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 the stigma around mental illness.
This page will give you an overview of stigma-related topics that have been covered on the MH@H blog, and it will point you towards further reading.
For more background information about stigma, as well as information about my newest book that will be released later in 2021, visit the page for A Brief History of Stigma.
Stop the Stigma – Page Outline
A Primer on Stigma
Stigma isn’t inherent in mental illness; rather, it comes from social beliefs about what’s considered “normal” and socially acceptable, and what kinds of identities are considered deviant. These deviant identities, like mental illness, are seen as encompassing the whole person.
There are three components to stigma:
- Stereotypes: Stereotypes are ideas that represent groups of people. We learn these early in life. When it comes to mental illness, stereotyped beliefs are rigidly applied to all members of that social group, as though we’re one homogeneous entity. The stereotype that mentally ill people are violent is particularly pervasive and damaging, and it’s regularly reinforced in the news and entertainment media.
- Prejudice: Prejudice refers to negative attitudes based on stereotypes. When faced with those stereotypes, someone who is prejudiced will experience negative thoughts and emotions. For example, the violence stereotype may trigger fear and a desire to avoid being around someone who has a mental illness.
- Discrimination: This refers to behaviours that result from prejudice that end up disadvantaging people with mental illness. An example of discrimination would be an employer choosing not to hire someone with a mental illness based on their prejudiced attitudes towards mental illness and the associated stereotypes.
Stigma occurs through a 4-step process:
- Distinguishing and labelling of human difference
- Linking those differences to stereotypes
- Separating “us” from “them,” making the person with mental illness Other
- Status loss and discrimination
Levels of Stigma
There are multiple levels on which stigma can occur:
- public stigma: public views and discrimination around mental illness
- structural stigma: this is entrenched in laws and policies in governments and other institutions, and often involves arbitrary distinctions based solely on membership in the broad group of people with mental illness.
- self-stigma: occurs when public stigma is internalized
- 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
The Self-Stigma Process
Sometimes stigma is internalized to become self-stigma.
This happens when stereotypes that are part of public stigma are seen as being valid. These stereotypes are then applied to the self. This has significant consequences, including devaluation of the self and behavioural changes related to a “why try” attitude.
Peer support can be a powerful way of combatting self-stigma.
Strategies to Stop the Stigma
This section has moved over to the book page for A Brief History of Stigma.
Language & Stigma
We choose our words based on our beliefs, not the other way around. Research has shown that language policing doesn’t tend to be effective; in fact, it can actually worsen stigma by triggering reactance, a form of psychological resistance. As satisfying as protesting word usage can be, if it’s not working to change the attitudes of the target audience, then it’s probably not the best strategy to be using (and people with mental illness should not be the target audience).
The Euphemism Treadmill is a fascinating way of looking at the way the “correct” language for a concept because tainted and is then replaced by new “correct” language that means essentially the same thing. It’s not the word that’s the problem; it’s negative attitudes toward what’s being named/described. As long as we’re continually having t come up with new and prettier words to talk about mental illness, it’s a sign that we’re missing the underlying attitudes that are driving the euphemism treadmill.
These MH@H posts have more on this topic:
- Is It Helpful to Sanitize Mental Illness?
- “Rules” for Talking About Mental Illness
- Stigma and Pathologizing Normal Human Experience
- What’s in a Name? Labelling and Mental Illness
Taking the Illness out of Mental Illness?
We all have mental health, ranging from poor to excellent, but only some of us have a mental illness. Yet, for some reason, this seems to be unclear, and even people with mental illnesses use them synonymously.
No one seems to have trouble differentiating physical health from physical illness, so I don’t know why the wheels fall off when you sub in the word mental. Perhaps it’s the euphemism treadmill and trying to prettify mental illness.
Mental health ≠ Mental illness
Person-First vs. Identity-First Language
Person-first language has become the “correct” way of talking about illness and disability; the idea is that an illness doesn’t define someone. However, not everyone identifies themselves that way.
If I talk about being female or brown-haired, it doesn’t mean that either of those defines the sum total of who I am. So why should it be any different if I identify as mentally ill?
If someone has a problem with me because I’m female, that’s probably because of misogyny rather than the word “female.” Likewise, if someone has a problem with me because I’m mentally ill, that has a lot more to do with the stereotypes in their minds rather than the fact that I say “mentally ill” instead of “person with a mental illness.”
Stereotypes are a kind of social knowledge structure that capture social knowledge and attitudes about members of a particular group. This becomes a problem when stereotypes are rigidly applied to all members of a group. There may be a grain of truth in some cases, but mental illness stereotypes do not accurately represent the population of people with a mental illness as a whole.
Common stereotypes about people with mental illness are that we are:
- Lacking control/willpower
- Weak character
- Responsible for causing our own illness
One of the most common, enduring, and damaging stereotypes about mental illness is that mentally ill people are chronically dangerous and violence-prone. This stereotype, which is regularly reinforced by the media, evokes fear, leading to discriminatory behaviours. No matter how attached to it people are, though, the stereotype is not accurate.
