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World Psychiatry. 2002 February; 1(1): 16–20. | PMCID: PMC1489832 |
Understanding the impact of stigma on people with mental illness PATRICK W CORRIGAN1 and AMY C WATSON1 1University of Chicago Center for Psychiatric Rehabilitation and Chicago Consortium for Stigma Research, 7230 Arbor Drive, Tinley Park, IL 60477, USA 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 result
from misconceptions about mental illness. As a result of both, people with
mental illness are robbed of the opportunities that define a quality life:
good jobs, safe housing, satisfactory health care, and affiliation with a
diverse group of people. Although research has gone far to understand the
impact of the disease, it has only recently begun to explain stigma in mental
illness. Much work yet needs to be done to fully understand the breadth and
scope of prejudice against people with mental illness. Fortunately, social
psychologists and sociologists have been studying phenomena related to stigma
in other minority groups for several decades. In this paper, we integrate
research specific to mental illness stigma with the more general body of research
on stereotypes and prejudice to provide a brief overview of issues in the
area. The impact of stigma is twofold, as outlined in Table 1. Public stigma is the reaction that the general population
has to people with mental illness. Self-stigma is the prejudice which people
with mental illness turn against themselves. Both public and self-stigma may
be understood in terms of three components: stereotypes, prejudice, and discrimination.
Social psychologists view stereotypes as especially efficient, social knowledge
structures that are learned by most members of a social group ( 1- 3). Stereotypes are
considered "social" because they represent collectively agreed upon notions
of groups of persons. They are "efficient" because people can quickly generate
impressions and expectations of individuals who belong to a stereotyped group
( 4). | Table 1Comparing and contrasting the definitions of public stigma and self-stigma |
The fact that most people have knowledge of a set of stereotypes does not
imply that they agree with them ( 5).
For example, many persons can recall stereotypes about different racial groups
but do not agree that the stereotypes are valid. People who are prejudiced,
on the other hand, endorse these negative stereotypes ("That's right; all
persons with mental illness are violent!") and generate negative emotional
reactions as a result ("They all scare me!") ( 1, 3, 6).
In contrast to stereotypes, which are beliefs, prejudicial attitudes involve
an 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, leads
to discrimination, the behavioral reaction ( 9).
Prejudice that yields anger can lead to hostile behavior (e.g., physically
harming a minority group) ( 10). In
terms of mental illness, angry prejudice may lead to withholding help or replacing
health care with services provided by the criminal justice system ( 11). Fear leads to avoidance; e.g., employers do not want
persons 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 persons
to not pursuing life opportunities for themselves ( 13, 14). The remainder of this paper further
develops examples of public and self-stigma. In the process, we summarize
research on ways of changing the impact of public and self-stigma. Stigmas about mental illness seem to be widely endorsed by the general
public in the Western world. Studies suggest that the majority of citizens
in the United States ( 13, 15- 17) and many Western
European nations ( 18- 21) have stigmatizing attitudes about mental illness. Furthermore,
stigmatizing views about mental illness are not limited to uninformed members
of the general public; even well-trained professionals from most mental health
disciplines 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 represents
a cultural sphere that does not promote stigma or a dearth of research in
these societies. The available research indicates that, while attitudes toward
mental illness vary among non-Western cultures ( 26, 27), the stigma of mental illness may be
less severe than in Western cultures. Fabrega ( 26)
suggests that the lack of differentiation between psychiatric and non-psychiatric
illness in the three great non-Western medical traditions is an important
factor. While the potential for stigmatization of psychiatric illness certainly
exists in non-Western cultures, it seems to primarily attach to the more chronic
forms of illness that fail to respond to traditional treatments. Notably,
stigma seems almost nonexistent in Islamic societies ( 26- 28). Cross-cultural
examinations of the concepts, experiences, and responses to mental illness
are clearly needed. Several themes describe misconceptions about mental illness and corresponding
stigmatizing attitudes. Media analyses of film and print have identified three:
people with mental illness are homicidal maniacs who need to be feared; they
have childlike perceptions of the world that should be marveled; or they are
responsible for their illness because they have weak character ( 29- 32). Results of
two independent factor analyses of the survey responses of more than 2000
English and American citizens parallel these findings ( 19, 33): - fear and exclusion: persons with severe mental illness should be feared
and, therefore, be kept out of most communities;
- authoritarianism: persons with severe mental illness are irresponsible,
so life decisions should be made by others;
- benevolence: persons with severe mental illness are childlike and need
to be cared for.
