Considerations on the Stigma of Mental Illness

Stigma, prejudice, and discrimination are closely related and tightly interwoven social constructs. These constructs affect many, based on age, religion, ethnic origin, or socio- economic status. However, a person can potentially move out of these groups, if not physically—as in age or ethnic background—then by moving up the social ladder, which makes the affected person less of a target. Conversely, stigma, prejudice, and discrimination against those with mental illness cut across all classes and social groups, and, to the extent that many mental conditions are chronic and incapacitating, those affected can hardly migrate out of the grip of negative social attitudes. The result is social annihilation that constricts the lives of those with mental illness, preventing them from fully reengaging in their communities and participating in the social activities of their groups of reference.

The general public most frequently makes contact with mental illness through the media or the movies. Unfortunately, the media often depict patients as unpredictable, violent, and dangerous (1), and movies usually follow the popular “psycho- killer” plot (2) long exploited by the cinematographic industry. Associating mental illness with violence helps to perpetuate stigmatizing and discriminatory practices against mentally ill persons; it is only one of many negative stereotypes and common prejudicial attitudes about them.

This editorial has 2 purposes. It first reviews theoretical elements fundamental to stigma as a social construct, together with stigma’s negative consequences for persons with mental illness and their families (3). Second, based on the review, it comments on this issue’s papers on stigmatization and discrimination.

Historical Elements

For the ancient Greeks, stizein, to tattoo or to brand, described a distinguishing mark burned or cut into the flesh of slaves or criminals so that others would know who they were and that they were less-valued members of society. Although the term may not have been applied to mental illness, stigmatizing attitudes about the mentally ill were already apparent in Greek society: as found in Sophocles’ Ajax or Euripedes’ The Madness of Heracles, mental illness was associated with concepts of shame, loss of face, and humiliation (4).

In the Christian world, the word stigmata is applied to peculiar marks resembling the wounds of Christ that some individuals develop on their palms and soles. Paul, for example proclaimed, “I bear in my body the stigmata of Christ” (5). Although the roots of the term are the same, the religious connotation of stigmata is not the same as stigma: stigma is a social construct indicating disgrace that, at the same time, identifies the bearer. Hawthorne exemplifies this in his novel The Scarlet Letter (6). In this novel set in the puritanical New England town of Salem, Massachusetts, a woman accused of being an adulteress is ordered to wear the letter “A” to signify her sin and shame. The town of Salem is also famous for having been the place of a mass execution of witches in 1662, a period in which the Malleus Maleficarum (7) (Witches’ Hammer) was still a highly regarded reference textbook for the management of witches. The Inquisitorial approach to witches, apart from being highly misogynous, also represented a negative and condemning attitude toward mental illness; it may have been the origin of the stigmatizing attitudes toward those with mental illness that have existed in Christian cultures from the rise of rationalism in the 17th century to the present (8). Madness has long been held among Christians to be a form of punishment inflicted by God on sinners (9). Stigmatizing and discriminatory attitudes against those with mental illness have also been reported and are known to exist in many other cultures.

Theoretical Considerations

Goffman thought of stigma as an attribute that is “deeply discrediting.” According to Goffman, stigmatized persons are regarded as being of less value and “spoiled” by the stigmatizing effects of 3 conditions: “abominations” of the body, such as physical deformities; “tribal identities,” such as ethnicity, sex, or religion; and “blemishes of individual character,” such as mental disorders or unemployment (10). This static concept of stigma has now been enlarged to encompass a social construct linked to values placed on social identities through a process consisting of 2 fundamental components: the recognition of the differentiating “mark” and the subsequent devaluation of the bearer. Stigma is therefore a relational construct based on attributes. Consequently, stigmatizing conditions may change with time and among cultures (11).

Stigma develops within a social matrix of relationships and interactions and has to be understood within a 3-dimensional axis. The first of these dimensions is perspective; that is, the way stigma is perceived by the person who does the stigmatizing (perceiver) or by the person who is being stigmatized (target). The second dimension is identity, defined along a continuum from the entirely personal at one end to group-based identifications and group belongingness at the other. The third dimension is reactions; that is, the way the stigmatizer and the stigmatized react to the stigma and its consequences. Reactions can be measured at the cognitive, affective, and behavioural levels. The stigmatizing mark also has 3 major characteristics: visibility, or how obvious the mark is; controllability, or whether the mark is under the bearer’s control; and impact, or how much those who do the stigmatizing fear the stigmatized (12). Stigmatizing attitudes get worse if the mark is very visible, if it is perceived to be under the bearer’s control, and if it instills fear by conveying an element of danger.

