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.
- A Primer on Stigma
- Strategies to Stop the Stigma
- Raise Your Voice
- Language & Stigma
- Health Care
- Law Enforcement
- Correctional System
- Social Stigma
- Stop the Stigma – Further Reading
- TED Talks on Stigma
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
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 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 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.
Education campaigns that focus on framing mental illness as a biological brain disease have repeatedly been found to increase stigma, as strange as that may sound. You can read more about this in an article by Patrick Corrigan and Amy Watson in Schizophrenia Bulletin.
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)
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.
- Bring Change to Mind
- Join the Conversation
- Like Minds, Like Mine (New Zealand)
- NAMI StigmaFree initiative
- See Me (Scotland)
- Stigma Fighters
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 with political advocacy; you can also jump on board with the efforts of mental health organizations lobbying for positive changes.
This blog post on political advocacy can give you some ideas on how to get started.
You may be interested in getting involved with these organizations’ advocacy efforts:
- American Foundation for Suicide Prevention (AFSP): Field advocates | Public Policy Action Center
- Canadian Mental Health Association
- JED Foundation Advocacy
- Mental Health America: Advocacy Network | Current Mental Health Legislation
- Mind: Be a Mind Campaigner
- NAMI Advocacy
Resources for Advocates
WEGO Health’s Patient Leader Network has supports for health advocates, including networking opportunities and advocacy training. Here’s an invitation to join me there!
These sites also have information to support you in your advocacy work:
- CMHA Alberta: Making Mental Health Matter Advocacy Toolkit
- NAMI Smarts for Advocacy training
- Orygen Global Youth Mental Health Advocacy Toolkit
- Rethink Mental Illness: Take Action: Your Guide to Campaigning on Mental Health
- Schizophrenia Society of Canada Advocacy Tool Kit
- STRIPED @ Harvard T.H. Chan School of Public Health: Power Prism Advocacy Framework
- University of Kansas Community Toolbox: Principles of Advocacy | Conducting a Direct Action Campaign
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:
- Centre for Innovation in Peer Support toolkit for sharing your story effectively
- Mental Health Commission of Canada Headstrong campaign: Sharing Your Personal Story Speaker Toolkit
- NAMI Connect: Best Practices for Presentations by Suicide Loss and Suicide Attempt Survivors
Speaking with the media is another option for getting the word out. Most of us don’t have much, if any, practice with that, but there are resources that can help you 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.
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:
- Beyond Blue (Australia) has a speaker series, although they’re not always recruiting
- Jack.org (Canada) has speaking opportunities for young adults 18-26
- NAMI (US) has a few different speaker series; check with your local NAMI organization
- In Our Own Voice training
- Sharing Your Story with Law Enforcement training – NAMI is involved in police Crisis Intervention Team (CIT) training
The post Ways to Share Your Story contains links to mental health sites where you can submit stories.
Language & Stigma
Words can hurt, but I think it can be easy to get caught up in the words people choose, to the point that we lose sight of the work that needs to be done changing attitudes.
Language policing, or word policing, involves identifying certain words as being right or wrong, telling people which words to use, and then scolding people if they use the words that have been deemed to be wrong.
The problem with this is that telling people how to talk can trigger reactance, a psychological phenomenon that occurs when people feel like their freedom is threatened. This can actually make them more likely to say what they’re being told not to say, especially if perceive it to be a matter of political correctness. While it may be possible to control language in certain specific circumstances and contexts, what will produce lasting change across contexts is changing the attitudes that underlie word choices.
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 society’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.
Person-First vs. Identity-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.
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, 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. If we feel the need to talk around mental illness rather than about it, that’s a pretty good indicator that stigma is still a problem.
Mental Health ≠ Mental Illness
How We Talk About Ourselves
- “Rules” for Talking About Mental Illness
- What’s in a Name? Labelling and Mental Illness
- Stigma, Word Policing, and Targeting the Wrong Audience
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
While stigma and stereotypes reduce us down to only one thing, i.e. mentally ill, we are so much more than that. Being grounded in an awareness of your own many identities and social roles can help with deflecting stigma away from the whole self and framing it as something arising from society’s attitudes towards that one specific mentally ill identity.
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
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.
Sanitizing vs. Stereotyping
In an attempt to counteract stereotypes, sometimes people will sanitize mental illness, presenting it as something that doesn’t cause a huge disruption in most people’s lives, doesn’t cause suffering, and is always possible to recover from.
The problem is, a lot of people (like me) don’t experience a sanitized version of mental illness. Neither the stereotyped version nor the sanitized version represent all experiences of mental illness; there’s a whole lot of diversity in the middle.
