Mental illness may be difficult to live with, but the associated stigma can be even more challenging. It’s time to let the light in to shine on those of us working hard every day to make the most of the hand that mental illness has dealt us. We all have the power to be stigma warriors. It’s time to come together to stop stigma.
Stop Stigma – Page Outline
What Is Stigma?
In the 1960s, sociologist Erving Goffman observed that stigma is not inherent in mental illness; rather, it comes from the associated social response to it. The degree of social distance from the individual has a greater impact than any direct effect of the illness.
Researcher Patrick Corrigan describes stigma as encompassing both prejudiced attitudes and discriminatory actions that can result.
In a paper published in Annual Review of Sociology, Link and Phelan described mental illness stigma as a 4-step process driven by differentials in power.
- Distinguishing and labelling of human difference
- Association of those differences with negative attributes that are linked to stereotypes, which often occurs automatically
- Separating “us” from “them,” thus othering the person with mental illness
- Status loss and discrimination experienced by the person with mental illness; this discrimination may be individual or structural (built into institutions like governments, schools, and employers)
Stigma can occur on multiple different levels:
- individual level
- structural stigma: entrenched in laws and in institutions
- public stigma: public views and discrimination around mental illness
- self-stigma: occurs when public stigma is internalized
- label avoidance: perceived and individual level stigma related to a particular illness leads to attempts to avoid having that label attached to oneself
- feared vs. experienced: even if prejudice and discrimination aren’t presently occurring, the expectation that they’re likely to occur and the hypervigilance that results are also very damaging
There’s more info in a post on internalizing stigma. Connecting with others within the mental illness community can be an important way of combatting self-stigma.
Strategies to Stop Stigma
There are three broad approaches that tend to be used as part of stigma reduction campaigns. This info comes from Corrigan & Shapiro (2010).
Protest strategies call out stereotypes and discrimination, and call on people to address the injustices identified. However, they can potentially trigger psychological resistance, leading to the opposite of the intended effect.
Education about mental illness can provide corrective information to counteract stereotypes. These types of strategies can be done on a large scale and are relatively low-cost to implement. However, this approach makes the assumption that lack of information is the cause of stigma, which isn’t necessarily the case.
Contact with people who have a mental illness is the most effective way to decrease stigma. Specifically, it’s most effective when the contact involves:
- equal social status
- one-on-one contact
- engaging together in a rewarding activity
- interactions that moderately disconfirm stereotypes (but the person is still “convincing” as someone who has a mental illness)
It explores what research tells us about stigma and how it can most effectively be challenged. Surprisingly, education campaigns don’t work as well as you might think, nor do pushes for language change.
Raise Your Voice to Stop Stigma
In order to stop stigma, we need to speak up. Research has shown that the most effective way to fight stigma is for those of us with mental illness to come out loud and proud. Contact with regular people with mental illness is the most effective way to bring about change in people’s stigmatized attitudes.
What Does It Mean to Be a Mental Health Advocate? It means you raise your voice in whatever way you safely can.
These are just a few of the organizations doing some amazing work to stop stigma by promoting dialogue around mental health and stigma on a broader scale. On their sites, you can read the stories of others living with mental illness, plus you can get involved in their awareness initiatives.
You can also check out the anti-stigma pledges on these sites, which you can share across your social channels:
- b stigma-free pledge
- Join the Conversation pledge to end stigma
- Make It OK pledge to erase stigma
- National Alliance on Mental Illness (NAMI) StigmaFree pledge
- Stamp Out Stigma pledge to recognize, reeducate, and reduce stigma
Sometimes, the problem with anti-stigma campaigns isn’t what they’re talking about, but what they don’t talk about. What if the Elephant in the Room Could Speak? was a piece I wrote on Bell Let’s Talk Day looking at the kind of things that don’t make it into the conversation.
Want to share your mental health story? Ways to share your mental health story contains links to major mental health sites where you can submit stories.
I also welcome guest posts from new mental health bloggers as part of the Emerging Blogger series. The Wounded Healers interview series showcases people with mental illness who work in helping fields.
Responding to stigma
Ignorance and stigma seem to be all around us, so how best to respond? Should you challenge is, or is it sometimes better to just ignore it?
The posts How Do You Respond to Stigmatized Language? and Should You Challenge or Ignore Ignorance on Social Media? talk more about that.