Mental health patients who show visible signs of their conditions because either their symptoms or medication side effects make them appear strange, who are socially construed as being weak in character or lazy, and who display threatening behaviours usually score high on any of these 3 dimensions. By a process of association and class identity, all persons with mental illness are equally stigmatized: regardless of impairment or disability level, the individual patient is lumped into a class, and belonging to that class reinforces the stigma against the individual.

Describing the characteristics of stigma—or what it is and how it develops—begets the question why it develops. Unfortunately, little literature on the subject exists, but the hypothesis has been advanced that 3 major elements are required for stigmatizing attitudes to happen: an original “functional impetus” that is accentuated through “perception” and, subsequently, consolidated through “social sharing” of information. The sharing of stigma becomes an element of a society that creates, condones, and maintains stigmatizing attitudes and behaviours. According to Stangor and Crandall (13), the most likely candidate for the initial “functional impetus” is the goal of avoiding a threat to the self (Table 1). Threats can be either “tangible,” if they threaten a material or concrete good, or “symbolic,” if they threaten the beliefs, values, and ideologies upon which the group ordains its social, political, or spiritual domains.

Table 1 The origins of stigma^a

· Functional impetus: initial perception of tangible or symbolic threat

· Perception: perceptual distortions that amplify group differences

· Social sharing: consensual sharing of threats and perceptions

^aAdapted from Stangor and Crandall (13, p 73).

Cultural perceptions of mental illness may be associated with tangible threats to the health of society because mental illness engenders 2 kinds of fear: fear of physical attack and fear of contamination (that is, that we may also lose our sanity). To the extent that persons with mental illness are stereotyped as lazy, unable to contribute, and a burden to the system, mental illness may also be seen as posing a symbolic threat to the beliefs and values shared by members of the group.

In place for centuries, the custodial, institution-based model of care for those with mental illness contributed to their stigmatization by segregation. The mentally ill were separated from the physically ill, who were treated in local hospitals in their own communities. The decision to send persons with mental illness to far-away institutions, although well intentioned in its origins, dislocated them from their communities. With time, they lost their connections with coworkers, friends, and relatives; ultimately, they lost their personal identity. At a system level, the institutional model also contributed to the banishment of mental illness, and also of psychiatry, from the general stream of medicine. The therapeutic nihilism that for centuries permeated most psychiatric work also contributed to the asylum mentality. The few-and-far-between therapeutic successes—such as the discovery of the cause and treatment of mental conditions like general paresis and pellagra—only helped to reinforce the nihilism, in that the remaining conditions were considered incurable. With time, the stigma associated with mental conditions and mental health patients also extended to those in charge of caring for them, psychiatrists included.

Stigma and Discrimination

Based on social distance measurements that show acceptance of mental patients and on findings that the behaviour and not the label is stigmatizing, some researchers have argued that persons with mental illness are not stigmatized (14). They also argue that mental health patients themselves are rarely able to report concrete instances of rejection (15). However, findings denying the pernicious effects of stigma have been refuted based on the poor methodology of these studies (16).

For the stigmatized, stigma is a feeling of being negatively differentiated owing to a particular condition or state. Stigma is related to negative stereotyping and prejudicial attitudes that in turn lead to discriminatory practices which deprive the stigmatized person from legally recognized entitlements. Stigma, prejudice, and discrimination are therefore inextricably related. Unlike prejudice, however, stigma involves definitions of character and class identification. Consequently, it has larger implications and impacts.

Prejudice often stems from ignorance or unwillingness to find the truth. For example, a study conducted by the Ontario Division of the Canadian Mental Health Association in 1993–1994 found that the most prevalent misconceptions about mental illness include the belief that mental patients are dangerous and violent (88%); that they have a low IQ or are developmentally handicapped (40%); that they cannot function, hold a job, or have anything to contribute (32%); that they lack willpower or are weak and lazy (24%); that they are unpredictable (20%); and finally, that they are to be blamed for their own condition and should just “shape up” (20%) (17). Similarly, a survey among first-year university students in the US found that almost two-thirds believed “multiple personalities” to be a common symptom of schizophrenia, and a poll among the general public found that 55% did not believe that mental illness exists, with only 1% acknowledging that mental illness is a major health problem (18). Some of these myths also surfaced in a study conducted in Calgary during the pilot phase of the World Psychiatric Association (WPA) project Open the Doors (19). Respondents to this study believed that persons with schizophrenia cannot work in regular jobs (72%), have a split personality (47%), and are dangerous to the public because of violent behaviour (14%) (20).

