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Visions Journal

The Three Faces of Stigma

Steven J. Barnes, PhD

Reprinted from "Recovery: Stigma and Inclusion" issue of Visions Journal, 2017, 13 (1), p. 28

Having lived with bipolar disorder for more than 20 years, I have had many encounters with the stigma associated with mental illness. Sometimes the stigma can be quite in-your-face: a week seldom passes when I don’t encounter a news article highlighting that a particular violent criminal had a form of mental illness. (In reality, people living with a mental illness are more likely to be the victims, rather than the perpetrators, of violent crime.1) On the other hand, stigma can also be quite subtle—like the wary look I got from the pharmacist the other day when I handed him my prescription for lithium, a drug commonly used for the treatment of bipolar disorder. 

As is true for many people living with a mental illness,2 the negative effects of the stigma I experience often outweigh those of my symptoms. That may sound absurd, but it is important to realize that there are multiple sorts of stigma that can impact an individual living with a mental illness.

Types of stigma

Researchers who study psychiatric stigma often talk about three different types of stigma (also see pages 5–7 of this issue).

Structural stigma refers to particular policies of large entities (e.g., governments, companies, schools) that place restrictions on the rights or opportunities of persons living with mental illness.3 For example, in Lithuania, citizens with long-term mental health problems are excluded from home owndership.4 

Social stigma is what most people think of when they think of stigma. In general, social stigma refers to supporting stereotypes about individuals with a mental illness. For example, I remember as a student telling one of my professors that I had bipolar disorder. She subsequently began talking to me more slowly and even subtly questioned my ability to complete a graduate degree. In essence, she was endorsing a common stigmatizing misconception: that having a mental illness makes an individual less intelligent or less capable.5

Stigma can impact recovery from a mental illness and one’s ability to live well with a mental illness.6 Based on my own experiences, as well as the research literature,7 this is particularly true for the third type of stigma: self-stigma

In a nut shell (pun intended), self-stigma is the internalizing of stigma (social or structural). Self-stigma can affect how you think about yourself and your relationships with others; it can even affect your motivation to recover8 and your adherence to treatments.9 For example, following my diagnosis, I came to believe that I was intellectually and artistically impaired.

Self-stigma also distorted my beliefs about what other people thought of me. For example, I often assumed that others thought less of me once they learned of my diagnosis. I thought that people talked about me, and my diagnosis, behind my back, and that people could see behavioural differences in me—that they could see my diagnosis! And I thought that many people were two-faced—smiling when they saw me but otherwise trying to avoid me. Regardless of whether those perceptions were true, the important point is that such self-stigma had a major impact on my sense of self-worth and my perceptions of my worth in the eyes of others.

Battling stigma on all fronts

So, what can one do to combat stigma? There are several approaches, many of which are specific to the type of stigma you are battling. 

Structural stigma can be effectively tackled through educational programs for individuals in positions of power, such as educational programs for medical students and police officers.10

Social stigma has been effectively addressed using educational interventions, such as the communicating of positive stories about people with mental illness—which is not as easy as it sounds because changing how the media presents mental illness can be challenging. In addition, social stigma can be effectively battled through interventions that place a person in direct contact with an individual living with a mental illness.10 Both of these approaches can have a positive effect on structural stigma as well; as individuals’ attitudes and understandings change, so do the attitudes and understandings reflected in the organizations they participate in.

It is also important to realize that certain strategies that would seem to be intuitively reasonable ways of battling social stigma can actually be ineffective or even counterproductive. For example, simulations of mental illness (such as the simulation of the auditory hallucinations of an individual living with schizophrenia) and educational interventions that focus on the “medicalizing” of mental illness (that is, informing people that mental illness is just like any other illness or disease) are generally ineffective.11

Self-stigma can be improved using several approaches, including: 

  • altering one’s stigmatizing attitudes and beliefs through educational interventions 

  • improving one’s skills for coping with self-stigma by improving one’s self-esteem, empowerment and help-seeking12 

