When developing websites and digital platforms around diversity, equity, and inclusion (DEI) principles, it’s important to not only consider overt physical disabilities people live with, but also those often unseen and overlooked—known as “hidden” or “invisible” disabilities. These include learning and cognitive impairments, such as dyslexia and nonverbal disorders, along with mental health disabilities, such as anxiety, depression, bipolar disorder, and many more. Those diagnosed with mental health conditions require an inclusive online experience devoid of problematic colors, images, fonts, or specific language—all of which can cause frustration, angst, and other sensitivities.
According to the National Institute of Mental Health (NIMH), as of 2019, approximately one in five adults in the United States live with a mental illness—that’s 51.5 million people experiencing a wide range of diagnoses classified as mild, moderate, or severe.
The NIMH organizes these within two broad categories: Any Mental Illness (AMI) and Serious Mental Illness (SMI). The former is defined as “a mental, behavioral, or emotional disorder,” while the latter represents those “resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.”
Due to the breadth and diversity of people living with mental health conditions and our collective reliance on digital devices, it’s more important than ever that public and private institutions alike work toward a more inclusive experience.
"Mindfully inclusive language and design consider the sensitivities of readers/viewers,” Angie Chaplin, owner of Mindful Leadership, an Iowa-based leadership, coaching and consulting practice, tells InclusionHub. “Because their traumas and experiences become a filter through which they process information, both content and context are impacted—positively and negatively."
The novel coronavirus (COVID-19) pandemic has exacerbated mental health issues and shined a light on the critical need for greater investments in this field. The nonprofit healthcare organization Kaiser Family Foundation found that the number of adults reporting anxiety or depressive disorder has increased during the pandemic—from one in 10 in the last six months of 2019 to four in 10 since the COVID-19 took hold.
“As the pandemic wears on, ongoing and necessary public health measures expose many people to experiencing situations linked to poor mental health outcomes, such as isolation and job loss,” reads the foundation’s issue brief.
As we move forward, anyone with an online platform must adopt basic inclusive design features to support a more accessible digital world.
Consult this useful explainer for more information on improving web accessibility and digital inclusion for those with mental health disabilities by focusing on elements such as design, language, tone, imagery, fonts, user-friendly portals, and others.
Improving accessibility is critical, especially in an increasingly digital world where someone’s body language, tone and stance can be challenging to decipher.
While having an accessible and digitally inclusive web platform is important for all industries, healthcare organizations, such as hospitals, doctor’s offices, and other patient care groups, can benefit most, especially when working with individuals living with anxiety, depression, bi-polar disorder, and other mental health disabilities. Many often utilize web-based patient portals to manage and understand symptoms, diagnoses, medications, and relevant side effects.
Underscoring that point, a survey published in the peer-reviewed Journal of Medical Internet Research (JMIR) in April 2021 found higher usage of digital mental health tools during the early stages of the COVID-19 pandemic.
“Findings suggested increased use of digital mental health tools and other technologies over time during the early stages of the COVID-19 pandemic,” researchers wrote. “As such, additional effort is urgently needed to consider the quality of these products, either by ensuring users have access to evidence-based and evidence-informed technologies and/or by providing them with the skills to make informed decisions around their potential efficacy.”
Dr. Peter Raffalli, Assistant, Department of Neurology, Boston Children’s Hospital, says having digitally accessible and inclusive patient portals is most important, citing the pandemic-era shift to remote medical care.
“I think as far as why it’s so important to make these [websites] more inclusive, is that so much of healthcare, especially mental health, is moving online,” he explains. “Particularly with the pandemic, we were all ‘baptized by fire,’ and all of a sudden, everyone was on video calls, and we all had to learn how to use all of it.”
Even traditional web elements—such as stock imagery, colors and fonts, etc.—need to be accessible to benefit people living with mental health disabilities. That’s why designers, writers, and content managers, must go beyond conventional notions of web functionality.
“Businesses and other organizations want to create a well-planned website, and of course that’s important. But you know they may not know to think about elements, such as using dark colors, or a font that seems too serious or eerie’” Raffalli says. “I would be surprised how many people really do that right now with their websites, actually thinking from that perspective.”
Despite the United Nations (UN) classifying web accessibility as a basic human right, many websites are not living up to that standard.
While creating an accessible website makes sense for health, wellness, and the greater good, it’s also important from a business perspective, as you want to foster better customer service. Motivations aside, there appears to be more momentum behind digital accessibility efforts.