Outright discriminatory policies leading to abuses of human and civil rights and denial of legal entitlements can often be traced to stigmatizing attitudes or plain ignorance about the facts of mental illness. These policies and abuses are not the preserve of any country. In developed countries, health insurance companies openly discriminate against persons who acknowledge that they have had a mental problem. Life insurance and income-protection policies make it a veritable ordeal to collect payments when temporary disability has been caused by mental conditions such as anxiety or depression. Many patients see their payments denied or their policies discontinued. Government policies sometimes demand that mental health patients be registered in special files before pharmacies can dispense needed psychiatric medications. More broadly, the national research budgets in many developed countries provide only a modicum of funds for research in mental conditions. In Canada, for example, mental health research commands less than 5% of all the research health budgets, yet mental illness affects directly 20% of Canadians (21).

In developing countries, archaic beliefs about the nature of mental conditions, sometime enmeshed with religious beliefs and cultural determinants, stigmatize patients, who are denied access to treatment opportunities, and stigmatize their families when, for example, daughters in an affected family cannot marry because it is feared that they are contaminated (22). In some countries, patients languish in institutions for so long that they lose all contacts and, owing to poor records, even their names are forgotten. Obviously, the loss of personal identity deprives them of their civic and political rights.

Violence and Mental Illness

Few popular notions and misconceptions are so pervasive and stigmatizing as the belief that persons with mental illness are unpredictable and dangerous. This belief—so central to stigmatization and discrimination against those affected—cannot be easily discounted when hardly a month goes by without the media reporting the sad story of yet another horrendous crime allegedly committed by a patient with mental illness. This type of news, even when reported conscientiously and accurately, arouses fear and apprehension and pushes the public to demand measures to prevent further crimes. Those with mental illness in general bear the brunt of impact from the actions of the few. Unfortunately, the media do not inform the public that only a very small minority of mental health patients commit serious crimes and that the percentage of violence attributable to mental illness as a portion of the general violence in the community is also very small (23).

Sensational media reports (24,25) reinforce beliefs instilled by movies that depict mental health patients as “uncontrollable killers.” Relatives of the mentally ill assert that the way they are depicted in movies is the most important contributor to stigmatization (26). Movies have stigmatized not only those with mental illness but also psychiatrists, often extending negative stereotypes to portray them as libidinous lechers, eccentric buffoons, and evil-minded, vindictive, and repressive agents of the social system—and in the case of female psychiatrists, as loveless and sexually unfulfilled (27).

The association between mental illness—specifically, schizophrenia—and violence, although confirmed epidemiologically (28), remains unclear. It seems to flow not so much through direct links of causality as through a series of confounders and covariating causes, such as comorbidities with alcohol and substance abuse (not unlike that which drives violence among individuals without mental illness) and psychopathic personality. In addition, not every act of violence committed by a mental health patient should be catalogued as resulting from the mental condition, in that the context, such as taunting or victimization of the affected person, could be the main determinant for the violent reaction (29). Further, if a person with past mental illness commits a violent act, it should not be assumed automatically that the past mental illness is associated with the present violence. From a public health perspective, the risk of violence from those with mental illness should be measured via the attributable risk accrued to mental illness, compared with all other sources of violence in the community (30). These other causes, and not persons with mental illness, are the true threats to community security (31). Unfortunately, one single case of violence is usually sufficient to counteract the gains already made in community reintegration of mental health patients. The stigmatization of mental illness impacts negatively, not only on the level of services provided but also on the quality of these services; it compromises access to care because policy-makers and the public believe that persons with mental illness are dangerous, lazy, unreliable, and unemployable (32).

Research on the Stigma of Mental Illness

Although there does not seem to be a one-to-one relation between exposure to environmental stressors, such as stigma and discrimination, and adaptational outcomes, research on stigma has demonstrated that it has negative outcomes on physical health and self-esteem (33). Persons with mental illness often experience prejudice similar to that experienced by those who suffer racial or ethnic discrimination, but the practical effects are complex and affected by several factors, such as age, sex, and the degree of self-stigmatization (34).

It has often been confirmed that stigmatization and prejudice are the reasons why many persons do not seek assistance or postpone seeking assistance until too late (35). Recent research has also demonstrated that the fear of mental illness is not related just to the behaviour sometimes demonstrated by affected persons. It is also related to the label itself and to the consequences that flow from the illness. Thus, in the Alberta pilot site of the Open the Doors program, the Edmonton respondents rated “loss of mind” as more disabling than any other handicapping condition (36). In the same study, the Alberta group found that greater knowledge was associated with less-distancing attitudes but that exposure to persons with mental illness was not correlated with knowledge or attitudes (37). These findings confirm findings from other authors regarding the split between knowledge and attitudes among the general public (38). In different findings, the Alberta group also concluded that broad approaches to increase mental health literacy, as defined by Jorm (39), may not be as effective among already highly educated population groups (40) as would specifically focused interventions among small groups such as high school students or clinical workers. This conclusion supports Corrigan’s and Penn’s findings in regard to targeting specific groups and targeting specific beliefs about mental illness held by ethnic minorities (41).

