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
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). The post How Can We Fight Stigma Most Effectively? explores this further, and is based on Patrick Corrigan’s excellent book The Stigma Effect.
Protest strategies call out stereotypes and discrimination, and call on people to address the injustices identified. However, they can potentially trigger psychological reactance, 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)
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.
Raise Your Voice
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.
In case you wondered What Does It Mean to Be a Mental Health Advocate, what it really means is raising your voice in whatever way you safely can. That can look quite different for different people.
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. On MH@H, I welcome guest posts from new mental health bloggers as part of the Emerging Blogger series. The Wounded Healer 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
Language matters, in the sense that language can cause harm. But the underlying problem is not as simple as changing words, because if the underlying attitudes stay the same, the effects of stigma will still be felt, regardless of the words. Personally, I’d rather see the focus be on understanding the underlying issues rather than trying to spoon-feed unnatural language to people.
Posts on this topic:
- “Rules” for Talking About Mental Illness
- Stigma and Pathologizing Normal Human Experience
- The Problem with Language Policing
- What’s in a Name? Labelling and Mental Illness.
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. The push for person-first seems to have been driven by mental health organizations rather than starting with a preference expressed by people with mental illness.
A 1998 article in the National Mental Health Association’s The Bell newsletter called People First Language Matters has been cited by several more recent sources, including the HuffPost and the Dave Nee Foundation site. It has several examples of the war on adjectives.
It raises concerns about saying people are bipolar or autistic, and additionally says that we shouldn’t say someone is psychotic; rather, we should say “He experiences symptoms of psychosis” or “He hears voices.” Is that level of nitpicking actually helpful?
Perhaps the best approach is to let people identify themselves; we shouldn’t be trying to do it for them.
Taking the illness out of mental illness?
We all have mental health, but only some of us have mental illness. Yet for some reason, this seems to be unclear, and even people with mental illnesses use them synonymously.
Yet 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.
Besides the people who seem to confuse mental health and mental illness, some advocates try to take the illness out of mental illness as much as possible. Some particularly zealous advocates will even try to tell people with mental illness what words we should use to describe ourselves.
We’re not supposed to say that someone is “suffering” from mental illness, but I think it’s pretty safe to say that if someone hasn’t suffered, then it’s not actually a mental illness.
We’re not supposed to talk about people being “mentally ill.” The newsletter article cited earlier says that instead of saying “She is mentally ill/emotionally disturbed/ psycho/insane/lunatic,” we should say “She has a mental health problem or challenge” or “She is a person with lived experience of a mental health condition.” Lumping “mentally ill” in with psycho and lunatic seems rather over the top.
If we’re expected to use euphemisms like mental health problem/challenge/condition, because the reality of mental illness is just too scary, I would argue that’s actually likely to fuel stigma by suggesting the reality of mental illness shouldn’t be talked about.
When we try to counter stereotypes by santitizing mental illness to make it more palatable for outsiders, and present only well people as the public face of illness, that leaves out all the people who aren’t so well. Just because a stereotype is bad doesn’t mean that going to the opposite extreme is helpful or representative. There are a whole load of people in between those extremes, and it’s really not serving anyone to brush them aside.
How do we talk about ourselves?
“Patient” is not a term that’s acceptable to the person-first language police. Various wordy and unwieldy alternatives have been identified, along with client, consumer, survivor, and assorted others.
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 it implies an economically-focused relationship, and using it as an across-the-board term defines us by the services we do or do not consume, which strikes m as odd. But we’ve each got our own preferences.
There are also plenty of derogatory terms, like psycho, schizo, lunatic, mad, and crazy. It seems unlikely that these terms 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 reduce the negative associations that way. Reappropriation of language can be an empowering process, and examples can be seen within the LGBTQ+ community.
Pop psychology phenomena
Pop psychology looks superficially like actual psychology, but without the science behind it. This can sometimes result in mental illness terminology being used in arbitrary ways. Narcissism and narcissistic abuse are hot topics currently, but if you were to talk about any other mental disorder that way, it starts to look a lot like stigma.
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?
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.
In some cultures, mental illness may be seen as coming from God, or caused by demons or evil spirits. Attempts to manage the illness are religious rather than medical in nature. People are sometimes chained to trees for years at a time. There’s more about this disturbing practice in the post Mentally Ill People In Chains – A Disturbing Reality.
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.