  • self-disclosure13,14 

Self-disclosure involves disclosing one’s diagnosis to others. Self-disclosure can take many forms, from discreetly telling a close friend to broadcasting one’s experience to a much larger audience. It is important to weigh the pros and cons before disclosing one’s diagnosis in a particular setting. For example, in a work setting, the costs of disclosing one’s mental health issues (for example, the potential for gossip) may outweigh the benefits (for example, not having to lie to one’s supervisor when taking time off for appointments with your psychiatrist).13

In battling my own self-stigma, I took the self-disclosure approach. Because I was initially wary of the effects of self-disclosing, I began by disclosing my condition in a relatively safe environment: a peer-run support group called The Kaleidoscope. Feeling empowered by that experience, I next began disclosing my condition to students in the courses I teach, in my lectures on the topic of mental illness. Finally, I moved to sharing my experiences with mental illness more broadly—through my work with the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD), in my psychology textbook15 and through articles like the one you have just read.

 
About the author
Dr. Barnes teaches psychology at UBC and is part of the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD). His expertise is in psychiatric disorders and neuroplasticity. He is also an artist who produces both traditional and new-media pieces. Dr. Barnes lives well with bipolar disorder
Footnotes:
  1. Varshney, M., Mahapatra, A., Krishnan, V., Gupta, R. & Deb, K.S. (2016). Violence and mental illness: What is the true story? Journal of Epidemiology and Community Health, 70(3), 223-225.

  2. Hinshaw, S.P. & Stier, A. (2008). Stigma as related to mental disorders. Annual Review of Clinical Psychology, 4, 367-393.

  3. Hawke, L.D., Parikh, S.V. & Michalak, E.E. (2013). Stigma and bipolar disorder: A review of the literature. Journal of Affective Disorders, 150(2), 181-191.

  4. See www.time-to-change.org.uk.

  5. Goodwin, J. (2014). The horror of stigma: Psychosis and mental health care environments in twenty-first-century horror film (Part I). Perspectives in Psychiatric Care, 50(3), 201-209.

  6. Wood, L., Byrne, R., Burke, E., Enache, G. & Morrison, A.P. (2017). The impact of stigma on emotional distress and recovery from psychosis: The mediatory role of internalised shame and self-esteem. Psychiatry Research, 255, 94-100.

  7. Oexle, N., Müller, M., Kawohl, W., Xu, Z., Viering, S., Wyss, C., Vetter, S. & Rüsch, N. (in press). Self-stigma as a barrier to recovery: A longitudinal study. European Archives of Psychiatry and Clinical Neuroscience. doi:10.1007/s00406-017-0773-2.

  8. Corrigan, P.W., Bink, A.B., Schmidt, A., Jones, N. & Rüsch, N. (2016). What is the impact of self-stigma? Loss of self-respect and the “why try” effect. Journal of Mental Health, 25(1), 10-15.

  9. Kamaradova, D., Latalova, K., Prasko, J., Kubinek, R., Vrbova, K., Mainerova, B., Cinculova, A., Ociskova, M., Holubova, M., Smoldasova, J. & Tichackova, A. (2016). Connection between self-stigma, adherence to treatment, and discontinuation of medication. Patient Preference and Adherence, 10, 1289-1298.

  10. Livingston, J.D., Milne, T., Fang, M.L. & Amari, E. (2011). The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review. Addiction, 107(1), 39-50.

  11. Griffiths, K.M., Carron-Arthur, B., Parsons, A. & Reid, R. (2014). Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry, 13(2), 161-175.

  12. Mittal, D., Sullivan, G., Chekuri, L., Allee, E. & Corrigan, P.W. (2012). Empirical studies of self-stigma reduction strategies: A critical review of the literature. Psychiatric Services, 63(10), 974-981.

  13. Corrigan, P.W., Kosyluk, K.A. & Rüsch, N. (2013). Reducing self-stigma by coming out proud. American Journal of Public Health, 103(5), 794-800.

  14. Corrigan, P.W. & Rao, D. (2012). On the self-stigma of mental illness: Stages, disclosure, and strategies for change. Canadian Journal of Psychiatry, 57(8), 464-469.

  15. Pinel, J.P.J. & Barnes, S.J. (2017). Biopsychology. 10th edition. Hoboken, NJ: Pearson Higher Education

     

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