The following posts address this:
- Are “Psycho Killers” Psychotic? (most likely not)
- Psychotic Does Not Mean Violent
- Why Psychosis Scares People
- Stigma in the News: “Psychotic” Abuser: a news article uses “psychotic” as an adjective, apparently intending it to mean violent
In an article on the online magazine National Affairs, Manhattan Institute fellow Stephen Eide argued In Defense of Stigma. Among the points he made were that people with mental illness actually are violent, and people with schizophrenia are fundamentally different from everyone else. While off-the-cuff endorsement of such stereotypes isn’t that unusual, it’s a bit surreal to see someone writing an essay trying to justify it.
Mental health care and research have not kept up with the resources allocated to physical health. Adequately funding community mental health care could make a huge difference with better service levels and reduced spending on high-cost acute care over the longer term. By addressing this social disparity, people with mental illness can gain greater autonomy and improved prospects for recovery.
An oddity of the mental health care system in the US is they use the term behavioural health. How is mental illness a “behaviour” disorder? Does that manner of labelling actually reflect underlying structural stigma?
When those of us with mental illness seek care for physical health problems, there’s a very real risk that the health care provider could get caught up in diagnostic overshadowing. This means they’re so caught up in the psych diagnosis that they fail to realize that someone might be having a heart attack. That lack of recognition of a heart attack is a very real example; people with a psych diagnosis presenting to ER with heart attack symptoms are less likely to be accurately diagnosed and sent to the cardiac catheterization lab for treatment.
Serenity Integrated Mentoring was a program adopted by almost half of NHS Trusts in England. It involved pairing high emergency service users (mostly people with borderline PD and a history of sexual abuse) with a police “mentor.” Under SIM, patients could be refused emergency services, including at an A&E (ER) after a suicide attempt. A grassroots coalition of mental health service users and allies called StopSIM forced the NHS to stand up and take notice, in a remarkable example of the impact people with mental illness can have when they come together.
Mental health professionals may use labels like:
- “Attention-seeking” is a bad thing, while “help-seeking” is a good thing
- “Drug-seeking” is a bad thing, while “medication compliance” is a good thing
- If you’re a “difficult patient,” you may be labelled a “borderline”
- If you have borderline personality disorder, you’ll probably get labelled as manipulative
These posts on stigma and health care are based on my own and others’ experiences:
- Adventures in Stigma in the ER
- “It’s all in your head”
- Just a Psych Patient? – Stigma in the ER
- My Negative Experiences of Psychiatric Treatment
- The Problem with Involuntary Psychiatric Treatment
Resources for challenging stigma in health care
- Parity Track (US): works to ensure access to behavioural health treatment
- SharedHumanity online anti-stigma modules for health care providers and patients
- The Kennedy Forum: Parity Registry and Don’t Deny Me campaign supporting parity in mental health and physical health insurance coverage in the US
- Understanding Stigma: free online course for health professionals from the Mental Health Commission of Canada and Centre for Addiction and Mental Health
The case for investment in mental health care:
- Australian National Mental Health Commission: The economic case for investing in mental health prevention: Summary
- Centre for Mental Health (UK): Mental health promotion and mental illness prevention: The economic case
- Mental Health Commission of Canada:
- World Health Organization: Investing in Mental Health: Evidence for Action
Health Professions Legislation
Health professionals who have a mental illness may face licensing hurdles that someone with a physical illness wouldn’t have to deal with. I live in British Columbia, Canada, where provincial the Health Professions Act requires hospitals to report any regulated health professional who is hospitalized for psychiatric reasons. This has nothing to do with a determination that a specific individual poses a risk to the public; it’s simply whether someone has a physical condition (e.g. brain tumour) or mental condition (e.g. depression). That kind of arbitrary difference is one of the fundamental characteristics.
You can read more about this issue in these posts:
- Legislated Stigma
- The Health Professions Act and the Fight Against Stigma
- Open Letter to BC’s Minister of Mental Health and Addictions
Law Enforcement & Corrections
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 later stepping on her head. Compounding the problem, a local newspaper headline said she was “arrested” by police, when, in fact, she was apprehended under the Mental Health Act and taken to hospital.
Retraumatization and Another Police Wellness Check Gone Wrong tells another story of a wellness check that went south when police entered the wrong home, retraumatizing residents who had already been traumatized by police.
Defunding the Police questions why police are the de facto emergency mental health service rather than having it dealt with as a health issue by health services.
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. I addressed a stigmatized comment on that post in That’s Stigma.
The documentary Alien Boy examines the police brutality that resulted in the death of a man with schizophrenia.
People with mental illness are over-represented in jails and prisons. This phenomenon has developed since deinstitutionalization beginning in the 1960s dumped large numbers of people out of psychiatric hospitals without adequate community supports. This has been referred to as transinstitutionalization.