My personal choice is most often to focus on people who are ignorant due to lack of corrective information and ignore people who are clearly ignorant by their own choosing. It can be very easy to expend a lot of cognitive and emotional energy trying to convince someone who has no interest in being convinced.
Language and Stigma
One thing that’s important to keep in mind if we start telling people how to talk about mental illness is that it’s not helpful to sanitize language so much that it no longer reflects the challenging reality of mental illness.
There’s more on this topic in What’s in a Name? Labelling and Mental Illness.
Language that minimizes
Using mental illness for everyday difficulties ends up pathologizing normal experience and/or minimizing the experience of mental illness. The documentary The Age of Anxiety gives a disturbing example of people who believe that almost everyone meets the criteria for an anxiety disorder.
Then you’ve got the language like “she’s so bipolar” and “I’m a little OCD” and “everyone’s a little ADHD.” The words themselves are not the problem per se; rather, it’s a conceptualization of those words as referring to normal human experience. It’s sort of like putting the sniffles and pneumonia on the same level.
A related issue is that the notion of mental illness is sometimes sanitized. Attempts to counter stigmatized stereotypes sometimes go too far in the opposite direction, and send the message that mental illness isn’t actually so bad. The problem with either extreme is that they leave out the multitude of people with mental illness who fall somewhere in the middle.
Person-first vs. illness-first language
Person-first: He has bipolar disorder.
Illness-first: He is bipolar.
We’re “supposed to” use person-first language, with the idea being that an illness doesn’t define someone. The thing is, though, there are a fair number of people who use illness-first language with respect to themselves. This seems to be particularly common among people with bipolar disorder.
My approach is it’s best to let people identify themselves; we shouldn’t be trying to do it for them. A good bet is to use person-first language with someone until you know how they self-identify. And when in doubt, ask.
How we talk about ourselves
Sometimes we’re faced with “Rules” for Talking About Mental Illness that not only try to tell “normal” people how to talk about us, but they also try to tell us how to talk about ourselves.
“Mentally ill” isn’t okay. “Suffering from” mental illness isn’t okay.
One of the role identities many of us play is person receiving mental health treatment, but there isn’t universally accepted language around that.
Personally, I like “patient.” That doesn’t mean it’s my sole identity, nor does it mean that I take a doctor-knows-best approach; that’s just the word I use for my role in relation to my doctor.
I really dislike the term “consumer”, because to me it implies an economically-focused relationship. But we’ve each got our own preferences.
How others talk about us
A 1998 article in The Bell newsletter called People First Language Matters of the National Mental Health Association has been cited by several more recent sources, and while I couldn’t locate the original, its recommendations are included on the Dave Nee Foundation site. I take issue with a number of them.
Recommendation: Instead of calling someone a patient, say “She is a person who receives help/treatment for mental health or substance use problem or a psychiatric disability.”
My reaction: This is all kinds of unwieldy, which makes it rather unlikely that anyone will use this suggested language.
Recommendation: Instead of “She is mentally ill/emotionally disturbed/ psycho/insane/lunatic”, say “She has a mental health problem or challenge” or “She is a person with lived experience of a mental health condition.”
My reaction: This bugs me on many levels. Lumping all of those “instead of” terms together is absurd. Saying someone is mentally ill is on a whole other planet from calling them a psycho. Why on earth can’t we just come out and say “mental illness”? If we’re expected to use euphemisms like mental health problem/challenge/condition, because the reality of mental illness is just too scary, that fuels stigma by suggesting the reality of mental illness shouldn’t be talked about.
Recommendation: Instead of saying someone is psychotic, say “He experiences symptoms of psychosis” or “He hears voices.”
My reaction: This just feels nitpicky to me. By this same logic, we shouldn’t say that someone “is depressed” or “is manic.” Personally, I’m far more concerned with people minimizing these terms by applying them casually to “normal” people who aren’t ill.
Recommendation: Instead of “He is autistic”, say “He has autism.”
My reaction: The debate around this kind of language seems to more spirited in the autism community than the mental illness community. Advocates for identity-first language argue that autism is part of who they are, not something that they “have”.
Recommendation: Instead of “Suffering with, or a victim of, a mental illness”, say “Experiencing, or being treated for, or has a diagnosis of, or a history of, mental illness.”
