AHMC writer Sara continues her series on the difficult topic of suicide and mental illness among graduate students. You can catch up on the first post here if you missed it.
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The Burden of Stigma
In our first post, I discussed the alarmingly high rates of mental illness and suicidality among graduate students, and reviewed risk factors especially pertinent to that population, highlighting how a confluence of variables – e.g., mental illness, competition, acquired capacity – can culminate in a perfect storm of triggers for vulnerable students. In this second installment, I address an additional important factor: the burden of stigma.
For present purposes, I’ll refer to stigma as negative, erroneous, and often pejorative attitudes concerning a particular social group – here, suicidal individuals (Batterham, Calear, & Christensen, 2013; Corrigan & Penn, 1999)]. Stigma is a complex beast, particularly when it comes to suicide. Despite recent increases in mental illness coverage among well-known public figures (e.g., Terry Bradshaw, Howie Mandel), suicide remains greatly stigmatized (e.g., Sudak et al, 2008).
In higher education, a handful of academics have “come out of the closet” about their struggles with mental illness (e.g., eminent professors Marsha Linehan and Elyn Saks come to mind); nevertheless, these individuals are few, far between, and almost always established/tenured within their field at the time of disclosure. Additionally, almost none of them talk about suicide (for a rare example, see Prof. Robert Brown’s 2015 editorial in the Boston Globe).
It is likely that fear of the consequences plays a large role in the silence surrounding suicide. Public stigma — the phenomenon wherein large social groups endorse stereotypes about and act against a marginalized group, such as suicidal individuals – is a major deterrent, and in a darkly ironic twist, often compounds mental health difficulties by exacerbating declines in self-esteem and self-efficacy among those who internalize those messages (Corrigan, Kerr, & Knudsen, 2005). Indeed, what is most concerning is that both public stigma and the resultant shame have been shown to reduce appropriate and necessary help-seeking among suicidal individuals (e.g., Link & Phelan, 2006; Tadros & Jolley, 2001).
To get a more personal perspective on the impact of such stigma, I spent some time chatting with VK, a doctoral student in a biological sciences program who has struggled with depression and suicidality. In our conversation, we delve into the overt and covert manifestation of stigma in academia, as well as implications for graduate students struggling with suicidality.
Editor’s note: Some responses have been edited for clarity and/or to preserve the anonymity of the interviewee.
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Sara Beth: Have you felt you’ve needed to keep your suicidality a secret in the educational sphere? If so, what are the reasons for this?
VK: Yes, definitely. There are many reasons for this. I have always felt that the professional atmosphere smothers my comfort with discussing personal problems; the old adage of “leave personal problems at home”… I think this is borne out of a fear I have that sharing my vulnerabilities – particularly volatile ones regarding suicidal thoughts or urges – will be shared and used to unfairly label me. I fear judgment and dismissal from colleagues and peers because of my mental illness. This fear has developed because of experiences I’ve had within my department.
What kinds of experiences?
VK: Two years ago, I assisted in planning a symposium, together with some graduate student colleagues. While selecting talks for the sessions, I put forward one abstract that seemed interesting. “No,” one of the other committee members said, quickly shuffling the abstract away from the center of the table, “Not him, he’s crazy. One time he had to take two weeks off of work because he had a breakdown or something in the lab. I don’t think we should let him give a talk, it will be bad.”
Another time, during a departmental talk, an audience member brought up a recent controversy regarding the fraudulent reproduction of stem cells, asking whether better communication between media, public, and scientists could have prevented the ensuing witch-hunt, and subsequent tragic suicide of Japanese researcher Yoshiki Sasai.
A member of my department responded with a joking comment suggesting that because Sasai was Japanese, he was likely “just crazy”. There were a few audible gasps from the audience, but mostly laughter. I was floored. The person who made the comment was and still is a well-respected and influential member of our department.
Just a few weeks later, someone was re-telling a story of a student in another department who leapt to his death several years ago, as if it was a joke. No one even knew his name, they just called him “some Asian guy”. There was no memorial, notification or obituary for him in the university communications.
Because of these experiences, I felt that I had to hide my suicidality. I am fearful that if my suicidal thoughts and ideations were ever “discovered”, it would ostracize me as an incapable PhD student; a defective unit.
Gosh! In addition to the stigma of mental illness, I’m struck by the overt racism you’ve mentioned. That kind of prejudice sends a loud and clear message in terms of what is considered acceptable/normative versus deviant, which adds another layer to the problem of stigma. I’m curious if you can speak to how this affected you personally?
