Stop the Stigma

Mental illness: Stop the stigma - graphic of face and megaphone with the words "speak up"

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.

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

To learn more about stigma, check out my latest book, A Brief History of Stigma. It explores the nature of stigma, the contexts in which it occurs, and how we can most effectively challenge it.

You can find it on Amazon and Google Play.

Stop the Stigma – Page Outline

While this page includes links to featured blog posts, you can find all of the posts on MH@H related to stigma here.

Suicide is the target of a great deal of stigma, with selfishness being a prominent theme. There’s more on this on the Straight Talk on Suicide page.

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:

  1. Distinguishing and labelling of human difference
  2. Linking those differences to stereotypes
  3. Separating “us” from “them,” making the person with mental illness Other
  4. 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
Corrigan and Rao's model for the process of how self-stigma happens

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.


How do we fight stigma most effectively? Education? Contact? Language change? Protest?

Strategies to Stop the Stigma

Three broad approaches are often used as part of stigma reduction campaigns. These are explored further in the post on fighting stigma most effectively, which is based on Patrick Corrigan’s excellent book The Stigma Effect.

Protest

Protest strategies point out stereotypes and discrimination and call on people to address the injustices identified. However, they may end up triggering reactance, a form of psychological resistance that arises from a sense that one’s freedom is threatened. This actually tends to promote the opposite of the intended effect, with people doing the opposite of what’s being asked in order to exert their freedom.

Education

Education about mental illness can provide corrective information to counteract stereotypes. Awareness campaigns also aim to increase public knowledge. These types of strategies can be done on a large scale and are relatively low-cost to implement. However, this approach assumes that lack of information is the cause of stigma, which isn’t necessarily the case.

Contact

Contact with people who have a mental illness is the most effective way to decrease stigma. Specifically, it’s most effective when that 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)

Anti-Stigma Organizations

These are just a few of the organizations working to promote dialogue around mental health and stigma on a broader scale. On their sites, you can get involved with their campaigns and read the stories of others living with mental illness.


Legislative & Policy Advocacy

Whether you like politics or not, what governments do can have a big impact on the lives of people with mental illness. That means we need to make sure that they hear our voices. Getting in touch with your local elected officials is one way of getting active; you can also jump on board with the efforts of mental health organizations lobbying for positive changes.

You may be interested in getting involved with these organizations’ advocacy efforts:


Advocacy Campaign Resources

WEGO Health’s Patient Leader Network has supports for health advocates, including networking opportunities and advocacy training. I invite you to join me there!

These sites also have information to support you in your advocacy work:

The Advocacy 101 video below is from the AFSP (American Foundation for Suicide Prevention).


Raise Your Voice

In order to stop the stigma around mental illness, we need to speak up and show that we are not the stereotypes that people try to force onto us. Coming out as having a mental illness, and sharing both the challenges and obstacles overcome, is a powerful way of demonstrating to the world what mental illness actually looks like without the stereotypes.

Tips & Tools:


Media

Speaking with the media is another option for getting the word out. The University of Kansas Community Toolbox has tips on media advocacy, and the Berkeley Media Studies Group has resources for Getting Started with Media Advocacy.

In the UK, the charity Mind has media volunteer opportunities.

The US site HARO (Help A Reporter Out) connects journalists with sources. You can sign up for their email list and keep an eye out for journalists looking to speak to people about mental health issues. The Twitter hashtag #journorequest is another way to connect with journalists looking for sources.

In Australia, SANE’s Stigma Watch program monitors and responds to inappropriate media reporting on mental illness. You can let them know if you come across something concerning.


Speaking

Public speaking isn’t everyone’s cup of tea, but it can be a powerful way of sharing your story. Check with your local mental health charities to find out about speaking opportunities in your area. These national charities offer speaking opportunities:


Ways to share your mental health story

Writing

The post Ways to share your story contains links to mental health sites where you can submit stories.


Language and mental illness 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 are the wrong 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:


Taking the Illness out of Mental Illness?

Contrasting mental health and 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, some people 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. It seems to be an attempt to prettify mental illness.

