The Double Barrier to Mental Health Care: Public and Internalized Stigma
Seeking help is a responsible and expected step.
Individuals who seek out mental health or substance use disorder (SUD) care have often crossed hundreds of invisible mental barriers long before they make the first call. Research shows that stigma operates repeatedly in this process. Public stigma is the widespread belief that mental health and SUD conditions reflect weakness, poor choices, or lack of willpower. Public stigma often becomes internalized stigma when people turn those messages inward. Internalized stigma shows up as thoughts like “I should be strong enough to handle this” or “I shouldn’t need help for this.”
The Double Barrier to Mental Health Care: Public and Internalized Stigma
Studies demonstrate that even after someone clearly recognizes they have a problem, internalized stigma alone can stop them from seeking care. When a person finally overcomes that inner barrier and accepts that they need help, they face the public stigma again. Asking for help becomes a high-risk social act, carrying fears of judgment, discrimination, loss of relationships, and/or career. Research describes this as a double barrier: first, internal; then, social, which explains why many people delay care despite insight and motivation.
The solutions must mirror the problem and address both public and internalized stigma. To reduce internalized stigma, research supports clear, repeated messaging that mental health and substance use conditions are medical issues, not moral failures, and that seeking help is a responsible and expected step.
To reduce public stigma at the point of care, systems must reduce the social risk of showing up. At Sanford Behavioral Health, this means designing services that look and feel like healthcare: respectful environments, simple access, privacy, and treatment that is not separated or “othered.” When care feels normal, individuals are more likely to seek help once they recognize they need help. Reducing stigma is not just about changing attitudes; it is about removing psychological barriers that prevent people from accessing care even when they are ready.
Bibhas Singla, MD, MBA, FACHE, CPE, FAPA
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