Ableism is pervasive in mental-health care, new study says
By Louise Kinross
Imagine you need to be hospitalized for psychiatric care. But the hospital has a policy that prevents you from being admitted.
That was the experience of a participant in a study published this month on ableism in American mental-health care.
“Mental-health practitioners can’t lift you,” the participant says in the SSM-Qualitative Research in Health study. “They can’t do personal care. They can’t even put the pills in your mouth or give you the injections you need. You have to be able to do all that yourself… they don’t have personal-care attendants. I can’t bring a personal-care attendant.”
“That a hospital’s policy would exclude a certain segment of the population was very shocking to me,” says lead study author Katie Wang, a professor in the Department of Social and Behavioral Sciences at Yale School of Public Health.
The study involved interviews during the pandemic with 20 disabled American adults who were diverse in race, ethnicity, sexual orientation and gender identity.
Researchers identified six types of ableism.
The first was inaccurate assumptions about the impact of disability on mental health. Providers “either assumed that all of [a patient’s] presenting mental-health concerns were disability-related or overlooked the connection between mental health and the disabled lived experience,” the researchers write. For example, an autistic student who sought counselling at a university health clinic was told: “Oh, you’re autistic? We don’t deal with that here. You need to go to the Disability Support Services Office.” This happened despite the student saying his current issues weren’t related to autism.
The second type of ableism involved dismissing or disbelieving the patient’s experiences or access needs. For example, insisting a student who questioned whether they were autistic was wrong, or refusing to wear a mask for a patient with a chronic health condition.
The third kind of ableism was interpersonal. It included microaggressions like speaking to the patient’s mother rather than the patient, or engaging in stereotypes about the sexuality of disabled people.
The fourth category of ableism was lack of basic disability knowledge. This meant participants had to devote huge amounts of therapy time to educating their therapist on their condition and disability issues. It also resulted in therapists making inappropriate and insensitive recommendations. For example, a blind patient was encouraged to go for a drive as a stress-management strategy.
Physical inaccessibility included being unable to manoeuvre rooms and narrow halls in a wheelchair, and patients not being able to participate in virtual appointments because they couldn’t afford reliable Wi-Fi.
The final form of ableism was systematic. “Ableism is engrained into every aspect of mental health practice,” Wang says. “We even found this when a participant saw a disabled therapist.” In this instance, a disabled clinician encouraged a patient to “overcome” their disability, just like the therapist had. As a different participant said: “People who work in that profession are generally not offered an opportunity to think about or learn about ableism on par with learning about other forms of discrimination, or marginalization…”
What’s ironic about the pervasiveness of ableism in mental-health care is that disabled people have higher rates of depression and anxiety and use mental health services more often than non-disabled people.
While previous studies looked at barriers to disabled people in accessing mental-health care, this study “looked at what happens after people with disabilities start receiving care,” Wang says. Also, “participants in the other studies were predominantly white, so there was less consideration of intersectionality in the types of discrimination people with disabilities are facing."
Wang said she was surprised by “the level of mistrust expressed by some participants. One talked about the fact that they felt like the mental-health system would never be safe for them.”
Structural reform is needed to make care disability-affirming, Wang says. “Graduate programs in fields such as clinical psychology, counselling psychology and social work should have more course work on disability issues as part of the curriculum. In recent years, we’ve seen emphasis on cultural competency, but only in the areas of race and LGBTQ-affirmative care. Disability-affirmative care is rarely talked about in psychology and social work, and it shows because participants talked about the lack of basic disability knowledge in providers.”
Wang hopes mental-health clinicians get the message that "ableism remains a very pervasive issue in mental-health care settings. I want them to understand the importance of emphasizing disability competency when training the next generation of mental-health service providers. I also want them to consider accessibility when delivering both in-person and virtual care, and to build in as much flexibility as possible in policy and procedures."
Wang is a stigma and mental-health researcher. She got interested in looking at ableism after doing a survey in 2020. “I’m a person with a disability,” she says. “I’m blind. I did a survey looking at the prevalence of mental-health concerns in the disability community in 2020. The data showed that more than half of 441 participants were reporting clinically significant levels of depression or anxiety."
Wang says her disability needs are well accommodated at Yale. “But there are larger issues in academia surrounding how to best support the professional development of people with disabilities. Training institutions need to more proactively recruit and retain people with disabilities, whether as grad students, post docs or faculty members. We want more people with disabilities in the field so disabled voices and perspectives can be represented in future research and clinical practice.”
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