In Defense of… Stigma?

In defense of... stigma? - graphic of hand with dialogue bubble on the palm

I recently came across Manhattan Institute fellow Stephen Eide‘s 2020 article In Defense of Stigma in the online magazine National Affairs. It had some… odd… ideas about mental illness stigma, so I thought I would explore some of them. Okay, forget about exploring, I’m going to rant.

The basic argument in the paper is that stigma isn’t the cause of the challenges faced by people with mental illness, so focusing on it isn’t going to change anything. I think there’s a germ of a reasonable argument tucked away in there, but that wasn’t really where the author ended up going with it.

Serious mental illness

The author argued that not every mental illness belongs in the same conversation; instead, he differentiated between conditions he characterized as non-serious, such as anxiety disorders and OCD, and “serious mental illness.”

Serious mental illness (SMI), sometimes referred to as serious and persistent mental illness (SPMI), doesn’t make an appearance in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). It lacks a universally accepted definition, but generally refers to mood or psychotic disorders that cause significant functional impairment for a prolonged period of time. The concept is used most often with regards to mental health services, and it has no business being used to delineate whose illness counts and whose doesn’t.

Mentally ill = violent?

The author also argues that the research literature clearly shows that people with serious mental illness are violent. He references DJ Jaffe (a self-made mental health policy lobbyist, not a researcher), whose site Mental Illness Policy Org says right on its about page that people with untreated SMI are violent, so this is clearly not an impartial source. The large MacArthur Violence Risk Assessment Study would say not so fast when it comes to the violence connection; there’s an increase in risk only in very specific populations, including those with high levels of psychopathy, substance abuse, and command hallucinations to harm others.

Less than 1% of gun-related homicides per year in the US are due to mass shootings by mentally ill people (Knoll & Annas, 2016). We crazy folk are far too busy killing ourselves, accounting for the majority of gun deaths. Stephen Eide argued that there is a link between mass shootings and mental illness, adding “The view that mentally ill individuals suffering from paranoia are dangerous is widely accepted by the public.” If we’re going to talk stigma, yeah, stereotypes like that would be it.

There’s little, if any, indication that psychiatric diagnosis has predictive value when it comes to gun violence.  “The lack of prognostic specificity is in large part a matter of simple math. Psychiatric diagnosis is in and of itself not predictive of violence, and even the overwhelming majority of psychiatric patients who fit the profile of recent US mass shooters—gun-owning, angry, paranoid White men—do not commit crimes” (Metzl and MacLeish, 2015).

Responding to mass shootings

Eide wrote that when politicians feel forced to do something following mass shootings, “taking on stigma is one of the safest routes. The public official who fails to denounce stigma risks being accused of accommodating intolerance.”

I’m not sure what news he’s been listening to (presumably Fox News, given the Manhattan Institute link), but does anyone remember when Donald Trump said “Mental illness and hatred pulls the trigger, not the gun” ( after mass shootings in 2019?

Criminal justice system

When it comes to diversion programs that route people to mental illness treatment rather than the jail, Eide writes, “There is a contradiction in saying, on the one hand, that mental illness poses no threat whatsoever to society and, on the other hand, saying that someone under indictment deserves leniency for having committed a crime that can be attributed to a mental illness.”

Marginalized populations of all kinds end up disproportionately represented in the critical justice system; that doesn’t mean that crimes are directly caused by the characteristic that relates to the marginalization.

Accessing mental health services

Regarding the possibility that police officers aren’t using employer-provided mental health services due to fear of career repercussions, the author wrote, “But shouldn’t we want police-department supervisors to be informed about patrol officers’ psychiatric conditions?” Unless there’s an impairment that gets in the way of their ability to job their job safely, I would answer with a resounding hell no.

This is important for health professionals as well. Impairment is a problem. Having a diagnosis and receiving treatment do not mean that someone is automatically impaired. When professionals dealing with mental health issues are reluctant to seek treatment, they are more likely to become impaired.

Why don’t people access treatment?