My reaction: Victim is a charged word that people often have strong feelings about. But suffering? I feel pretty confident in saying that everyone with a mental illness has suffered at some point to some degree because of their illness. That’s part of what makes it an illness rather than normal human experience.
Personally, I’d rather see the focus be on understanding the underlying issues rather than trying to spoon-feed unnatural language to people.
Mental health ≠ mental illness
We all have mental health, but only some of us have mental illness. Yet for some reason, this seems to be unclear.
I often see people using mental health synonymously with mental illness – even people with a mental illness. No one seems to have trouble differentiating physical health from physical illness, so I truly have no idea why the wheels fall off when you sub in the word mental.
Mental health, just like physical health, is a dimension of health we all have, and it can range from poor to excellent. Mental illness, like physical illness, is a pathological condition that impairs the health of certain individuals.
Psycho. Schizo. Lunatic. Mad. Crazy. There are plenty of derogatory terms out there that get applied to people with mental illness. Most of us use at least some of these terms. A personal favourite is “batshit crazy”, which I use regularly, but I’m fairly sure I’ve never used to refer to someone with a mental illness.
These terms aren’t going anywhere. They’re pervasive, and they’re learned early. A study by Rose and colleagues identified 250 stigmatizing terms used by 14-year-old students in England to describe people with mental illness.
If the terms are going to remain in use anyway, perhaps there’s something to be said for trying to reclaim them, and stop stigma that way. Reappropriation of language can be an empowering process, and examples can be seen within the LGBTQ+ community.
Suicide & Stigma
Did you know suicide is still illegal in some countries? It dates back to the Middle Ages, when the beliefs of the Catholic Church, and in particular St. Thomas Aquinas, we incorporated into British common law. There’s more in the post Where Is Attempting Suicide Illegal?
Public Views on Suicide describes the findings of an Australian study using the Stigma of Suicide Scale. The most common stigmatized responses were “punishing others,” “selfish,” “hurtful,” “reckless,” and “weak”; all of these were endorsed by at least 25% of participants.
Stigma was also apparent in people’s responses who jumped or fell from the World Trade Center towers on 9/11. This was not suicide in the sense that they wanted to die; they didn’t have a choice about dying. The stigma still applied, though, with public officials sweeping it under the rug and public backlash to newspapers who printed The Falling Man photo.
While it’s important to be mindful of how we talk about suicide, the stigma that exists around suicide is there no matter what words people choose to use. That stigma isn’t going to go away by getting demanding about language.
This is explored further in Is “Committed Suicide” Worth Making an Issue Out Of?
An older post, How Picky Should We Be About Suicide-Related Language? considers other terminology as well.
More Stop Stigma Posts on MH@H
These posts on Mental Health @ Home focus on the issue of stigma. To see what some other advocates have to say about stigma, check out the URevolution article 22 On-Point Quotes about Mental Illness Stigma, in which I was quoted.
- Attitudes About Mental Illness That Make You Go Hmm…: This post looks at a discussion paper from an anti-stigma researcher that seems to buy into some stereotypes about mental illness.
- Surprising Mental Illness Statistics : In a 2008 study, 55% of Canadians said they would be unlikely to marry someone with a mental illness, 46% saw mental illness as an excuse for bad behaviour, and 27% would be afraid to be around someone who was mentally ill.
- TED Talks on Stigma: These are some of my TED Talk favourites that address mental illness stigma.
- Why is Netflix Jumping Aboard the Stigma Train?: The documentary Take Your Pills offers a very skewed look at the stimulant medications used to treat ADHD, suggesting that they’re basically the same as crystal meth and they’re mostly misused.
Sadly, there are still people who believe that mental illness increases the risk of becoming violent. This is especially apparent when politicians blame gun violence on mental illness. The reality is that people with mental illness are no more likely than anyone else to become violent, and are actually at increased risk of being victims of violence.
Perhaps more than any other type of mental illness, psychotic illnesses trigger fear and activation of stereotypes, and in particular, stereotypes related to violence.
People also blame psychiatric medications for all kinds of things. Dead If You Do, Dead if You Don’t? addresses the reality of weighing risks vs. benefits of taking medications compared to what’s portrayed in the documentary Letters from Generation Rx. Prescription for Murder was another documentary, and it blamed psychiatric medication for murder.
