Understanding the impact of stigma on people with mental illness (2024)

Many people with serious mental illness are challenged doubly. On one hand,they struggle with the symptoms and disabilities that result from the disease.On the other, they are challenged by the stereotypes and prejudice that resultfrom misconceptions about mental illness. As a result of both, people withmental illness are robbed of the opportunities that define a quality life:good jobs, safe housing, satisfactory health care, and affiliation with adiverse group of people. Although research has gone far to understand theimpact of the disease, it has only recently begun to explain stigma in mentalillness. Much work yet needs to be done to fully understand the breadth andscope of prejudice against people with mental illness. Fortunately, socialpsychologists and sociologists have been studying phenomena related to stigmain other minority groups for several decades. In this paper, we integrateresearch specific to mental illness stigma with the more general body of researchon stereotypes and prejudice to provide a brief overview of issues in thearea.

The impact of stigma is twofold, as outlined in Table ​Table1.1. Public stigma is the reaction that the general populationhas to people with mental illness. Self-stigma is the prejudice which peoplewith mental illness turn against themselves. Both public and self-stigma maybe understood in terms of three components: stereotypes, prejudice, and discrimination.Social psychologists view stereotypes as especially efficient, social knowledgestructures that are learned by most members of a social group (1-3). Stereotypes areconsidered "social" because they represent collectively agreed upon notionsof groups of persons. They are "efficient" because people can quickly generateimpressions and expectations of individuals who belong to a stereotyped group(4).

The fact that most people have knowledge of a set of stereotypes does notimply that they agree with them (5).For example, many persons can recall stereotypes about different racial groupsbut do not agree that the stereotypes are valid. People who are prejudiced,on the other hand, endorse these negative stereotypes ("That's right; allpersons with mental illness are violent!") and generate negative emotionalreactions as a result ("They all scare me!") (1,3,6).In contrast to stereotypes, which are beliefs, prejudicial attitudes involvean evaluative (generally negative) component (7,8). Prejudice also yields emotional responses(e.g., anger or fear) to stigmatized groups.

Prejudice, which is fundamentally a cognitive and affective response, leadsto discrimination, the behavioral reaction (9).Prejudice that yields anger can lead to hostile behavior (e.g., physicallyharming a minority group) (10). Interms of mental illness, angry prejudice may lead to withholding help or replacinghealth care with services provided by the criminal justice system (11). Fear leads to avoidance; e.g., employers do not wantpersons with mental illness nearby so they do not hire them (12). Alternatively, prejudice turned inward leads to self-discrimination.Research suggests self-stigma and fear of rejection by others lead many personsto not pursuing life opportunities for themselves (13,14). The remainder of this paper furtherdevelops examples of public and self-stigma. In the process, we summarizeresearch on ways of changing the impact of public and self-stigma.

PUBLIC STIGMA

Stigmas about mental illness seem to be widely endorsed by the generalpublic in the Western world. Studies suggest that the majority of citizensin the United States (13,15-17) and many WesternEuropean nations (18-21) have stigmatizing attitudes about mental illness. Furthermore,stigmatizing views about mental illness are not limited to uninformed membersof the general public; even well-trained professionals from most mental healthdisciplines subscribe to stereotypes about mental illness (22-25).

Stigma seems to be less evident in Asian and African countries (26), though it is unclear whether this finding representsa cultural sphere that does not promote stigma or a dearth of research inthese societies. The available research indicates that, while attitudes towardmental illness vary among non-Western cultures (26,27), the stigma of mental illness may beless severe than in Western cultures. Fabrega (26)suggests that the lack of differentiation between psychiatric and non-psychiatricillness in the three great non-Western medical traditions is an importantfactor. While the potential for stigmatization of psychiatric illness certainlyexists in non-Western cultures, it seems to primarily attach to the more chronicforms of illness that fail to respond to traditional treatments. Notably,stigma seems almost nonexistent in Islamic societies (26-28). Cross-culturalexaminations of the concepts, experiences, and responses to mental illnessare clearly needed.

Several themes describe misconceptions about mental illness and correspondingstigmatizing attitudes. Media analyses of film and print have identified three:people with mental illness are homicidal maniacs who need to be feared; theyhave childlike perceptions of the world that should be marveled; or they areresponsible for their illness because they have weak character (29-32). Results oftwo independent factor analyses of the survey responses of more than 2000English and American citizens parallel these findings (19,33):

1. fear and exclusion: persons with severe mental illness should be fearedand, therefore, be kept out of most communities;

2. authoritarianism: persons with severe mental illness are irresponsible,so life decisions should be made by others;

3. benevolence: persons with severe mental illness are childlike and needto be cared for.

Although stigmatizing attitudes are not limited to mental illness, thepublic seems to disapprove persons with psychiatric disabilities significantlymore than persons with related conditions such as physical illness (34-36).Severe mental illness has been likened to drug addiction, prostitution, andcriminality (37,38). Unlike physical disabilities, persons with mental illnessare perceived by the public to be in control of their disabilities and responsiblefor causing them (34,36). Furthermore, research respondents are less likely topity persons with mental illness, instead reacting to psychiatric disabilitywith anger and believing that help is not deserved (35,36,39).