According to the 2020 Disability Equality Index Report, a joint initiative between the American Association of People with Disabilities (AAPD) and business disability inclusion nonprofit Disability:IN, approximately 64 percent of businesses have committed to making digital accessibility a company-wide policy, up from 59 percent in 2019.
There are obvious benefits associated with investing in accessibility, ranging from better customer retention and ease of use to making your digital platforms a trusted resource.
This also has a direct—and significant—financial impact. A 2019 “Click-Away” survey of residents in the United Kingdom found that seven in 10 disabled people left a site because it was inaccessible, and 86 percent of respondents said they would spend more if there were fewer barriers. As a result, businesses lost an estimated €17 million—the equivalent of nearly $20 million, according to the survey.
In the United States, the collective purchasing power of the disabled community has been estimated at nearly half a trillion dollars, according to a 2018 analysis conducted by the behavioral and social science research nonprofit American Institutes for Research (AIR), titled “A Hidden Market: The Purchasing Power of Working-Age Adults With Disabilities.”
For Sam Desmond, this is consistently top of mind as she navigates e-commerce platforms. A reporter for Long Island, NY-based local newspaper The Suffolk County News, Desmond was diagnosed with both bipolar 1 disorder and attention-deficit/hyperactivity disorder (ADHD), as well as bouts of depression and anxiety. One of the many side effects from her medications is weight gain, which she says can be challenging for online apparel purchases.
“I think I was maybe 118 pounds or around that when I first went on medication,” she tells InclusionHub. “Then within nine or 10 months, my weight shot up to 270. I’ve gotten some of the weight off, but still I am not the size that you often see depicted on online shopping websites.”
Desmond says she often gravitates toward websites with models depicting an inclusive look, such as those identifying as plus size, people of color, or other underrepresented groups.
“Every time I see a plus-size model, or even someone who isn’t what society deems ‘traditional,’ it just makes me feel like I can still exist,” she shares. “Especially as someone with a mental illness, it’s a struggle just to stay on medication, so if I see a website where I can feel like I can actually wear those clothes, and I can continue living right now, even though I’ve gained weight, I feel so much better.”
This also pertains to the healthcare patient portals, which are being utilized more than ever due to COVID-19. For the mental health community, user-friendly portals are even more important, as just one barrier could be a sensitivity trigger.
“It’s very clear that the internet is a tool for patients now, just like it is for doctors,” explains Dr. Raffalli of Boston Children’s Hospital. “A lot of medical care is moving in that direction, and I think we really need to have a digital-friendly environment. For example, someone might become anxious seeing pop-up ads or other communication trying to solicit them, or trying to gather information. For people with anxiety, paranoia, or obsessive compulsive disorder, this could make them feel intimidated, and excluded from that particular website.”
Desmond agrees with Raffalli’s patient portal assessment. Oftentimes, her disability prevents her from conducting regular activities, such as keeping doctor’s appointments. The experience, she adds, needs to be more personalized.
“Mental illness is so much of a spectrum of different reactions to things,” Desmond continues, “and it needs to be an easy process to cancel an appointment, rather than call and explain to someone [who isn’t your doctor] how you’re feeling, and why you’re canceling.”
While all disabilities frequently carry a stigma or stereotype, the mental health community experiences the added barrier of a condition that’s invisible to the general population. While covered and recognized by the Americans with Disabilities Act of 1990, many still feel the shame and stigma surrounding their diagnosis. This is caused by general bias, and lack of understanding and available resources.
Devin Boyle, a senior consultant at Washington, D.C.-based transformational change facilitator Wheelhouse Group—which guides business and technology evolution in the public and private sector—discusses these stigmas in a May 2021 blog for Government Executive, a media publication also based in D.C.
A government contractor who has bipolar disorder and post-traumatic stress disorder (PTSD), Boyle says she has personally faced both stereotypes and shame upon disclosing her diagnoses.
“Throughout my years as a communications professional, I have run up against bias in the workplace,” Boyle notes in the Government Executive blog titled “How to be Inclusive of Employees with Mental Health Disabilities.” “One employer went so far as to say, ‘I needed to just deal with it,’ in reference to my requests for reasonable accommodations to support my disability.”
The National Alliance on Mental Illness (NAMI) classifies a mental health disability as a “medical condition that disrupts a person's thinking, feeling, mood, ability to relate to others, and daily functioning,” underscoring the need for websites and content developers to consider those with mental health disabilities when developing digital platforms.
Also known as manic depression, this condition, which can last from days to months, often begins during the teenage or early adult years. Sometimes diagnosed in early childhood, this disorder severely alters mood, energy and functioning, combined with manic and depressive episodes.