Mental health ≠ Mental illness


Person-First vs. Identity-First Language

The word police: person first language

Person-first language has become the “correct” way of talking about illness and disability. This involves using nouns (e.g. “I have a mental illness” or “I am a person with depression”) rather than adjectives (e.g. “I am mentally ill” or “I am depressed”). The idea is that identity-first language using adjectives implies that the person is nothing but the adjectives.

However, not everyone identifies themselves using person-first language.

Where I really see a weakness in person-first language is that we use identity-first adjectives to describe positive and neutral characteristics. I am intelligent, educated, brown-haired, female, Canadian, and mentally ill, but the only one of those I’m not supposed to say is the last one.

If someone assumes that being mentally ill defines me as a person, that’s not a matter of grammar, because you wouldn’t assume the same thing with “brown-haired.” It’s the nature of stigma that deviant identities are seen as all-consuming. 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.” Changing the wording just avoids the underlying issue.


Stereotypes

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:

  • Dangerous
  • Unpredictable
  • Untrustworthy
  • Unreliable
  • Lacking control/willpower
  • Weak character
  • Responsible for causing our own illness
  • Incompetent

While stigma and stereotypes reduce us down to only one thing, i.e. mentally ill, we are so much more than that.


Violence Stereotype

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:

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.


Structural stigma: hospitals, police, laws, housing

Structural stigma can be found in the laws and policies of governments and institutions that limit the opportunities available to people who have a mental illness. These limitations are applied due to membership in a broad group (e.g. everyone with mental illness) rather than factors specific to the individual.

Health Care

If knowing better was enough to stop stigma, then it wouldn’t exist in health care. Unfortunately, that’s not the case, and health professionals can be a significant source of stigma. Stereotyping, prejudice, and discrimination in health care can occur on a structural level as well as on the level of individual professionals.

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.

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:

Addressing Health Care Professional Stigma

These sites offer anti-stigma training:

Recovery-oriented practice

Recovery-oriented practice is an approach to mental health care that emphasizes hope, choice, empowerment, and self-determination, and frames recovery as an individual journey rather than the absence of symptoms (i.e. remission). This is very different from the incompetence stereotypes and pessimism for recovery that are often involved in health professionals’ stigmatized attitudes. However, lip service to recovery-oriented practice while holding onto stigmatized beliefs isn’t good enough. For high-fidelity implementation of this approach to practice, people with lived experience need to be involved in systems-level changes.

Resources:

Systems-Level Issues

  • Behavioural health” is an oddity of the mental health care system in the US that refers to mental health and substance use disorders. But how is mental illness a disorder of behaviour? Does that manner of labelling actually reflect underlying structural stigma?
  • 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.

Funding Mental Health Care

One way that structural stigma shows up is in the under-funding of mental health care. 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.

These resources address parity issues in health care coverage in the United States:

  • Parity Track (US): works to ensure access to behavioural health treatment
  • The Kennedy Forum: Parity Registry and Don’t Deny Me campaign supporting parity in mental health and physical health insurance coverage in the US

The Economic Case

These organizations have laid out economic cases for investment in mental health care:


Law Enforcement

Why have police become the de facto emergency mental health service? Mental illness is not a crime. Perhaps defunding the police is part of the answer, and responsibility for non-violent mental health crisis response could be shifted over to the health care system.

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.

police wellness check gone wrong - graphic of police badge and handcuffs

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. A local newspaper headline later said she was “arrested” by police, when, in fact, she was apprehended under the Mental Health Act and taken to hospital.

You can read here about another police wellness check gone wrong.

The documentary Alien Boy examines the police brutality that resulted in the death of a man with schizophrenia.


Correctional System

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:


Employment

People who have a mental illness have higher than average levels of unemployment, and they can face significant challenges in the workplace.

These blog posts look at some of those challenges:

Various organizations have put together business cases for investing in workplace mental health, including:

The Mental Health Resource Directory has links to other workplace mental health resources, including accommodations for mental illness-related disabilities.


Housing

People who have a serious mental illness are at increased risk of homelessness. These blog posts address the issue of housing:


Social stigma: Outline of a woman's head with the words "we judge because we don't understand"

Social Stigma

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.

More on social stigma:


The Media

The media can play a major role in perpetuating stereotypes, especially the mentally ill = violent stereotype.

Several organizations have put together media reporting guidelines to support responsible reporting related to mental illness, including:


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:


Stop the Stigma – Further Reading


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!

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