The Stigma of Mental Illness
A nationwide survey to characterize public perceptions of mental illness found that although the majority of the public can accurately identify psychotic disorder and accept that multiple biological, genetic, and environmental stressors are involved in its etiology, there is a strong stereotype that mentally ill people are dangerous and to be avoided (Link et al., 1999). Dangerousness is most often ascribed to people suffering from psychotic disorders (Henderson et al., 2013). Negative attitudes toward mental illness that are shared by health care professionals contribute to the reluctance to seek help and the receipt of less adequate mental health care. (Thornicroft et al., 2007).
The stigma of mental illness can be a strong deterrent to seeking needed mental health care (Anglin et al., 2006; Link et al., 2001; Pattyn et al., 2014). A three-year ethnographic study of homeless women in inner-city Chicago is instructive. The study involved interviews with and observations of women who frequented a drop-in center that offered nonclinical services such as laundry facilities, a mail drop, and a daily meal. Although mental health services and housing opportunities were available, women who were homeless and psychiatrically ill often refused offers of help, including diagnosis-related supportive housing. The street culture in which the women lived exerted an overpowering influence. Being “crazy” signified weakness and vulnerability to victimization. When the women claimed that they were not crazy, they affirmed their ability to be strong, protect themselves, and survive in an environment fraught with danger and extreme challenges. Had the association of housing and services with a psychiatric diagnosis been downplayed, more of the homeless mentally ill women might have accepted offers of help (Luhrmann, 2008).
Characteristics of People Who Refuse Treatment
Reviews of service disengagement suggest that individuals who drop out of treatment may have greater needs for help and are more socially and psychologically impaired than those who remain connected to services (Killaspy et al., 2000; O’Brien et al., 2009; Owen et al., 1996). Individuals with severe mental illness and concurrent substance use disorder have high rates of disengagement, as do those with greater levels of psychopathology (Kreyenbuhl et al., 2009; Nose et al., 2003; O’Brien et al., 2009). People who refuse treatment are more likely to be young, male, of ethnic minority status (Kreyenbuhl et al., 2009; O’Brien et al., 2009), socially isolated, poorly educated, and unemployed. Disengagement from services is greater among those who have a forensic history, perhaps reflecting antisocial traits underlying both criminality and disengagement (O’Brien et al., 2009).