A look at prejudice and discrimination in the ﬁeld of mental illness and addiction
Reprinted from "Stigma & Discrimination" issue of Visions Journal, 2005, 2 (6), p. 4-5
In many human rights circles, the last 50 years has been an era of increasing (albeit imperfect) tolerance. Those of us working in the ﬁeld of mental health and addictions have seen change—from mysticizing, warehousing and criminalizing to medicalizing and psychologizing. We have moved people out of mental hospitals and into assisted living units; we have found that a range of treatment options and social supports help people recover like never before; we have spoken of addiction as an illness, not a moral issue.
But there’s still the language—addict, mentally ill, schizophrenic, psycho, junkie—personless, labelling language that, even today, is so hard to shake off.
And why? A person cannot choose their race or gender, or reverse a physical disability; behaviour, however, is different. There is an expectation that a person should be in control of their behaviour, thoughts and feelings. And though the experts have argued for, and proclaimed victory in, having mental illness and addiction viewed as health issues, for many people it remains an issue of poor self-control and character ﬂaw.
“What if he falls off the wagon?” “What if he acts strangely?” “What if she becomes violent?” These are not health concerns; they are judgements based on stereotypes, media depictions, and lay assumptions of causality that are embedded in our culture. “Come on, pull up your socks.” “Stop trying to get attention.” “Just say no.” “If you just got a job and got off the system…”
What it is and what it does
The mental health and addictions movements have historically always talked of stigma. According to the father of stigma theory, Erving Goffman, stigma is the situation of an individual being excluded from full social acceptance because of a trait that marks them as different from the so-called ‘normal’ majority. This difference then elicits some form of discrimination from the community, such as punishment, restriction of rights, ridicule and/or social rejection.
For the ancient Greeks, stigma referred to visible marks on the body that were branded on ‘undesirables’—slaves, criminals and traitors. Although nowadays people with mental illness and/or addictions are not tattooed upon diagnosis, the feeling is not altogether different; the brand is just invisible.
Throughout their history and up to the present day, mental health and substance use problems have been seen as sins, crimes, behavioural problems, diseases, or some combination of these. Despite the changing frame, the perception has basically remained the same: the person is, at worst, irreparable; at best, only capable of temporary recovery through strict adherence to “the program,” “the steps,” “the medication”...
People with mental illnesses and/or addictions are among the most devalued of all people with disabilities—and by extension, friends, family and professional care providers also face a kind of ‘stigma by association.’ A major US nationwide survey of mental health consumers found that almost 80% of survey respondents had overheard people making hurtful or offensive comments, with more than a quarter often being told to lower their expectations in life.
But the effects of discrimination go far beyond dirty looks and name-calling. Users of mental health or addictions services are denied basic rights of citizenship, encountering both subtle and blatant discrimination when accessing housing, employment, income assistance, higher education, insurance, parenting rights, immigration status and even recreational opportunities. They are often viewed as second-class citizens by the communities and neighbours they wish to live among and befriend, by the physical health care and criminal justice systems, media, mental health and addictions professionals, other service users, and even their own friends. Rejection from social supports, resources and institutions has a signiﬁcant impact on a person’s selfsufﬁciency, recovery and overall quality of life.
The case has been made3 that, due to discrimination, mental health and addictions systems are chronically under-funded—particularly when measured against the toll these conditions take on families, workplaces, and the health care and criminal justice systems.
Why prejudice is so hard to give up......
There are three main theories4 as to why stigma processes develop against any minority group. Each of these is at work against people with mental illnesses or addictions:
stigmas justify current social injustices (e.g., the belief that people with mental illness were inferior justiﬁed sterilizing them)
stigmas meet basic self-serving psychological needs (e.g., ‘I feel better about myself when I compare myself to addicts or the mentally ill’)
stigmas are efﬁcient mental shortcuts that allow people to quickly generate impressions and expectations of someone based on their membership in a stereotyped group (e.g., ‘If I encounter someone with mental illness or an addiction, I’ll know what to expect’)
The public wants to conceive of sickness or unusual behaviour as occurring with reason; otherwise, life is reduced to a game of chance. Therefore, people are viewed as extensions of their conditions, so we can separate ‘them’ from ‘us.’ Though the stereotypes attached to diagnoses and substances may differ, the myths driving the stereotypes are the same: people with mental illness and addictions are violent, unpredictable with poor social skills, incapable of recovery, and to blame for their conditions.5 They should be hospitalized or locked up; they are worthy of help, but the public shouldn’t have to see them.