A major issue identified by the Calgary group was the need for an instrument to measure “felt stigma” among persons with mental illness to provide an epidemiologic measure of levels, frequency, and degrees of stigmatization. In this regard, Corrigan advises that stigma research should examine 3 issues: 1) “signaling events” such as labelling, physical appearance, and behaviour; 2) knowledge structures to bridge information about controllability attributions and public attitudes about dangerousness and self-care; and 3) ways in which those knowledge structures lead to emotional reactions or behavioural responses (42).

The 3 papers included in this issue’s In Review section present research efforts on stigma from Canada and Germany that follow Corrigan’s agenda to a large extent. Focusing on empirical research into interventions for stigma and evaluations of their effectiveness, they make a cohesive set. The Canadian paper, by Dr Heather Stuart (43), deals with the problem of media reporting. It evaluates a media-intervention program carried out in Calgary within the activities of the Open the Doors pilot program, which aimed to combat stigma and discrimination toward persons with schizophrenia. This paper highlights both the importance of media reporting on sensational crimes supposedly committed by persons with mental illness and how broader social situations can influence media reporting. A conclusion to be drawn from this paper is that, while the media have a responsibility to inform the public, mental health service providers, relatives, and consumers alike also have a responsibility to ensure that patients are properly treated and adhere to acceptable treatment protocols to minimize or eliminate violent incidents caused by mentally ill persons. One single case of violence is enough to undermine any good work to combat stigma and discrimination.

The paper by Dr Wolfgang Gaebel and Dr Anja Baumann (44) deals with the effects and effectiveness of antistigma interventions within the framework of the Open the Doors program in Germany. It is interesting that this paper already provides some results of comparison data between Alberta, Canada, and 6 cities in Germany. In these data, the figures for social distance are practically the same for both countries. The rather unexpected negative effects from one type of inter- vention in Germany—viewing a film—are similar to the unexpected negative effects of media intervention in Calgary, which underscores 3 issues: that a very narrow line should be walked when mounting interventions against stigma, that fear of violence from persons with mental illness remains a common denominator to understanding stigma, and that any interventions regarding stigma should be accompanied by a thorough evaluation component to gauge their effectiveness and types of impact.

Finally, the second paper from Germany, by Dr Matthias Angermeyer, Dr Michael Beck, and Dr Herbert Matschinger, enters into more detail on the matter of social distance and its determinants (45). The paper examines whether labelling and beliefs about the causes and prognosis of schizophrenia are at the root of the social distance that most people seem to express regarding those who suffer from this mental condition. Findings presented in this paper reinforce the hypothesis that perceiving the mentally ill as dangerous and unpredictable is the basis of most stigmatizing attitudes and is a major determinant of levels of social distance felt by many among the general public. Unfortunately, high levels of knowledge can coexist with high levels of prejudice and negative stereotypes. As pointed out in this paper, teaching the public the biological model of schizophrenia may increase knowledge of the state of the art of psychiatric research and improve mental health literacy, but it may not increase understanding of persons suffering from this disorder and may, rather, intensify social distance.

The lesson to be drawn from these papers is simple: helping persons with mental illness to limit the possibilities that they may become violent, via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence, could be the single most important way to combat the stigma that affects all those with mental illness. While most myths about mental illness can be traced to prejudice and ignorance of the condition, enlightened knowledge does not necessarily translate into less stigma unless both the tangible and symbolic threats that mental illness poses are also eradicated. This can only be done through better education of the public and of mental health service consumers about the facts of mental illness and violence, together with consistent and appropriate treatment to prevent violent reactions. Good medication management should also aim to decrease the visibility of symptoms among patients (that is, consumers) and to provide better public education programs on mental health promotion and prevention.

Conclusions

Successful treatment and community management of mental illness relies heavily on the involvement of many levels of government, social institutions, clinicians, caregivers, the public at large, consumers, and their families. Successful community reintegration of mental health patients and the acceptance of mental illness as an inescapable element of our social fabric can only be achieved by engaging the public in a true dialogue about the nature of mental illnesses, their devastating effects on individuals and communities, and the promise of better treatment and rehabilitation alternatives. An enlightened public, working in unison with professional associations and with lobby groups on behalf of persons with mental illness, can leverage national governments and health care organizations to provide equitable access to treatment and to develop legislation against discrimination. With these tools, communities can enter into a candid exchange of ideas about the causes of stigma and the consequences of stigmatizing attitudes in their midst. Only these concerted efforts will eventually dispel the stigma associated with mental illness.

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Author(s)

1. Professor and Head, Department of Psychiatry, Queen’s University, Kingston Ontario.

Address for correspondence: Dr J Arboleda-Flórez, Department of Psychiatry, Brock V, Room 546, Hotel Dieu Hospital, 166 Brock Street, Kingston ON K7L 5G2