithonia, Georgia, Dixon doesn’t have any close friends who have sought therapy. People turn to drugs or alcohol instead, she says. “And I’m like, ‘If this person took out the time to just go to a therapist on the regular, maybe they wouldn’t be an alcoholic.’”

Stigma and misunderstanding surrounding mental illness and addiction won’t go away overnight, but as people speak openly about their struggles, the conversation can change. As one respondent explained about her own learning process with a mentally ill brother, “When we found out why he was behaving that way, the stress kind of changed to: ‘How can we help?’”

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* This interviewee’s name has been changed, per her request.

This post is the third in a “Listening to Low-Income Patients” series that draws on qualitative research to describe, in patients’ own words, different issues that impact their health such as quality of health care, community, and mental health and addiction. Detailed follow-up interviews were conducted with patients. 






Publication Details



S. Seervai and C. Lewis, Listening to Low-Income Patients: Mental Health Stigma Is a Barrier to Care, The Commonwealth Fund, March 2018.