VK: The constant hiding of my mental health struggles, particularly my suicidality, made me start to grow bitter and resentful toward those from whom I’m hiding these things. However, in the last while, I have given up trying to keep any aspect of my mental health problems secret. This is in part due to my deciding to not continue in academia after my PhD, and in part simply due to my emotional fatigue from depression; I don’t care anymore. The only exception is with my suicidality, which I only express in joking terms. “How’s your PhD going?” Well, I haven’t killed myself, yet, so I think it’s going pretty good. It’s easier to express than saying, In the last two years, I’ve had more days where I contemplated suicide than days when I did not.
What bitter irony!
VK: Yes.
Have you encountered/experienced stigma directly or indirectly?
VK: I have experienced aversion after disclosing my suicidality and mental health struggles, or experienced colleagues pretending that I had never disclosed anything to them at all, avoiding the subject altogether. In the past, people have thought that I’m using my mental health troubles as an excuse to avoid work and difficult decisions or situations.
What is the climate like in terms of attitude toward mental illness and disclosure at your university?
VK: Generally, I feel that mental illness is a neglected topic at my university. …Many people within my university and department refer to many mental health problems (depression, anxiety, eating disorders…) under a unitary blanket they call “burn out”. So when someone begins to visibly struggle with these issues, or undertakes treatment away from work, everyone just knows: so-and-so has burnout.
Sadly, I’m not sure that’s so unique to where you are. I’ve seen the same at other universities, including my own. How would you say this attitude affects service utilization among students, including issues of seeking treatment and obtaining support?
VK: Seeking mental help in the form of psychological or psychiatric care is heavily stigmatized. Many view persons in such treatment as ‘crazy’, and insist that they are better to speak to friends or relatives. Suggesting to someone who is struggling that they should seek professional help is considered an insult, if they have no prior experience with it. A good example of this was after a recent terror attack in my area.
A mutual friend of my partner and myself was present in the area during the incident, and witnessed the ensuing aftermath. She appeared to be struggling with a lot of anxiety and emotional distress after the experience, but when we suggested she seek professional help, she was visibly insulted and upset. Since then, she has refused to discuss the subject with us.
What about the attitudes toward self-care in your lab? Is there a discrepancy between what is encouraged and what is actually done to support students who are struggling?
VK: Within my own lab, we are fortunate to have a very caring boss. I can be open with him, tell him that I am struggling and he will encourage me to do what I need to do in order to recover. Yet, I have never expressed my problems with suicidality toward him, though; just the idea still rattles me. There are no formal systems set up to identify or help students who are struggling.
And in your larger department?
VK: Within my department, there exist no support systems for students struggling with mental health problems. From my perspective, I believe that the department sees it as the student’s responsibility to seek aid and support elsewhere. Past students within my department who have been clearly struggling with mental health problems become heavily stigmatized. They are labeled as lazy for taking extensive leave or working abnormal hours, “crazy” or weird for taking medication or appearing emotionally vulnerable, and incompetent or unreliable for not progressing in their research. I think that the attitudes and lack of support in the department either exacerbate or do nothing for the struggles of these people, leading them to make a war of attrition with their PhD, alternating between cycles of suffering and therapy until they either graduate or give up.
To me, the analogy is of a soldier crossing a battlefield, wounded with bullets and collapsing to the ground, bleeding. A medic can approach the soldier, either because of opportunity in proximity, or because the injured soldier can still crawl to find a medic. The medic patches the soldier up, and after some time, he stands back up in the battlefield. But the guns are still firing. Maybe if he’s lucky, the soldier won’t get hit. But probably not. Probably, he will get hit. And maybe that time, the medic won’t be there. Or maybe that time, the soldier won’t try to find one. Maybe that time, the soldier won’t get up.
So, to continue your analogy, what have your experiences with “the medic” been like? Have you been able to seek support in the educational setting? What has that been like? Ease of access? Any barriers? If you have received some sort of support in this domain, what has that experience been like qualitatively for you?
VK: Several years ago, I found myself in a situation where I felt I needed help, desperately. Being in a foreign country, I was unsure of how to do this. Because of many people’s views of mental illness, I was afraid to ask friends, colleagues or acquaintances. So I just made an appointment with the university general practitioner (GP) and said that I was struggling with depression and suicidal ideation. However, the language barrier created a difficult situation where I could not effectively communicate my problems, and the GP (and eventually, the therapist) could not effectively understand them. I was put on a waiting list to see a therapist; 8 months. After those 8 months, I was finally able to see someone. By that time, things had gotten worse. Then, I found out that I was only eligible for a short time of therapy. This was because while I was still a student, I was a PhD student, and thus, earned money. People who earned money weren’t allowed to see the university therapists, because of the long waiting times. So, after a year of therapy – during which I had improved – I faced two options, stop therapy, or go back onto another waiting list for a therapist, elsewhere.