The term “criminalization of mental illness” has also been used to describe people with serious mental illness getting caught up in the criminal justice system for minor nuisance offenses that could better be addressed by mental health treatment and better social supports, including housing.
For more information on this issue:
- Mental Health America position statements:
- Mental Health Commission of Canada: Who Experiences Mental Health Problems in the Criminal Justice System?
Other Areas of Structural Stigma
In 1991, the United Nations General Assembly adopted a set of principles for the protection of humans rights of people with mental illness. Talk is good, but action is what matters.
- Disclosing Mental Illness at Work: the good, the bad, and the ugly
- Employer discrimination
- Job interviews: the unique challenges with mental illness
Various organizations have put together business cases for investing in workplace mental health, including:
- American Heart Association CEO Roundtable: Mental Health: A Workforce Crisis
- Center for Workplace Mental Health: Making the Business Case
- Deloitte UK: Mental health and employers: Refreshing the case for investment
- Mental Health Commission of Canada: A Clear Business Case for Hiring Aspiring Workers
- Mental Health First Aid England: 10 Reasons Every Employer Should Invest in Staff Mental Health
The Mental Health Resource Directory has links to other workplace mental health resources, including accommodations for mental illness-related disabilities.
- NIMBYism and Mental Health Housing
- We All Deserve a Roof Over Our Heads, yet people with mental illness are at increased risk of homelessness. Hospitals may discharge patients from a psychiatric ward to an emergency shelter because there’s nowhere else to go.
In some rather surprising statistics from 2008, 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. Those numbers seem incredibly high for not all that long ago.
In some cultures, mental illness is believed to come from God or demons/evil spirits. Attempts to manage the illness are religious rather than medical in nature. People may be chained to trees for years at a time.
Narcissistic personality disorder and the associated narcissistic abuse phenomenon in pop culture are interesting exceptions to the push to speak more positively about mental illness. Armchair diagnosis is embraced, along with language that would be considered stigmatized and cringeworthy if one were to substitute in the name of any other diagnosis. Emotional abuse is obviously a bad thing, but dragging an illness diagnosis through the mud seems like a slippery slope.
Sometimes, the nonsense people come out with online is so absurd that it’s hard to tell whether to be offended or just laugh at the stupidity of it.
- Gems of ignorance from Quora: Quora.com is a hotbed of ignorance to begin with, and some of the questions (and answers) posted there absolutely reek of stigma.
- Willful Ignorance and Stigma: Speaking of ignorance, these gems come from Debate.org
The COVID-19 pandemic has brought mental health to the forefront, with governments and organizations putting out messaging around the importance of supporting one’s mental health. But will it bring about any change in stigma once the restrictions are over?
The media can play a major role in perpetuating stereotypes, especially the mentally ill = violent stereotype.
- Homelessness & Addiction: A Newspaper Embraces Stigma looks at a newspaper editorial that expressed negative views towards homeless people experiencing addictions
- Stigma in the News: “Psychotic” Abuser looks at a news story that used psychotic as a synonym for violent
Several organizations have put together media reporting guidelines to support responsible reporting related to mental illness, including:
- Canadian Journalism Forum on Violence and Trauma: Mindset: Reporting on Mental Health
- Mind (UK)
- Mindframe (Australian)
- Mindset: Reporting on Mental Health (Canadian)
- TEAM Up Style Guide (US)
Stigma in Film
- A Prescription for Murder is a documentary that blames psychiatric medication for James Holmes’ 2012 mass shooting in Aurora, Colorado.
- Letters from Generation Rx is a documentary that argues psychiatric medications turn people into killers.
- Take Your Pills is a Netflix documentary that 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.
Responding to Stigma
Ignorance and stigma seem to be all around us, so how best to respond? I would recommend not wasting your energy on people who are clearly ignorant by choice, as they’re likely to just feed off of your reaction. You’re more like to see positive results focusing on people who are ignorant through lack of information or perspective.
The following posts explore this further:
- How Do You Respond to Stigmatized Language?
- Should You Challenge Ignorance on Social Media?
- There’s Nothing Weak About PTSD – see how a former British Army sniper responds to being told he’s a pussy for having PTSD and just trying to get sympathy by talking about it
Stop the Stigma – Further Reading
- A Series of Unfortunate Stereotypes by Lucy Nichol
- No One Cares About Crazy People by Ron Powers
- Nobody’s Normal by Roy Richard Grinker
- The Stigma Effect by Patrick Corrigan
- Written Off by Philip T. Yanos
TED Talks on Stigma
In this talk, Sangu Delle addresses the stigma faced by African men experiencing mental health problems. He shares the results of a Nigerian study, in which 34% thought mental illness was due to drug use, 19% thought divine wrath was the cause, and 12% blamed witchcraft. Sounds like there’s a lot of work to be done!
This powerful talk by Max Silverman speaks to the ways in which mental illness is treated differently than mental illness.
In this passionate, high-energy talk, Ruby Wax uses humour to address common stereotypes and misconceptions about mental illness.
Together we have the power to stop the stigma!