Depression Is Real – And It Hurts – The Stigma Is Real Too! Part VI

According to The Merriam-Webster Dictionary, stigma is defined as:
a mark of shame or discredit. (“Stigma.” 2019. In Merriam-Webster.com Retrieved March 15, 2019 -https://unabridged.merriam-webster.com). As illogical as it may sound, some illnesses bear a stigma. In my experiences the stigma has been created due to lack of understanding of the disease or disease process. This is especially true when it comes to the stigma associated with mental illness in America.

I know a few readers are already rolling their eyes at this topic. To those readers I issue a challenge – finish reading this blog post. Yep, set your stereotypes aside and attempt to understand what the stigma is that so many with mental illnesses face every day of their lives. Try to understand why mental illness is still a closeted set of disorders. It, the stigma, really is a big deal.

One of the biggest stigmas associated with mental illness is blaming the individual with mental illness for their mental illness. Just like an individual who has a cold or the flu cannot be the cause of their own illness, a person suffering with mental illness cannot be the cause of their own illness. Saying things such as “get over it,” “deal with it,” and “you are just over reacting,” or “you’re not going through anything the rest of us are not going through” are not helpful to the individual with mental illness.

Other stigmatizing attitudes contain some core assumptions. Media analyses of film and print have identified three common misconceptions about people with mental illness: they are homicidal maniacs who should be feared; they are rebellious, free spirits; or they have childlike perceptions of the world that should be marveled.

Public stigma comprises reactions of the general public towards a group based on stigma about that group. Although we are used to distinguishing between groups in society and to label these groups with different attributes, this is not a self-evident process. Most human differences are mainly ignored and socially irrelevant in Western societies of our time. For example, the color of one’s car or the size of one’s shoes do not matter for most people under most circumstances. However, other personal features like skin-color, sexual orientation or income are often relevant to one’s social appearance. There is obviously a social selection of which human qualities matter socially and which do not.

It is often taken for granted to distinguish between different groups in society and to label human differences accordingly. However, every demarcation of groups requires an oversimplification. Even with obvious attributes like skin-color, there is no clear demarcation line between, for example, ‘black’ and ‘white’. Even more so, there is no sharp line between mental health and mental illness.

That cultural attitudes to behavior and (mental) illness change substantially over time is another aspect of the social selection of human differences in creating groups. Whether patterns of behavior, thinking and feeling are being noticed at all and if so, whether they are described in moral, psychosocial or medical terms is influenced by societal discourse and usually varies over time. Attention deficit hyperactivity disorder is an example of a label that was unknown a few decades ago and is likely to change again.

It is further important to note that labeling often implies a separation of ‘us’ from ‘them’. This separation easily leads to the belief that ‘they’ are fundamentally different from ‘us’ and that ‘they’ even are the thing they are labelled. ‘They’ become fundamentally different from those who do not share a negative label, so that ‘they’ appear to be a completely different sort of people. Our use of language is revealing regarding the use of labels to distinguish ‘us’ from ‘them’. For example, it is common to call someone a ‘schizophrenic’ instead to call her or him a person with schizophrenia. For physical illness, things are often handled differently and people usually say, a person has cancer. The person afflicted with cancer remains one of ‘us’ and has an attribute, while the ‘schizophrenic’ becomes one of ‘them’ and is the label we affix to the person. In this way, language can be a powerful source and sign of stigmatization.

Given this background of distinguishing between groups, labeling and separating ‘us’ from ‘them’, social psychology has identified different cognitive, emotional and behavioral aspects of public stigma: stereotypes, prejudice, and discrimination (see Table 1). It is important for both theoretical research and practical initiatives to understand these components. Stereotypes are knowledge structures known to most members of a social group. Stereotypes are an efficient way to categorize information about different social groups because they contain collective opinions about groups of persons. They are efficient in the sense that they quickly generate impressions and expectations of persons who belong to a stereotyped group.


