Visions Journal

Mark of shame or complex social process?

Heather Stuart, PhD (Epidemiology)

Reprinted from "Recovery: Stigma and Inclusion" issue of Visions Journal, 2017, 13 (1), p. 5

Few medical conditions have been associated with as much negativity as mental illness. One has diabetes, cancer or a broken leg, for example, but one is mentally ill. How we talk about mental illnesses suggests that we have come to view them as something that dominates all aspects of an individual’s personality. In some cases, mental illnesses can even become an individual’s identity. We might say, for example, “He is a schizophrenic” or “She is borderline”—even “They are addicts.”

Mental illness–related stigma has a long history and is present in virtually all cultures. People often describe mental illness stigma as more difficult to live with than the mental illness itself. The stigma can be more long-lasting and disabling than the illness, often presenting a major barrier to help-seeking and recovery.

The term “stigma” comes from the sharp stick (or stig) that early Greeks used to tattoo slaves, criminals and undesirables. Thus, “stigma” is often defined as a mark of shame, and this is the definition you are likely to find in the dictionary. Recently, however, the United Nations Convention on the Rights of People with Disabilities¹ has encouraged us to think about stigma in broader terms, as an issue of social justice, and asks us to pay more attention to how social and organizational structures perpetuate inequalities for people with mental and physical impairments. From this perspective, “stigma” is not a mark of shame borne by the individual; rather, “stigmatization” is a complex social process that results in discrimination and social inequity.

The research literature describing mental illness–related stigma can be organized into three mechanisms of stigmatization: structural stigma, public stigma and self-stigma.

Structural stigma

Organizations may behave in ways that exclude, disadvantage or discriminate against people with a mental illness. There are many examples of this structural stigma. In the workforce, people with a mental illness may not be able to get a job, for example, or keep a job or be promoted. They may be stuck in low-paying positions that don’t make full use of their knowledge and skills. In health care organizations, stigma may be expressed by not providing certain individuals with timely access to care. The media may also promote stigma through negative and stereotyped images. People who work in these organizations may be part of the stigmatization process (even if they aren’t prejudiced), simply by virtue of their following organizational policies and procedures. Anti-stigma programs targeting structural stigma must change the way organizations behave.²

Public stigma

The negative and harmful views that members of the public have of people with a mental illness are collectively called “public stigma.” Negative and prejudicial images and ideas may lead to unfair treatment and discrimination of people with mental illness. This can occur in the context of families and friends, and in day-to-day interactions.

Public stigma also has a way of “sticking” to individuals or things closely associated with the individual who has a mental illness. Families may be stigmatized (because they are perceived to have “caused” the illness or because they are thought to be harbouring a “dangerous” and “unpredictable” individual). They may lose the support of family networks and friends. Mental health providers are often devalued by their medical colleagues, and mental health treatments are frequently held in suspicion by members of the public. Finally, mental health research is underfunded, particularly when we consider it in light of the financial and other burdens caused by mental illnesses. Anti-stigma programs targeting public stigma must change the way members of the public think and behave.²

Self-stigma

Finally, self-stigma occurs when individuals who have a mental illness internalize negative public images and apply them to themselves. Self-stigma changes a person’s perceptions of self: the individual sees him- or herself as less deserving, as blameworthy and powerless. People who self-stigmatize may experience embarrassment and shame. They may avoid social interactions and have difficulty managing their recovery process.³ Anti-stigma programs must be developed to target self-stigma and change the way people with a mental illness think and feel about themselves.

Not all mental illnesses are stigmatized in the same way or to the same degree. Substance-use disorders and schizophrenia are more stigmatized than depression and psychological distress, for example. Members of the public think that people with substance-use disorders or schizophrenia are more dangerous and unpredictable than those who have depression or who are psychologically troubled. Members of the public are comfortable imposing more restrictions on groups that they think are more dangerous, and may support actions to limit civic or human rights.⁴

Because different disorders are stigmatized in different ways, a one-size-fits-all anti-stigma approach isn’t the most effective way to combat stigma. The message may be too watered down, or it may miss the mark altogether. What we would want a police officer to know and do in order to combat stigma, for example, is not the same as what we would want an emergency room nurse or an employer to know and do.

For example, we may want a police officer to de-escalate a difficult situation involving someone with a mental illness by talking to them rather than using undue force. In the emergency room, we may want nurses to understand that people who have attempted suicide are in acute pain and crying out for help, and not simply monopolizing important health resources that could be otherwise used for people who want to live. We would want employers to provide appropriate accommodations and supports for employees with a mental illness rather than assuming that they are no longer competent to do the job.

Many anti-stigma programs provide factual information about mental illnesses in the hope that this information will change public attitudes and behaviours. Sometimes these programs can backfire and create greater intolerance. For example, decades of “sound-bytes” encouraging us to think of mental illnesses as “illnesses like any other” have increased our empathy towards people with a mental illness. At the same time, however, our feelings of social distance have not changed; in some cases, they’ve increased.⁵

The most successful anti-stigma programs include positive social contact with people who have had a mental illness. People with lived experience of a mental illness can dispel myths and provide a positive role model for recovery. This type of “contact-based education” has been used extensively in schools, health care settings, workplaces and the media—groups that the Mental Health Commission of Canada (MHCC) has noted are particularly affected by the negative and damaging impacts of stigma.⁶

In Canada and elsewhere, stigma has become a matter of public health concern. Many countries now have large national anti-stigma programs. MHCC’s Opening Minds anti-stigma initiative has been operating since 2009. It targets youth, health care providers, employers and the media in an effort to improve awareness and reduce discrimination towards people living with a mental illness. Opening Minds has partnered with programs across Canada to help develop best practices in stigma reduction, using contact-based educational approaches.⁶

Because stigmatizing views of mental illnesses are socially ingrained, we all have the capacity to stigmatize, even when we don’t intend to. We do it automatically, without being consciously aware of doing so. That is why becoming more aware of how people with mental illness are stigmatized is an important first step in addressing this problem.

Some simple things that we can all do are listed on the Bell Let’s Talk website.⁷ These include:

• Paying attention to the words we use to describe people with a mental illness and avoiding words that are derogatory or demeaning

• Educating ourselves so that we learn and understand the signs of mental illness and know how to respond to them

• Remembering to be kind to people who are experiencing a mental illness. Small acts of kindness (like inviting the individual for coffee or sending a get-well card) can go a long way

• Making sure we listen non-judgementally to people instead of telling them what we think they should do or minimizing their illness. (Don’t say, for example, “What have you got to be depressed about?”)

Most importantly, we need to learn how to talk about mental illness so that we can break the silence and combat the stigma.

One in five Canadians will experience a mental illness this year. Stigma is a key barrier to their help-seeking and recovery. We all have a role to play in creating more inclusive social environments—at structural, community and individual and personal levels.