On the index of fear and stigma, mental illness and addiction cluster with sexually-transmitted diseases, epilepsy and leprosy:6 three conditions that have historically induced great fear in people. These are not the diseases modern-day telethons are made of. As Susan Sontag wrote, “It seems that societies need to have one illness, which becomes identiﬁed with evil, and attaches blame to its ‘victims’… any disease that is treated as a mystery and acutely enough feared...”7 Though she was writing about AIDS, the concept easily applies to mental illness and addictions.
But there is also hope found in Sontag’s words. Over time, stigmas are malleable. They can be created (drinking and driving, smoking) and reduced (cancer, AIDS). By learning from other campaigns against ignorance, there will hopefully come a time for mental health and addictions when searching for the right language will be irrelevant—when the people will have superseded their labels and symptoms and behaviours.
Researchers have argued that people with physical disabilities have not found stigma a useful concept because stigma puts the focus on the ‘branded’ person, while prejudice and discriminationput the onus where it belongs: on the individuals and institutions that practise it. Why should our movement be any different from other human rights movements? As researcher Liz Sayce says, “It’s not as if we talk about the ‘stigma of being black’—no, we talk of racism.”8 The adoption of a social approach that links disability, human/civil rights, mental illness and addictions with empowerment, participation and human dignity is key.
And yet, there is hope. Cultures vary in their levels of prejudice toward mental illness. For example, schizophrenia has a better outcome in developing nations because of greater community acceptance.9 So we need to be open to doing innovative research and learning the lessons from people’s experiences. Some of the articles in this issue of Visions may be a step toward that end.
About the Authors
Sarah is Director of Public Education and Communications at the Canadian Mental Health Association’s BC Division, and Visions Production Editor. She has been involved in anti-stigma campaigns at CMHA and in 2002 wrote a report on stigma and discrimination for the BC Minister’s Advisory Council on Mental Health. She is also a consumer of mental health services
Corrine is board President of From Grief to Action (FGTA). As a relative of an amazingly resilient recovering substance user and mental health consumer, she regularly receives lessons in humility, compassion and the need for increased public awareness. Through FGTA, Corrine promotes addiction as a public health issue to assist in breaking through prevailing stigmas
Goffman, E. (1963). Stigma: The management of spoiled identity. Harmondsworth, UK: Penguin.
Wahl, O.F. (1999). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25(3), 467-478.
Gross, C.P., Anderson, G.F., and Powe, N.R. (1999). The relation between funding by the National Institutes of Health and the burden of disease. New England Journal of Medicine, 340(24), 1914-15.
uCrocker, J. & Lutsky, N. (1986). Stigma and the dynamics of social cognition. In S.C. Ainlay, G. Becker & L.M. Coleman (eds.), The dilemma of difference: A multidisciplinary view of stigma (pp. 95-122). NY: Plenum.
Hayward, P. & Bright, J.A. (1997). Stigma and mental illness: A review and critique. Journal of Mental Health, 6(4), 345-54.
Neaman, J.S. (1975). Suggestion of the devil: The origins of madness. Garden City, NY: Anchor Press.
Sontag, S. (1988).AIDS and its metaphors. London: Penguin Books.
Sayce, L. (1999). From psychiatric patient to citizen: Overcoming discrimination and social exclusion. NY: St. Martin’s.
Jablensky, A., Satorius, N., Emberg, G. et al. (1992). Schizophrenia: Manifestations, incidence and course in different cultures. A WHO ten-country study. Psychological Medicine, 20(Suppl.), 1-97.