Table 1

Public StigmaSelf Stigma
StereotypeStereotype
Negative belief about a group:Negative belief about self such as:
IncompetenceIncompetence
Character WeaknessCharacter Weakness
DangerousDangerous
PrejudicePrejudice
Agreement with belief ofAgreement with belief of
Negative emotionof negative emotional response
AngerLow self-efficacy
FearLow self-esteem
DiscriminationDiscrimination
Behavior response to prejudice such as:
Avoidance of work and housing
opportunities
Withholding help
Behavior response to prejudice
such as:
 Fails to pursue work and
housing opportunities
 Does not seek help from others

People do not necessarily agree with the stereotypes they are aware of. Many persons may, for example, be aware of stereotypes of different ethnic groups but do not think these stereotypes are valid. Prejudiced persons, on the other hand, endorse these negative stereotypes (“That’s right! All persons with mental illness are violent“) and have negative emotional reactions as a consequence (“They all scare me”). Prejudice leads to discrimination as a behavioral reaction. Prejudice that yields anger can lead to hostile behavior. In the case of mental illness, angry prejudice may lead to withholding help or replacing health care with the criminal justice system. Fear leads to avoidant behavior. For example, employers do not want persons with mental illness around them so they do not hire them. This association between perceived dangerousness of persons with mental illness, fear, and increased social distance has been validated for different countries, including Germany, Russia, and the United States.

Stereotypes and prejudice alone are not sufficient for stigma. In addition, social, economic and political power is necessary to stigmatize. For example, if individuals with mental illness form stereotypes and prejudices against staff in a mental health service, this staff is unlikely to become a stigmatized group because the persons with mental illness simply do not have the social power to put serious discriminatory consequences against the staff into practice.

In summary, public stigma consists of these three elements – stereotypes, prejudice and discrimination – in the context of power differences and leads to reactions of the general public towards the stigmatized group as a result of stigma.

Self-stigma refers to the reactions of individuals who belong to a stigmatized group and turn the stigmatizing attitudes against themselves. Like public stigma, self-stigma comprises of stereotyping, prejudice and discrimination (Table 1). First, persons who turn prejudice against themselves agree with the stereotype: “That’s right; I am weak and unable to care for myself!” Second, self-prejudice leads to negative emotional reactions, especially low self-esteem and self-efficacy. Also self-prejudice leads to behavior responses. Because of their self-prejudices, persons with mental illness may fail to pursue work or independent living opportunities. If they fail to reach this goal this is often not due to their mental illness itself but due to their self-discriminating behavior. How can self-stigma arise? Many persons with mental illness know the stereotypes about their group such as the belief that people with mental illness are incompetent. But, as in public stigma, knowledge alone does not necessarily lead to stigma, if persons are aware of the stereotypes but do not agree with them. Thus, fortunately for many persons with mental illness, awareness of stereotypes alone does not lead to self-stigma.

Now that we have identified exactly what stigma is, let’s shift gears to the impact of the stigma.

As far as mental illness is concerned, stigmas seem to be widely supported by the general public. This is true for the United States and for other Western nations including Norway, Greece, or Germany while levels of stigmatisation may differ between nations. Unfortunately, research suggests that public attitudes toward people with mental illness seem to have become more stigmatizing over the last decades: Survey research suggests that a representative 1996 population sample in the US was 2.5 times more likely to endorse dangerousness stigma than a comparable 1950 group, i.e. perceptions that mentally ill people are violent or frightening substantially increased ( Phelan, J.C., Link, B.G., Stueve, A., and Pescosolido, B.A. Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared?. J. Health Soc. Behav. 2000; 41: 188–207) . A recent German study also found increasing stigmatizing attitudes towards people with schizophrenia ( Angermeyer, M.C. and Matschinger, H. Causal beliefs and attitudes to people with schizophrenia. Trend analysis based on data from two population surveys in Germany. Br. J. Psychiatry. 2005; 186: 331–334) . On the other hand, the use of outpatient psychotherapy in the US increased between 1987 to 1997, at least among people about 60 years old, among the unemployed and persons with mood disorders (Olfson, M., Marcus, S.C., Druss, B., and Pincus, H.A. National trends in the use of outpatient psychotherapy. Am. J. Psychiatry. 2002; 159: 1914–1920). It has been speculated that the increased use of psychotherapy in these groups may be due to decreased stigmatisation especially of mood disorders. However, the link between stigma and use of psychotherapy was not assessed in this study, psychotherapy was very broadly defined including treatments of only one or two sessions, and the overall use of psychotherapy did not change in this period. In addition, being in psychotherapy may not necessarily mean to consider oneself having a ‘mental illness’ or to be considered ‘mentally ill’ by one’s environment, so different stigmata may apply and change independently over time. Another sobering fact is that mental health professionals equally support stigmatizing views ( Gray, A.J. Stigma in psychiatry. J. R. Soc. Med. 2002; 95: 72–76; Lauber, C., Anthony, M., Ajdacic-Gross, V., and Rössler, W. What about psychiatrists’ attitude to mentally ill people?. Eur. Psychiatry. 2004; 19: 423–427; Page, S. Social responsiveness toward mental patients: The general public and others. Can. J. Psychiatry. 1980; 25: 242–246; Sartorius, N. Stigma: what can psychiatrists do about it?. Lancet. 1998; 352: 1058–1059).