Stereotypes tend to inflate the gap between mental illness and normal human experience, but it’s also a problem when people try to shrink that gap to the point that it’s nonexistent. Pathologizing normal human experience can take the form of the attitudes that everyone gets depressed or anxious or that people are a little OCD/ADHD/etc. Just like having the sniffles is not the same as having pneumonia, conflating normal human experiences with mental illness minimizes the very real challenges that people face when they actually do have a mental illness.
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.
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.
Health care professionals often have stereotypes about what a “good patient” will look like. Patient behaviours may be framed positively or negatively depending on how well they conform to stereotypes. For example:
- “Attention-seeking” is a bad thing, while “help-seeking” is encouraged.
- “Drug-seeking” is a bad thing, while “medication compliance” is expected.
Mental health professionals often have particularly stigmatized attitudes towards borderline personality disorder. People with BPD are often labelled as being manipulative. People with BPD also tend to be seen as “difficult”, and patients who don’t have BPD but are labelled as “difficult patients” are sometimes given a BPD label to accompany that. The first time I was hospitalized, I was diagnosed with borderline traits purely because my behaviour at the time was considered difficult.
Physical Health Care
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.
These posts on stigma and health care are based on my own and others’ experiences:
Anti-Stigma Training for Health Care Professionals
These sites offer anti-stigma training:
- Mental Health Commission of Canada: Understanding Stigma: free online training, with modules for physicians and nurses
- SharedHumanity online anti-stigma modules
Another way to address stigma among health care professionals might be a shift towards recovery-oriented practice, which 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.
These sites have information on implementing recovery-oriented practice:
- American Psychiatric Association: Recovery-Oriented Care in Psychiatry video modules
- American Psychological Association: Recovery to Practice Curriculum Modules
- Boston University Center for Psychiatric Rehabilitation: Recovery Promoting Competencies Toolkit
- Mental Health Commission of Canada: Recovery-oriented practice – An implementation toolkit
Stigma Around Health Professionals with Mental Illness
The Health Professions Act and the Fight Against Stigma: Legislation in the Canadian province of British Columbia requires hospitals to report any health professional admitted specifically for psychiatric reasons to be reported to their regulatory college.
“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
These organizations have laid out economic cases 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
Why have police become the de facto emergency mental health service? Mental illness is not a crime.
In many places, when there are concerns about someone’s welfare or stability in the community related to their mental health, police are the first point of contact. When they receive calls from the public, they will perform a “wellness check” on the identified individual, who may have no idea that the police have been called about them. In some cases, wellness check can result in significant harm, or even death, for the target individual.
Perhaps defunding the police is part of the answer, with responsibility for non-violent mental health crisis response being shifted over to the health care system.
When police are involved in mental health crises, and especially when they’re handcuffing people to take them to hospital, that can be extremely traumatizing for mentally ill people. When the public witnesses this, it’s also likely to be stigma-reinforcing.
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?
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:
- Disclosing Mental Illness at Work
- 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
The Mental Health Resource Directory has links to other workplace mental health resources, including information on accommodations for mental illness-related disabilities.
People who have a serious mental illness are at increased risk of homelessness. This is influenced by multiple factors, including a downward socioeconomic drift due to stigma and lack of employment.
Stigma can make landlords reluctant to rent to potential tenants who have a mental illness. It can also be a barrier to the development of mental health housing; this can take the form of NIMBYism, the perspective that something like mental housing is fine, just as long as it’s Not In My BackYard.
The COVID pandemic has put mental health on more people’s radar, but will that bring about a change in stigma once restrictions are over? Unfortunately, I’m inclined to think that it’s not going to have much of an effect when it comes to more serious forms of mental illness.
One way that stigma manifests is as a desire for social distance. 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.
An interesting example of stigma being not only condoned but encouraged relates to narcissistic personality disorder and the narcissistic abuse phenomenon that’s all over the internet. While abuse is clearly a bad thing, the way that abuse is framed as inherent in a certain mental illness and the amount of armchair diagnosing going on seems like an awfully slipper slope.
The ways that society treats mentally ill individuals may be influenced by societal views about the causes of mental illness. 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.
The news and entertainment media can play a major role in perpetuating stereotypes, especially the mentally ill = violent stereotype.
The news media often frames stories related to mental illness in a stigmatizing way. 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)
Films also play a role in perpetuating stigma related to mental illness and different forms of treatment. Documentaries like A Prescription for Murder, Letters from Generation Rx, and Take Your Pills promote negative attitudes about psychiatric medications, and the way that many members of the public think of electroconvulsive therapy is heavily influenced by One Flew Over the Cuckoo’s Next.
Stop the Stigma – Further Reading
- A Brief History of Stigma by Ashley L. Peterson
- 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!