So, I stopped therapy. Instead, I just met with the GP once a month, discussed medication options and talked about the problems I had with my PhD. This is also what I am currently doing, and while I do not feel that I am mentally healthy or stable, I don’t feel like I have any other options. It would be possible for me to see a psychiatrist, but psychiatric therapy is not covered by my health insurance, and the language barriers would still exist.
What has that been like?
VK: Currently, I feel like I am trapped. Stuck inside a cage, rattling the bars, doing what I can to fight back my depression and control my anxiety. I feel like the cage has been pushed down a mountain and I’m just steering it away from the steep cliffs and boulders. It seems like circumventing an inevitable end – a collision at some bottom that I might survive with my own constitution.
I never felt comfortable discussing my suicidality with the GP, or with a therapist. This is irrespective of the university, though, as I’ve always been afraid of disclosing my suicidality to a medical professional, for fear of it stigmatizing me in future, unrelated medical appointments. I have also been afraid that expressing my suicidality would jeopardize my professional life, even though I’m aware that’s irrational.
Given your experiences, what suggestions do you have about changes in the way suicidality/mental illness is handled in university?
VK: In my own university and in many others, I think there needs to be a strong mental health communication and outreach initiatives… It is important to first raise awareness and reduce stigmatization and aversion of suicidality and mental health. Only once this is done can people come forward to disclose their struggles with mental health and openly seek therapy.
My biggest problem is the feeling that I have no one to talk to. I feel isolated, empty and often, desperate. So for me, it would be helpful to have support groups with other graduate students struggling with similar issues. This is something that could be organized at the level of the graduate program or the university. While the risk of co-rumination exists, I think the potential benefits are far greater.
Secondly, I feel that despite being around so many highly educated, intelligent people, they hold a surprising amount of misconceptions and misunderstandings about mental health and psychiatric illness. I think here, education would be important. Graduate students and staff could be required to attend a one-time course at the beginning of their PhD about mental health risks, similar to ethics courses. This would provide them with a base understanding of mental health issues and giving suggestions and resources for handling them. It would be an important step in building a bridge between struggling colleagues, instead of further isolating them due to ignorance.
Next, I find that I struggle with knowing how to recover from my mental health problems. I feel guilty about taking days off or arriving late, and feel judged by other people in my department when they ask me about it. Including an annual number of mental health days, like those which exist in other professions, could help.
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It is clear that for VK, the departmental culture of stigma regarding mental illness, combined with a lack of resources at the university level (especially as someone with international status), function as barriers to accessing needed supports. [Editors’ note: check out our recent Twitter discussion on the variety of supports available – or not available – at various institutions.]
VK’s thoughtful reflections and suggestions for improvement (e.g., increasing availability of support groups for graduate students; providing up-front information about the mental health risks of completing a PhD) raise additional questions related to educational policy. Indeed, while it seems patently clear from this interview that de-stigmatizing suicide would have beneficial effects on struggling graduate students, how this should be accomplished is a complex and nuanced issue. For example, some experts caution against the potentially iatrogenic effects that can result from awareness-raising campaigns – e.g.., normalizing the behaviour, thus making suicide seem a viable option (Niederkrotenthaler, Reidenberg, Till, & Gould; 2014). At present, the jury remains out regarding such broad-scale awareness programs; the beneficial (vs. harmful) effects of such initiatives likely depend on various factors that require further investigation. In a future installment, I’ll tackle this seeming conundrum, addressing issues specific to graduate student suicide prevention and intervention endeavors – from grassroots-level efforts to broad, wide-ranging policy legislation.
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References
Batterham, P. J., Calear, A. L., & Christensen, H. (2013). The Stigma of Suicide Scale: Psychometric properties and correlates of the stigma of suicide. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 34(1), 13-21.
Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765–776.
Corrigan, P. W., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology, 11(3), 179-190.
Link, B. G., & Phelan, J. C. (2006). Stigma and its public health implications. The Lancet, 367(9509), 528.
Niederkrotenthaler, T., Reidenberg, D. J., Till, B., & Gould, M. S. (2014). Increasing help-seeking and referrals for individuals at risk for suicide by decreasing stigma: The role of mass media. American Journal of Preventive Medicine, 47(3, Suppl 2), S235-S243.
Tadros, G., & Jolley, D. (2001). The stigma of suicide. The British Journal of Psychiatry, 179(2), 178-178.
Sudak, H., Maxim, K., & Carpenter, M. (2008). Suicide and stigma: a review of the literature and personal reflections. Academic Psychiatry, 32(2), 136-142.
Academic Mental Health Collective 