Two deleterious consequences of stigma can only briefly be mentioned here. First, public stigma results in everyday-life discriminations encountered by persons with mental illness in interpersonal interactions as well as in stereotyping and negative images of mental illness in the media ( Wahl, O.F. Media madness: Public images of mental illness. Rutgers University Press, New Brunswick, NJ; 1995). Second, structural discrimination includes private and public institutions that intentionally or unintentionally restrict opportunities of persons with mental illness (Corrigan, P.W., Markowitz, F.E., and Watson, A.C. Structural levels of mental illness stigma and discrimination. Schizophr. Bull. 2004; 30: 481–491). Examples of structural discrimination are discriminatory legislation or allocation of comparatively fewer financial resources into the mental health system than into the somatic medical system (Corrigan, P.W. and Watson, A.C. Factors that explain how policy makers distribute resources to mental health services. Psychiatr. Serv. 2003; 54: 501–507;
Matschinger, H. and Angermeyer, M.C. The public’s preferences concerning the allocation of financial resources to health care: Results from a representative population survey in Germany. Eur. Psychiatry. 2004; 19: 478–482) . It is important to note that for example a person with schizophrenia may experience structural discrimination whether or not someone treats her or him in a discriminatory way because of some stereotype about schizophrenia ( Link, B.G. and Phelan, J.C. Conceptualizing stigma. Annu. Rev. Sociol. 2001; 27: 363–385) .

In this blog post, I want to focus on two other negative consequences of stigma that are both related to the way a person with mental illness reacts to the experience of being stigmatized in the society: Self-stigma/empowerment and fear of stigma as a reason to avoid treatment. I focus on these two aspects because both are highly relevant for clinicians working in the mental health field. By this I do not imply that stigma is only an individual problem. In contrast I believe stigma to be primarily a social problem that should be addressed by public approaches (Mills, C.W. The sociological imagination. Oxford University Press, Oxford; 1967). Still, until stigma has been reduced in society, all clinicians should be aware of the meaning and consequences of stigma for individuals with mental illness.

Research has shown that empowerment and self-stigma are opposite poles on a continuum ( Corrigan, P.W. Empowerment and serious mental illness: Treatment partnerships and community opportunities. Psychiatr. Q. 2002; 73: 217–228)_. At one end of the continuum are persons who are heavily influenced by the pessimistic expectations about mental illness, leading to their having low self-esteem. These are the self-stigmatized. On the other end are persons with psychiatric disability who, despite this disability, have positive self-esteem and are not significantly encumbered.

Many persons who are discriminated against and suffer from public stigma do not experience self-stigma while others do. Correspondingly, the evidence is equivocal on this point: Some studies suggest that people with mental illness, who are generally well aware of the prejudices against them, show diminished self-esteem ( Wright, E.R., Gronfein, W.P., and Owens, T.J. Deinstitutionalization, social rejection, and the self-esteem of former mental patients. J. Health Soc. Behav. 2000; 41: 68–90). On the other hand, other surveys did not find that awareness of common stereotypes leads to diminished self-esteem in persons with mental illness. Even more amazingly, some stigmatized minority groups show increased self-esteem, including persons of color ( Hoelter, J.W. Factorial invariance and self-esteem: Reassessing race and sex differences. Soc. Forces. 1983; 61: 834–846) and people with physical disabilities (Llewellyn, A. Self-esteem in children with physical disabilities. Dev. Med. Child Neurol. 2001; 43: 70–71). Being stigmatized may stimulate psychological reactance so that instead of applying the common prejudices to themselves persons oppose the negative evaluation which results in positive self-perceptions. This fact that some react with righteous anger to stigma, while others are indifferent to stigma and yet another group self-stigmatizes has been called the paradox of self-stigma and mental illness (Corrigan, P.W. and Watson, A.C. The paradox of self-stigma and mental illness.Clin. Psychol. Sci. Pract. 2002; 9: 35–53). Why do people react so differently to public stigma? Corrigan and colleagues developed a model of the personal response to mental illness stigma (Fig. 1).

