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.
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.
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
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
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
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
|Table 1 The origins of stigmaa
Functional impetus: initial perception of tangible or symbolic
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
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
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
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
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.
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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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