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Stigma

An Opinion by Michael B. Friedman, LMSW
First published in Spanish in Salud Mental, Winter 2006

“Stigma”. Mental health advocates, providers, and public officials often talk about the problem of stigma. But what is it, what are its consequences, and what can be done about it?

What is Stigma?

“The stigma of mental illness” refers to the common perception in our society, and in most human societies, that it is shameful to be mentally ill. This attitude links to a number of common myths about mental illness—that people with mental illness are dangerous; that they cannot function like normal people; that they need constant supervision; that they are unpleasant to be around; and so forth. At the extreme, some people and cultures still regard severe mental illness as a kind of demonic possession.

Stigma also links to a variety of troubling images of people with mental illness:

Of a madman pushing a woman to her death in front of a subway
Of a slasher on the Staten Island Ferry
Of a shopping bag lady wandering the streets of the city
Of a bedraggled homeless person sleeping on a heating grate in the cold of winter
Of a person cut off from reality and lost listening to inner voices
Of a person immobilized by depression
Of a person pursuing impossibly grandiose visions

What Are Its Consequences?

Images of this kind are constantly reinforced in the media, and they have dreadful consequences for people with mental illnesses and their families:

As a result of stigma some people with mental illness feel dreadful about themselves, a kind of inner shame, a need to hide their illness from the world around them or even from themselves.
As a result of stigma, family members sometimes want to hide mentally ill family members and feel that they are somehow to blame, tainted by their family member’s illness.
As a result of stigma it is difficult for people known to have a mental illness to get a job, to get into college, to get housing, even to be a fully accepted member of a religious congregation.
As a result of stigma some children with serious emotional disturbances are pushed out of their schools and excluded from recreation programs. As a result of stigma some people do not seek help.
As a result of stigma, it is difficult to get funding for community mental health programs, and it is exceedingly difficult to defeat the sentiment of “not in my backyard” so as to develop housing for people with mental illnesses.
As a result of stigma, funding for mental health research is far less than for other less prevalent illnesses.

The fact of stigma is particularly troubling in the context of a public mental health policy that emphasizes helping people with mental illnesses to live freely in the community rather than to be incarcerated in institutions. The community mental health movement was built, to some extent, on the assumption that people with serious mental illnesses would be accepted in the community. Stigma blocks community acceptance.

What Can Be Done to Overcome Stigma?

There are two fundamentally different, but complementary, approaches to overcoming stigma. One is to work to change people’s beliefs and attitudes. The other is to focus on winning community acceptance in specific ways—without worrying very much about what people feel or believe. The first approach calls for fairly broad-based community education efforts. The second approach calls for anti-discrimination legislation, for changes in law that make housing development feasible despite community opposition, for job development initiatives, for supported education, and so forth.

Community education efforts focus on dispelling the myths about, and creating new images of, mental illness.

Yes, some people with mental illness are dangerous, but very few.
Yes, some people with mental illness live in squalor and desperation, but also very few.
Yes, some people with mental illness are cut off from reality and highly dysfunctional, but also relatively few.
About 20% of the American population has a mental illness in any given year, and 50% will have a mental illness in their lifetime.
The vast majority of them lead apparently normal lives most of the time. They work, go to school, live as part of families, have friends, have interests.
Their suffering is often quiet, unnoticeable to almost everyone. Their illness often disrupts some area of functioning to some extent, but most are able to carry on.

Community education efforts also focus on the effectiveness of treatment.

The majority of people with mental illness, even with very serious mental illness, respond to good treatment.
Recovery is a real possibility for a great many people with severe and protracted mental illnesses.
Quiet suffering is unnecessary for people who carry on despite painful fears and depressions.
Treatment can help them.

Sadly, few of them get good treatment, not only because there isn’t enough available but also because the stigma they, their families, and their communities carry with them keeps them from seeking professional help.

Stigma is Lack of Community Acceptance of People with Mental Illness

In the early 1990’s I was privileged to serve on the National Institute of Mental Health’s Services Research Planning Panel. Stigma was one of the topics to which we devoted considerable attention. We recommended that, in addition to broad-based community education efforts to reverse stigma, more specific efforts should be developed drawing from a re-conceptualization of stigma in terms of its consequences. Stigma should be seen, we suggested, as lack of community acceptance of people with mental illness.

Our recommendation was based on the realization that change of attitude does not necessarily result in change of behavior and that behavioral change can be brought about in a variety of ways without a change in attitude. For example, The Civil Rights Act of 1964 resulted in the end of Jim Crow but not in the elimination of racist attitudes. Indeed reduced racism in America has occurred in part because changes in law forced changes in behavior, which in turn has resulted in changes in attitude. Similarly, we thought, community acceptance might be enhanced with laws like the Fair Housing Act, the Padavan Law, and the Americans with Disabilities Act, laws that require community acceptance under certain circumstances.

We also speculated that specific efforts to develop jobs for people with mental illnesses, to develop partnerships with schools and colleges, to open up opportunities for recreation and for participation in religious organizations could help people develop satisfying lives for themselves in the community. In a sense we took the position that overcoming stigma and supporting recovery are one and the same thing.

Stigma and Culture

A word about stigma and culture before I close. Stigma, I believe, is a cross-cultural phenomenon. Every culture that I know of has troubling perceptions of what we call “mental illness” in Western culture. But the nature of these perceptions and the way people are treated varies from culture to culture. And each culture has its own indigenous pathways to help—often through religious and spiritual life. Clearly these nuances of cultures must be understood to deal with the cultural phenomenon of stigma effectively.

Over the past quarter century much has been done to help people understand that mental illness is an expectable part of human life, that treatment is generally effective, that mental anguish need not be a part of one’s life, and that even people with the most severe mental illnesses can recover— can, that is, create lives of personal meaning and satisfaction.

Has stigma been overcome? Not by a long shot. But we have made some progress; and with greater investment in public education, in promoting community acceptance, and in developing cultural competence, I am confident that we can make much more.

(Michael B. Friedman is the Director of the Center for Policy and Advocacy of the Mental Health Associations of NYC and Westchester. The opinions expressed in this article are his own and do not necessarily reflect the views of the MHAs. Mr. Friedman can be contacted at center@mhaofnyc.org.)

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