Many persons who are discriminated against and suffer from public stigma do not experience self-stigma while others do. Correspondingly, the evidence is equivocal on this point: Some studies suggest that people with mental illness, who are generally well aware of the prejudices against them, show diminished self-esteem ( Wright, E.R., Gronfein, W.P., and Owens, T.J. Deinstitutionalization, social rejection, and the self-esteem of former mental patients. J. Health Soc. Behav. 2000; 41: 68–90). On the other hand, other surveys did not find that awareness of common stereotypes leads to diminished self-esteem in persons with mental illness. Even more amazingly, some stigmatized minority groups show increased self-esteem, including persons of color ( Hoelter, J.W. Factorial invariance and self-esteem: Reassessing race and sex differences. Soc. Forces. 1983; 61: 834–846) and people with physical disabilities (Llewellyn, A. Self-esteem in children with physical disabilities. Dev. Med. Child Neurol. 2001; 43: 70–71). Being stigmatized may stimulate psychological reactance so that instead of applying the common prejudices to themselves persons oppose the negative evaluation which results in positive self-perceptions. This fact that some react with righteous anger to stigma, while others are indifferent to stigma and yet another group self-stigmatizes has been called the paradox of self-stigma and mental illness (Corrigan, P.W. and Watson, A.C. The paradox of self-stigma and mental illness.Clin. Psychol. Sci. Pract. 2002; 9: 35–53). Why do people react so differently to public stigma? Corrigan and colleagues developed a model of the personal response to mental illness stigma (Fig. 1).

Figure 1

Persons with a stigmatizing condition like serious mental illness perceive and interpret their condition and the negative responses of others. The collective representations in the form of common stereotypes influence both the responses of others and the interpretation of the stigmatized. Persons with a stigmatizing condition who do not identify with the stigmatized group are likely to remain indifferent to stigma because they do not feel that prejudices and discrimination actually refer to them (Fig. 1). However, those who identify with the group of the mentally ill apply the stigma to themselves ( Jetten, J., Spears, R., and Manstead, A.S.R. Intergroup norms and intergroup discrimination: Distinctive self-categorizationand social identity effects. J. Pers. Soc. Psychol. 1996; 71: 1222–1233). Their reaction is moderated by perceived legitimacy. If they consider the stigmatizing attitudes to be legitimate, their self-esteem and self-efficacy are likely to be low ( Rüsch N, Lieb K, Bohus M, Corrigan PW. Personal response of women with mental illness to public stigma: self-stigma empowerment, and the role of perceived legitimacy. Psychiatr Serv (in press)); (Schmader, T., Major, B., Eccleston, C.P., and McCoy, S.K. Devaluing domains in response to threatening intergroup comparisons: Perceived legitimacy and the status value asymmetry. J. Pers. Soc. Psychol. 2001; 80: 782–796). If, on the other hand, they regard public stigma to be illegitimate and unfair, they will probably react with righteous anger.(Fig. 1). People who are righteously angry are often active in empowerment efforts, targeting the quality of services.

Related to empowerment and self-stigma is the issue of stigma and disclosure. To disclose one’s mental illness may have both significant benefits, e.g. possibly increased self-esteem and decreased distress of keeping one’s illness a secret, and costs, e.g. social disapproval. Whether or not individuals decide to disclose will depend on context and their sense of identity (Corrigan, P.W. and Matthews, A.K. Stigma and disclosure: Implications for coming out of the closet. J. Ment. Health. 2003; 12: 235–248). For instance, if a woman with mental illness does not consider her illness a relevant part of her identity, she will be unlikely to tell her relatives about her mental illness, especially if those have repeatedly made stigmatising remarks about mental illness. If, on the other hand, a man with mental illness who is active in self-help groups and regards his mental illness as an important part of his life has trustworthy colleagues that have not shown discriminating behavior against people with mental illness, he is more likely to disclose his mental illness at work.

