Figure 1. Though awareness of mental health issues continues to increase, there is still a stigma associated with many mental disorders that should be addressed, both at an individual and societal level.

Public-opinion studies have confirmed the widespread existence of negative stereotypes about individuals with mental health problems: they are considered dangerous, unpredictable, and difficult to talk to. These negative stereotypes can have detrimental consequences on the users of mental health services through processes of public stigma, self-stigma, and stigma expectations with regard to such outcomes as self-efficacy, depressive symptoms, self-esteem, life satisfaction, client satisfaction, work, income, and social relationships, in addition to treatment continuation and medication adherence. A stereotype, in general, refers to an expectation that people might have about every person of a particular group. A stereotype is distinct from stigma. Public stigma refers to a set of negative attitudes and beliefs that motivate individuals to fear, reject, avoid, and discriminate against people with mental illness (Corrigan and Penn 1999).^[1] Self-stigma is thought to be particularly damaging, and is said to occur when individuals internalize stigmatizing social attitudes and come to believe the negative societal conceptions and stereotypes associated with their condition (Corrigan and Watson, 2002; Watson et al., 2007; Corrigan and Rao, 2012). Whether stigma is only anticipated or directly experienced, self-stigmatizing beliefs can lead to withdrawal from social support, rejection of help, avoidance of treatment, treatment withdrawal, and limited prospects for recovery (Link and Cullen, 1990; Link, 2001; Corrigan, 2004; Vogel et al., 2007).^[2]

With regard to culture and mental health stigma, stigma expectations—“the extent to which individuals believe that ‘most people’ (the community at large) will devalue and discriminate against a mental patient”—do not differ between individuals with and without mental health problems or history of treatment. They interpret this as an indication that such expectations constitute a component of culture. In addition, stigma expectations lead individuals with mental health problems to use adaptive strategies (e.g., secrecy or withdrawal). They thus do not necessarily believe in these negative stereotypes; they only know (and fear) that the stereotypes will be applied to them once they have been “labeled.”

Applying this logic, cultural stereotypes might hinder the utilization of mental health services due to fear of discrimination and devaluation. In this vein, a fear of disclosure can be viewed as the core reason why users of mental health services keep their psychiatric status secret. The preference for nondisclosure; the anticipation of social judgement, rejection, and discrimination; and the anticipation of disrespect from professionals are but a few of the many reasons why individuals refrain from seeking help, even if they do not personally adhere to such stigma beliefs. Stigma thus constitutes a major barrier to the utilization of mental health services. ^[3]

Stigma of Mental Illness

The word stigma referred originally to a mark or brand on Greek slaves, clearly separating them from free men. It is a label that causes us to regard certain people as different, defective, and set apart from mainstream members of society.

In his 1963 book,^[4], Goffman defines stigma as “a trait which is deeply discrediting.” He clearly says that stigmatization is an interactive social process, but some interpret his work as indicating that the blame lies with the person carrying the stigma. More recent authors have used the term stigma in a wider sense—for example, to refer to the reaction of other people, or even to include the attitude and behavior of both the victim and the perpetrator.

It is important for researchers to define which concept of stigma they are working with. For some, stigma takes on the two forms as described below:

• Enacted stigma—(external stigma, discrimination) refers to the experience of unfair treatment by others.
• Felt stigma —(internal stigma or self-stigmatization) refers to the shame and expectation of discrimination that prevents people from talking about their experiences and stops them from seeking help.

Felt stigma can be as damaging as enacted stigma since it leads to withdrawal and restriction of social support. Many psychiatric disorders can be hidden once the person has recovered. This allows people to pass as normal so long as no one finds out. In his classic treatise, Goffman (1963)^[5] delineates between people who are discredited—whose stigma is clearly known or visible—and people who are discreditable—whose stigma is unknown and can be concealable. Goffman describes people with a discreditable condition—e.g., bipolar disorder in remission—as having to decide how much to tell and to whom. By careful information management, they can minimize social rejection and enacted stigma. Individuals who live with a discrediting condition—such as schizophrenia with tardive dyskinesia—will have difficulties with information management and are at higher risk of experiencing enacted stigma. ^[6][7]

#Stigma Free

Words can hurt. Many derogatory words and phrases are used in relation to mental illness. However, these words maintain the stereotyped image and not the reality about mental illness. “Mentally ill people are nuts, crazy, wacko.”  How often have we heard comments like these or seen these types of portrayals in movies, television shows, or books? We may even be guilty of making comments like them ourselves. Is there any truth behind these portrayals, or is that negative view based on our ignorance and fear? Try not to use these words, and encourage others not to use them. It is more appropriate to refer to “a person who has a mental illness” when speaking about someone. Each of those preconceptions about people who have a mental illness is based on false information. Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different chronic disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body.