Classified as a serious mental illness, this little-understood condition manifests unstable moods, relationships, self image and relevant behaviors. Known as an emotional dysregulation disorder, BPD severely disrupts daily activities, such as family, work, and other important areas.
According to the World Health Organization (WHO), “major depression is a leading cause of disability within the United States and other developed countries.” With more than 264 million diagnosed worldwide, this persistent condition interferes with several functions, such as thoughts, behavior, mood, relationships, and physical activity.
The American Psychological Association (APA) defines anxiety as “an emotion characterized by feelings of tension, worried thoughts and physical changes like blood pressure.” Those with this disability have daily, recurring thoughts and justify avoiding specific situations. Many experience physical symptoms, such as sweating, trembling, dizziness, headaches, and a racing heartbeat.
This occurs when the individual feels a sense of compulsion and obsession for more than one hour per day. It becomes a disorder when these thoughts interfere with daily activities. Common themes include obsession with organization, fear of germs and illness, and loss of control.
This recurring disability is marked by at least one month of escalating thoughts of anxiousness and other avoidances. Usually diagnosed once the individual experiences less than four episodes, it also includes regular concerns of having another panic attack.
Often following a traumatic or life-altering event, this disability comprises symptoms of anxiety and depression, as well as reliving the event repeatedly in their mind. Those suffering from PTSD avoid individuals, or other activities related to the event. Symptoms can appear within three months of the related experience, or as long as months or years after the event.
This mental disability affects clear thinking and the difference between real-life and fiction. It also interferes with decision-making, relationships, and emotions.
With recurring depression the most common, this disability occurs as temperatures become cooler, and days become shorter with less natural sunlight. Usually arising within fall and winter months, SAD patients experience regular or increased moods during the remainder of the year. It is often experienced by those with severe depression or bipolar disorder.
When designing and developing websites for the mental health community, it’s best to follow the Web Content Accessibility Guidelines (WCAG) and Title III of the Americans with Disabilities Act (ADA). For writers, it’s recommended to consult the National Center on Disability and Journalism Disability Language Style Guide for additional information.
As aforementioned, there are several ways organizations can create accessible websites for those with mental health disabilities. This includes a platform designed with sensitivity and awareness in mind regarding words they use in headlines, text, imagery, and even fonts and colors.
Chaplin, the owner of Mindful Leadership, says critical components of web accessibility and digital inclusion can encompass anything from headlines and images to specific topics and wording.
Alcohol-free since early 2020, she also suffers from general anxiety disorder and depression, stressing there needs to be sensitivity and awareness on websites, as certain words and images are triggers for her.
Rather than following the mentality of: “If it leads, it bleeds,” Chaplin advises taking a softer approach:
“If there’s a shocking headline, that can be a trigger to someone with mental health issues. If you’re being inclusive, it’s better to consider a gentler tone that isn’t as right in their face for someone who might see a specific word or image.”
“A lot of times I will see stock photos of people crouching, or with their head in their hands,” explains Chaplin. “I always avoid these sites, because they depict despair and hopelessness, which is not something you want to convey to someone suffering from mental illness.”
Design background, font choice, and overall topology are other areas Chaplin says can make a difference, particularly if the topics are healthcare and other related industries.
“Don’t design everything with black or dark colors,” she suggests. “It could further illustrate how bleak or how dire a situation might be. Having some type of awareness as to what colors match the design, the content you’re putting out there, and even font choices all kind of gets into the psychology behind topology and all of the different components when it comes to the design process.”
Content should also be handled with care. Chaplin says it’s best to avoid the second person, or a seemingly authoritative tone:
“If it’s written as ‘You need to do this,’ and ‘You should do this,’ to me that is very abrasive and confrontational and can also be perceived as being judgmental—especially more related to my previous alcohol use—around triggers of shame and guilt, because I got stuck there for so long. I still go through some periods of that [feeling judged], and if I feel something is a trauma trigger for me, then I will scroll past it.”
While creating an accessible and digitally inclusive web platform is something that takes time, care, research, and dedication, the benefits both from a community and financial perspective can be immense.
One way to begin this process is by simplifying the messaging you’re trying to convey, and considering everyone as part of your community.
Christopher Patnoe, Google’s head of Accessibility Programs and Disability Inclusion, previously tells InclusionHub this can be accomplished by working together as one cohesive group.
“Work with people in the community, not for people in the community,” he explains. “If you start with one, you can solve a problem for one person, and this problem can be expanded for other people. You never want to do anything for people, you want to do it with people.”