The behavioral impact (or discrimination) that results from public stigmamay take four forms: withholding help, avoidance, coercive treatment, andsegregated institutions. Previous studies have shown that the public willwithhold help to some minority groups because of corresponding stigma (36,40).A more extreme form of this behavior is social avoidance, where the publicstrives to not interact with people with mental illness altogether. The 1996General Social Survey (GSS), in which the Mac Arthur Mental Health Modulewas administered to a probability sample of 1444 adults in the United States,found that more than a half of respondents are unwilling to: spend an eveningsocializing, work next to, or have a family member marry a person with mentalillness (41). Social avoidance is notjust self-report; it is also a reality. Research has shown that stigma hasa deleterious impact on obtaining good jobs (13,42-44)and leasing safe housing (45-47).

Discrimination can also appear in public opinion about how to treat peoplewith mental illness. For example, though recent studies have been unable todemonstrate the effectiveness of mandatory treatment (48,49), more than40% of the 1996 GSS sample agreed that people with schizophrenia should beforced into treatment (50). Additionally,the public endorses segregation in institutions as the best service for peoplewith serious psychiatric disorders (19,51).

STRATEGIES FOR CHANGING PUBLIC STIGMA

Change strategies for public stigma have been grouped into three approaches:protest, education, and contact (12).Groups protest inaccurate and hostile representations of mental illness asa way to challenge the stigmas they represent. These efforts send two messages.To the media: STOP reporting inaccurate representations of mental illness.To the public: STOP believing negative views about mental illness. Wahl (32) believes citizens are encountering farfewer sanctioned examples of stigma and stereotypes because of protest efforts.Anecdotal evidence suggests that protest campaigns have been effective ingetting stigmatizing images of mental illness withdrawn. There is, however,little empirical research on the psychological impact of protest campaignson stigma and discrimination, suggesting an important direction for futureresearch.

Protest is a reactive strategy; it attempts to diminish negative attitudesabout mental illness, but fails to promote more positive attitudes that aresupported by facts. Education provides information so that the public canmake more informed decisions about mental illness. This approach to changingstigma has been most thoroughly examined by investigators. Research, for example,has suggested that persons who evince a better understanding of mental illnessare less likely to endorse stigma and discrimination (17,19,52). Hence, the strategic provision of information aboutmental illness seems to lessen negative stereotypes. Several studies haveshown that participation in education programs on mental illness led to improvedattitudes about persons with these problems (22,53-56).Education programs are effective for a wide variety of participants, includingcollege undergraduates, graduate students, adolescents, community residents,and persons with mental illness.

Stigma is further diminished when members of the general public meet personswith mental illness who are able to hold down jobs or live as good neighborsin the community. Research has shown an inverse relationship between havingcontact with a person with mental illness and endorsing psychiatric stigma(54,57).Hence, opportunities for the public to meet persons with severe mental illnessmay discount stigma. Interpersonal contact is further enhanced when the generalpublic is able to regularly interact with people with mental illness as peers.

SELF-STIGMA

One might think that people with psychiatric disability, living in a societythat widely endorses stigmatizing ideas, will internalize these ideas andbelieve that they are less valued because of their psychiatric disorder. Self-esteemsuffers, as does confidence in one's future (7,58,59).Given this research, models of self-stigma need to account for the deleteriouseffects of prejudice on an individual's conception of him or herself. However,research also suggests that, instead of being diminished by the stigma, manypersons become righteously angry because of the prejudice that they have experienced(60-62).This kind of reaction empowers people to change their roles in the mentalhealth system, becoming more active participants in their treatment plan andoften pushing for improvements in the quality of services (63).

Low self-esteem versus righteous anger describes a fundamental paradoxin self-stigma (64). Models that explainthe experience of self-stigma need to account for some persons whose senseof self is harmed by social stigma versus others who are energized by, andforcefully react to, the injustice. And there is yet a third group that needsto be considered in describing the impact of stigma on the self. The senseof self for many persons with mental illness is neither hurt, nor energized,by social stigma, instead showing a seeming indifference to it altogether.

We propose a situational model that explains this paradox, arguing thatan individual with mental illness may experience diminished self-esteem/self-efficacy,righteous anger, or relative indifference depending on the parameters of thesituation (64). Important factors thataffect a situational response to stigma include collective representationsthat are primed in that situation, the person's perception of the legitimacyof stigma in the situation, and the person's identification with the largergroup of individuals with mental illness. This model has eventual implicationsfor ways in which persons with mental illness might cope with self-stigmaas well as identification of policies that promote environments in which stigmafesters.

CONCLUSIONS

Researchers are beginning to apply what social psychologists have learnedabout prejudice and stereotypes in general to the stigma related to mentalillness. We have made progress in understanding the dimensions of mental illnessstigma, and the processes by which public stereotypes are translated intodiscriminatory behavior. At the same time, we are beginning to develop modelsof self-stigma, which is a more complex phenomenon than originally assumed.The models developed thus far need to be tested on various sub-populations,including different ethnic groups and power-holders (legislators, judges,police officers, health care providers, employers, landlords). We are alsolearning about stigma change strategies. Contact in particular seems to beeffective for changing individual attitudes. Researchers need to examine whetherchanges resulting from anti-stigma interventions are maintained over time.

All of the research discussed in this paper examines stigma at the individualpsychological level. For the most part, these studies have ignored the factthat stigma is inherent in the social structures that make up society. Stigmais evident in the way laws, social services, and the justice system are structuredas well as ways in which resources are allocated. Research that focuses onthe social structures that maintain stigma and strategies for changing themis sorely needed.

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