In fact, not all brain diseases are categorized as mental illnesses. Disorders such as epilepsy, Parkinson’s disease, and multiple sclerosis are brain disorders, but they are considered neurological diseases rather than mental illnesses. Interestingly, the lines between mental illnesses and these other brain or neurological disorders is somewhat blurring. As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain’s structure, chemistry, and function, and that mental illness does indeed have a biological basis.^[9]

Stigma and Illness

Stigma has been defined as an attribute that is deeply discrediting. This stigmatized trait sets the bearer apart from the rest of society, bringing with it feelings of shame and isolation. Often, when a person with a stigmatized trait is unable to perform an action because of the condition, other people view the person as the problem rather than viewing the condition as the problem. More recent definitions of stigma focus on the results of stigma—the prejudice, avoidance, rejection, and discrimination directed at people believed to have an illness, disorder, or other trait perceived to be undesirable. Stigma causes needless suffering, potentially causing a person to deny symptoms, delay treatment and refrain from daily activities. As mentioned earlier, Stigma can exclude people from access to housing, employment, insurance, and appropriate medical care. Thus, stigma can interfere with prevention efforts, and examining and combating stigma is a public health priority.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the CDC have examined public attitudes toward mental illness in two surveys. In the 2006 HealthStyles survey, only one-quarter of young adults between the ages of 18 and 24 believed that a person with mental illness can eventually recover (HealthStyles survey). In 2007, adults in 37 states and territories were surveyed about their attitudes toward mental illness, using the 2007 Behavioral Risk Factor Surveillance System Mental Illness and Stigma module. This study found that

• 78% of adults with mental health symptoms and 89% of adults without such symptoms agreed that treatment can help persons with mental illness lead normal lives.
• 57% of adults without mental health symptoms believed that people are caring and sympathetic to persons with mental illness.
• Only 25% of adults with mental health symptoms believed that people are caring and sympathetic to persons with mental illness.

These findings highlight both the need to educate the public about how to support persons with mental illness and the need to reduce barriers for those seeking or receiving treatment for mental illness.

Challenging Stereotypes about Mental Illness

Recovery from mental illness is a complex process. As with all serious illness, the well-being of recovering individuals is affected by the attitudes that surround them. Despite increasing sensitivity about most disabilities, mental illness all too often remains a target for ridicule and misrepresentation in advertising, entertainment, and the mainstream media.

Most of what we know as individuals comes not from personal experience, but from the stories that surround us from birth. In the past, it was families, religious institutions, schools, and respected members of the community who instilled cultural attitudes. But “Today, this is done by the mass media,” says George Gerbner, founder of the Cultural Environment Movement, and a researcher whose career includes 30 years of monitoring the cultural impact of television on society. Television is, in Gerbner’s words, “the wholesale distributor of the stigma of mental illness.” Gerbner’s research has shown that characters portrayed on television as having mental illnesses have four times the violence rate and six times the victimization rate of other characters. Gerbner notes that “Violence and retribution are shown as inherent in the illness itself and thus inescapable. No other group in the dramatic world of television suffers and is shown to deserve such a dire fate.”

The portrayal of mental illness in the movies is similarly distorted. In the late 1980s, Steven E. Hyler of Columbia University and his colleagues identified six categories of psychiatric characters in films: homicidal maniac, narcissistic parasite, seductress, enlightened member of society, rebellious free spirit, and zoo specimen. Hyler concluded that these predominantly negative stereotypes had a damaging effect on the viewing public and on the patients themselves, their family members, and policy makers. More recently, Otto F. Wahl of George Mason University, an authority on public images of mental illness, found that in the decade from 1985 to 1995, Hollywood released more than 150 films with characters who have mental illnesses, the majority of them killers and villains. There can be no doubt that Hollywood stereotypes are a large part of what people know, or think they know, about people with psychiatric vulnerabilities. Newspaper reports about mental illness are often more accurate than the characters one sees in TV entertainment and movies. Still, people with psychiatric histories generally are reported negatively. In 1991, researchers Russell E. Shain and Julie Phillips found that 86% of all print stories dealing with former mental patients focused on violent crime. Media stereotypes of persons with mental illness as villains, failures, buffoons—together with the misuse of terms like “schizophrenia” and “psychotic” in negative contexts—have far-reaching consequences. On the most deeply personal level, biased stereotypes damage the sense of self-worth of millions of persons diagnosed with serious psychiatric illnesses. On the social and economic levels, negative stereotyping may result in large-scale discrimination against an entire class of people in the areas of housing, employment, health insurance, and medical treatment.

Increasingly, the media are doing better work; at times, their efforts are excellent. Diana Ross’s moving and realistic portrayal of schizophrenia in Out of Darkness, an ABC television drama, was praised by mental health activists. “Good” characters with mental illness are appearing from time to time in prime-time television entertainment. Feature stories about the achievements of individuals diagnosed with mental illness—such as  a New York Times business section feature about John Forbes Nash, Jr., the winner of a Nobel Prize for economics—also help shatter stereotypes. In 1959, Nash began showing clear signs of mental illness, and spent several years at psychiatric hospitals being treated for paranoid schizophrenia. After 1970, his condition slowly improved, allowing him to return to academic work by the mid-1980s. His struggles with his illness and his recovery became the basis for Sylvia Nasar’s biography, A Beautiful Mind, as well as a film of the same name starring Russell Crowe as Nash.  And increasingly, people with first-hand experience of mental illness are writing books, appearing on television news and talk shows, producing documentaries and radio programs, and contributing articles to the print media. The disparity between mental illness as it is perceived by much of the public and mental illness as it is lived and experienced is a gulf to be bridged.