People do all kinds of terrible things, but that doesn’t mean they’re mentally ill, even if it seems like they “must” have a mental illness to commit such horrible acts. There’s more on this in the posts Are “Psycho Killers” Psychotic? and Should You Blame Mental Illness for Bad Behaviour?
Stigma in Context
To stop stigma entirely means that we need to address it in all of the different contexts where it occurs.
Disclosing Mental Illness at Work talks about the good, the bad, and the ugly that can result from opening up; I’ve experienced all three since I chose to be open about my illness. My choice has always been to disclose, mostly because circumstances haven’t allowed for much choice in the matter. There are pros and cons either way, and what’s right for each individual will depend on a number of factors.
Employer discrimination against people with mental illness is illegal, but unfortunately, that doesn’t stop it from happening.
One would hope that at least the realm of health care would be stigma-free, but sadly, that’s not the case. It’s one area where I think it’s truly essential to stop stigma.
The history of mental health “care” is rather frightening. Early Insane Asylums – Bedlam and Beyond addresses the infamous Bedlam institution in London, complete with some rather disturbing sketches of restraints.
I’ve reviewed the book No One Cares About Crazy People, which gives a compelling account of how the system failed not only the writer’s son, but also centuries worth of people with mental illness
Care for physical health
People with mental illness are far too likely to have our physical health concerns dismissed as being a result of the mental illness. Adventures in Stigma in the ER recounts two experiences in the emergency department in which I experienced just that, while “It’s all in your head” is as real as it gets looks at how concerns may be dismissed as “just” anxiety.
Care for mental health
Behavioural Health? is often used in the U.S. to refer to both mental illness and substance use disorders. My question, though, is how is any of that a “behaviour” disorder? Is labelling it that way actually a reflection of stigma?
The labels “Drug-seeking” and “Attention-seeking” are sometimes applied to people with mental illness by health care professionals, but they really just demonstrate the prejudiced attitudes of the people applying the labels.
Borderline Personality Disorder: Are the helpers actually hurting? looks at the considerable stigma among mental health care providers when it comes to patients with BPD.
God Knows Where I Am: Death by Mental Illness comments on the documentary God Knows Where I am, which tells the story of a woman with bipolar disorder who was released from hospital in the middle of winter with no where to go. She subsequently died by starvation after the health care system utterly failed her.
Health professions legislation
Legislated Stigma tells my story of experiencing stigma as a result of health professions legislation in my province. This legislation requires hospitals to report any regulated health professional hospitalized for psychiatric reasons to the appropriate regulatory body. The nursing regulator gave me the non-choice of voluntarily giving up my practicing registered nurse license or having it taken away from me.
The Health Professions Act and the Fight Against Stigma includes an email message I sent to my provincial Minister of Health speaking up against the stigma enshrined in that piece of legislation. An Open Letter to BC’s Minister of Mental Health and Addictions follows up on the same issue a year later.
NIMBYism and Mental Health Housing – Not-in-my-backyard attitudes that lead people to protest against new mental health housing developments in their neighbourhoods are just another form of stigma.
We All Deserve a Roof Over Our Heads, yet people with mental illness are at increased risk of homelessness. People may even be discharged from a psychiatric ward to an emergency shelter because there’s nowhere else to go.
Police and Mental Illness
Alienation and Brutality looks at the documentary Alien Boy and the police brutality that killed a man with schizophrenia.
A Police “Wellness Check”/”Arrest” Gone Wrong looks at how a police “wellness check” on nursing student Mona Wang turned into a police officer dragging her along the floor while semi-conscious and in handcuffs, and stepping on her head. To compound the problem, the local newspaper described how she was “arrested” by police, when in fact she was apprehended under the Mental Health Act and taken to hospital.
Defunding the Police: What It Could Mean for Mental Illness questions why police are the de facto emergency mental health service rather than having it dealt with as a health issue by health serviecs.
Should People in Mental Health Crisis Be Handcuffed? was written after my encounter while working as a nurse with a local police force that, as standard practice, handcuffs anyone being taken to hospital because of a mental health crisis.
There’s a Name For That — It’s Stigma was written in response to a comment I received regarding police handcuffing those with mental illness.