The author writes that factors other than stigma are the primary reasons why some people with mental illness don’t access treatment. What’s particularly interesting there is that he doesn’t quote anyone with a mental illness or research that involved speaking to people with mental illness, and there’s no indication that he’s ever in his lifetime had an actual conversation with a real live crazy person, so perhaps he’s just offering his opinion?

He probably hasn’t heard the story of the Toronto-area man with bipolar who had to crawl out of the ER after ER staff blew off the pain that kept him from walking and blamed it on his bipolar disorder. More recently than Eide’s article was the NHS’s Serenity Intensive Mentoring program, which could involve sending someone to jail for showing up in the emergency department after a suicide attempt. The health care world isn’t exactly rolling out the welcome mat.

Mild mental illness is good?

As for people with “mild” mental illness, apparently, they’re not the government’s problem. What a bunch of pussies, right?

“Mental-health problems that affect otherwise-functional people, such as mild anxiety or obsessive-compulsive disorders among corporate strivers, or depression among artists and writers, might even enhance their functioning.” That’s remarkably ignorant, and it seems like further confirmation that he hasn’t ever spoken to anyone who has a mental illness.

Keep the crazies away

Another gem: “There is undeniable social benefit in stigmatizing erratic behavior in public places; few of us would enjoy living in a community where such behavior was encouraged and pervasive.” Perhaps he would also like to spend in his life in a suburb with white picket fences, white picket people, and not a soul with a disability. Grandma has Alzheimer’s? Not welcome. Grandpa has Parkinson’s? Far too erratic to be acceptable.

The author also argues for “humane discrimination,” and distinguishing between the rights and responsibilities of people who are and are not in possession of their reason. “Schizophrenic individuals are, by and large, not like you and me. Insisting that they are flies in the face of simple observation and all manner of raw data on rates of employment, income levels, and participation in government-benefit programs.”

Had it been 100 years ago, I can imagine he would have been enthusiastically jumping aboard the eugenics train. Sterilize them all! Or better yet, go with the Nazi approach and try to kill them all off. Humane discrimination, right?

So yeah, I’m not impressed. The author is a fellow at the Manhattan Institute, a conservative free-market think tank, and it appears that crazy folk and homeless folk are his targets of choice. Maybe I should start a think tank. The Crazy Institute has a nice ring to it.

Anyway, going back to the germ of a reasonable idea, do you think stigma should be a top priority for mental health advocacy efforts?


Book cover: A Brief History of Stigma by Ashley L. Peterson

My latest book, A Brief History of Stigma, looks at the nature of stigma, the contexts in which it occurs, and how to challenge it most effectively.

You can find it on Amazon and Google Play.

There’s more on stigma on Mental Health @ Home’s Stop the Stigma page.

34 thoughts on “In Defense of… Stigma?”

  1. This is an outstanding example of someone who should NOT have been writing a book on the subject they decided to write about.

  2. It is attitude like this fellow has that keeps the progress of mental health from moving forward.
    I am glad he wasn’t around one of my family member who suffered with schizophrenia. On meds the family member was fine Off the meds and it was total chaos.
    My beef is with media that also lends to this type of attitude.

  3. Should stigma be a priority of mental health advocates? I suppose so, yes, but keep the drug manufacturers and populations of people who benefit from medication compliance, out of the plan! The whole mental health discussion can go in different directions quite quickly, I see. Let’s not allow people like this author airtime simply because he has it out for people like us. Qualify the sob to write about things he has more experience with, which his experience here is skewed.

      1. Yeah, it’s BS that people like the author get to air their thoughts, because someone who doesn’t know much about the topic, could be reading and formulating biases based on said author’s write up. I guess responsible journalism is Jared to comment by!

        1. It was published in a magazine rather than a newspaper or news site, so I think it’s an essay from a think tank policy wonk rather than a piece of journalism.

  4. Thank you for outlining this topic with such care and insight Ashleyleia. I’m appalled by such articles when people writing about the stigma have no business doing so. Geez. I’m all for better police training too. Recently I was pulled over by a motorcycle cop on my bike, threatened and shamed because I was “making stupid faces”. I didn’t say a word but yes, was in shock of his belligerent treatment of me. We all have off days and this was his, I could tell from the posturing he had the moment I was pulled over. The old me would have cried, attempted to defend myself or worse. High anxiety situations like that used to trigger dissociation quickly. This time I listened and once I was told I could leave promptly filed a report online with the sheriff’s department.