While the model of self-stigma, originating in social psychological research on other stigmatized groups (e.g. people of color, people with physical diseases), is useful to understand the different ways people react to stigma, three aspects have to be included to take into account the special case of mental illness. First, self-stigma resulting in decreased self-esteem and self-efficacy must be distinguished from decreased self-esteem during depressive syndromes that are common not only in affective disorders. Second, reaction to stigmatizing conditions depends on the awareness of having a mental illness, which may be impaired during episodes of, for instance, a psychotic condition.( Rüsch, N. and Corrigan, P.W. Motivational interviewing to improve insight and treatment adherence in schizophrenia. Psychiatr. Rehabil. J. 2002; 26: 23–32). Third, the reaction to a stigmatizing environment is dependent on one’s perception of the subtle stigmatizing messages from other people. This social cognition may be impaired in serious mental illness such as schizophrenia. (P.W. Corrigan, D.L. Penn (Eds.) Social cognition and schizophrenia. American Psychological Association Press, Washington DC; 2001).

Most people who live with mental illness have, at some point, been blamed for their condition. They’ve been called names. Their symptoms have been referred to as “a phase” or something they can control “if they only tried.” They have been illegally discriminated against, with no justice. This is the unwieldy power that stigma holds.

Stigma causes people to feel ashamed for something that isout of their control. Worst of all, stigma prevents people from seeking the help they need. For a group of people who already carry such a heavy burden, stigma is an unacceptable addition to their pain. And while stigma has reduced in recent years, the pace of progress has not been quick enough.

All of us in the mental health community need to raise our voices against stigma. Every day, in every possible way, we need to stand up to stigma. If you’re not sure how, here are nine ways folks on my inpatient unit responded to the question: “How do you fight stigma?

Talk Openly About Mental Health

“I fight stigma by talking about what it is like to have bipolar disorder and PTSD on Facebook. Even if this helps just one person, it is worth it for me.” – Patient 1

Educate Yourself And Others

“I take every opportunity to educate people and share my personal story and struggles with mental illness. It doesn’t matter where I am, if I over-hear a conversation or a rude remark being made about mental illness, or anything regarding a similar subject, I always try to use that as a learning opportunity and gently intervene and kindly express how this makes me feel, and how we need to stop this because it only adds to the stigma.” – Patient 2

Be Conscious Of Language

“I fight stigma by reminding people that their language matters. It is so easy to refrain from using mental health conditions as adjectives and in my experience, most people are willing to replace their usage of it with something else if I explain why their language is problematic.” – Patient 3

Encourage Equality Between Physical And Mental Illness

“I find that when people understand the true facts of what a mental illness is, being a disease, they think twice about making comments. I also remind them that they wouldn’t make fun of someone with diabetes, heart disease or cancer.” – Patient 4

Show Compassion For Those With Mental Illness

“I offer free hugs to people living outdoors, and sit right there and talk with them about their lives. I do this in public, and model compassion for others. Since so many of our homeless population are also struggling with mental illness, the simple act of showing affection can make their day but also remind passersby of something so easily forgotten: the humanity of those who are suffering.” – Patient 5

Choose Empowerment Over Shame

“I fight stigma by choosing to live an empowered life. To me, that means owning my life and my story and refusing to allow others to dictate how I view myself or how I feel about myself.” – Patient 6

Be Honest About Treatment

“I fight stigma by saying that I see a therapist and a psychiatrist. Why can people say they have an appointment with their primary care doctor without fear of being judged, but this lack of fear does not apply when it comes to mental health professionals?” – Patient 7

Let The Media Know When They’re Being Stigmatizing

“If I watch a program on TV that has any negative comments, story lines or characters with a mental illness, I write to the broadcasting company and to the program itself. If Facebook has any stories where people make ignorant comments about mental health, then I write back and fill them in on my son’s journey with schizoaffective disorder.” – Patient 8

Don’t Harbor Self-Stigma

“I fight stigma by not having stigma for myself—not hiding from this world in shame, but being a productive member of society. I volunteer at church, have friends, and I’m a peer mentor and a mom. I take my treatment seriously. I’m purpose driven and want to show others they can live a meaningful life even while battling [mental illness].” – Patient 9

This is what our collective voice sounds like. It sounds like bravery, strength and persistence—the qualities we need to face mental illness and to fight stigma. No matter how you contribute to the mental health movement, you can make a difference simply by knowing that mental illness is not anyone’s fault, no matter what societal stigma says. You can make a difference by being and living #StigmaFree!

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