      1. Yes, I used it as an opportunity to see my own growth and celebrate how much I have healed. The entire time I was thinking, “Don’t you need a hug sir” he felt really worn out and angry to begun with and took the opportunity to take it out on me. People who’s job it is to protect and care for our communities need to understand their communities more, be more kind and empathetic. They need to be held to a higher standard. We’re all in this thing together, right my friend? Geesh😊

  5. It’s the whole mass shooters must have mental health issues that really infuriate me. Yes I’m sure some do or have but i don’t think it’s the deciding factor when choosing to kill people. I’m sitting here thinking how do i phrase this. It’s like saying a parent that beats their child to the point of abuse has mental illness. What they have is trauma of their own that they don’t recognize to do better. It they have a bad judgements call that is human and they “lose control” it doesn’t mean it’s a mental illness. I hope that made sense

  6. A justified rant in my opinion! People who think like that make my flesh crawl. I agree that fighting stigma is super important because it’s the primary barrier impacting someone’s likelihood of getting help. Fighting stigma saves lives. And please email me an application to The Crazy Institute!

  7. I haven’t clicked on the links within your post so apologies if this has been answered. How is the % of mass shooters with mental illness actually determined? I imagine that not all shooters with mental illness are diagnosed or being treated for mental illness before the shooting (although maybe I am wrong), so is it based on assessments done after the shooting? What about shooters who kill themselves or are killed by police following the mass shooting? Sorry for being so macabre; I’m just struggling to understand how this is assessed while being too lazy to actually read the article you linked to.

    Anyway, I wonder if the author was aiming more for “the benefits of institutionalization” and just missed it entirely by using the word “stigma” instead? I’m being charitable (as institutionalization is definitely not a universally wonderful solution and is rife with its own difficult history) because again I didn’t read the original article. In any case, I would say that the problem isn’t stigma, but lack of the right help for mental health conditions.

    1. Most mass shooters are killed, either by themselves or by police, during the incident, so the only way to attempt to put the pieces together is to hunt down their health records. It’s far from an exact science, and more about guesswork. Plus it doesn’t happen often enough, statistically speaking, to come up with any real pattern.

      I think the author was pro-institutionalization, not because it would be good for the crazy people, but because it would be good to keep the crazy folk away from the public.

      The lack of the right help can also be influenced by stigma, in terms of lower funding for mental health services and research and stigma among health professionals that deters people from seeking help.

  8. Nick Pipitone

    Holy crap! This guy sounds like a total asshole! If anything, it sounds like his “think piece” was just a seminar on what mental illness stigma looks and sounds like.

    1. I’ve never really been entirely sure what a think tank involved, but it’s probably just a bunch of people sitting around writing about things they think they know about, without doing any research for front line work to actually know what they’re talking about.

  9. The stigma surrounding mental illness is a massive issue and definitely one that needs to be addressed. I just have no idea how to go about it. Half the people don’t even know they are discriminating. And would educating people make a difference? That would imply that ignorance is the problem and I’m not sure that’s true!
    I almost died because of the stigma. I was taken to hospital by a friend after overdosing. I was neglected for over 5hrs because I was just another pill popping mental patient. Luckily for me somebody noticed me unresponsive still in the waiting room. I was close to death, I ended up in the ICU. Stigma almost killed me.
    People with mental illnesses are assumed to be dangerous, uneducated, untrustworthy, unworthy of medical care and generally just sub human. I’m still in shock at how I am treated after 20 years of public service, dealing with criminals daily. In that whole time I never failed to see them as human beings, yet medical professionals can neglect an ill patient in their time of need. When they are at their most vulnerable and in need of help. Too unacceptable for words really!

    1. I’m so sorry you had such a horrible experience. Stigma really is unacceptable, and I agree, educating people likely isn’t enough. But I think telling our stories and refusing to be silent can help to replace stereotypes with real human faces.

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