Although stigmatizing attitudes are not limited to mental illness, the
public seems to disapprove persons with psychiatric disabilities significantly
more than persons with related conditions such as physical illness ( 34- 36).
Severe mental illness has been likened to drug addiction, prostitution, and
criminality ( 37, 38). Unlike physical disabilities, persons with mental illness
are perceived by the public to be in control of their disabilities and responsible
for causing them ( 34, 36). Furthermore, research respondents are less likely to
pity persons with mental illness, instead reacting to psychiatric disability
with anger and believing that help is not deserved ( 35, 36, 39). The behavioral impact (or discrimination) that results from public stigma
may take four forms: withholding help, avoidance, coercive treatment, and
segregated institutions. Previous studies have shown that the public will
withhold help to some minority groups because of corresponding stigma ( 36, 40).
A more extreme form of this behavior is social avoidance, where the public
strives to not interact with people with mental illness altogether. The 1996
General Social Survey (GSS), in which the Mac Arthur Mental Health Module
was 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 evening
socializing, work next to, or have a family member marry a person with mental
illness ( 41). Social avoidance is not
just self-report; it is also a reality. Research has shown that stigma has
a 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 people
with mental illness. For example, though recent studies have been unable to
demonstrate the effectiveness of mandatory treatment ( 48, 49), more than
40% of the 1996 GSS sample agreed that people with schizophrenia should be
forced into treatment ( 50). Additionally,
the public endorses segregation in institutions as the best service for people
with 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 as
a 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 far
fewer sanctioned examples of stigma and stereotypes because of protest efforts.
Anecdotal evidence suggests that protest campaigns have been effective in
getting stigmatizing images of mental illness withdrawn. There is, however,
little empirical research on the psychological impact of protest campaigns
on stigma and discrimination, suggesting an important direction for future
research. Protest is a reactive strategy; it attempts to diminish negative attitudes
about mental illness, but fails to promote more positive attitudes that are
supported by facts. Education provides information so that the public can
make more informed decisions about mental illness. This approach to changing
stigma has been most thoroughly examined by investigators. Research, for example,
has suggested that persons who evince a better understanding of mental illness
are less likely to endorse stigma and discrimination ( 17, 19, 52). Hence, the strategic provision of information about
mental illness seems to lessen negative stereotypes. Several studies have
shown that participation in education programs on mental illness led to improved
attitudes about persons with these problems ( 22, 53- 56).
Education programs are effective for a wide variety of participants, including
college undergraduates, graduate students, adolescents, community residents,
and persons with mental illness. Stigma is further diminished when members of the general public meet persons
with mental illness who are able to hold down jobs or live as good neighbors
in the community. Research has shown an inverse relationship between having
contact with a person with mental illness and endorsing psychiatric stigma
( 54, 57).
Hence, opportunities for the public to meet persons with severe mental illness
may discount stigma. Interpersonal contact is further enhanced when the general
public is able to regularly interact with people with mental illness as peers. One might think that people with psychiatric disability, living in a society
that widely endorses stigmatizing ideas, will internalize these ideas and
believe that they are less valued because of their psychiatric disorder. Self-esteem
suffers, as does confidence in one's future ( 7, 58, 59).
Given this research, models of self-stigma need to account for the deleterious
effects of prejudice on an individual's conception of him or herself. However,
research also suggests that, instead of being diminished by the stigma, many
persons 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 mental
health system, becoming more active participants in their treatment plan and
often pushing for improvements in the quality of services ( 63). Low self-esteem versus righteous anger describes a fundamental paradox
in self-stigma ( 64). Models that explain
the experience of self-stigma need to account for some persons whose sense
of self is harmed by social stigma versus others who are energized by, and
forcefully react to, the injustice. And there is yet a third group that needs
to be considered in describing the impact of stigma on the self. The sense
of 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 that
an individual with mental illness may experience diminished self-esteem/self-efficacy,
righteous anger, or relative indifference depending on the parameters of the
situation ( 64). Important factors that
affect a situational response to stigma include collective representations
that are primed in that situation, the person's perception of the legitimacy
of stigma in the situation, and the person's identification with the larger
group of individuals with mental illness. This model has eventual implications
for ways in which persons with mental illness might cope with self-stigma
as well as identification of policies that promote environments in which stigma
festers. Researchers are beginning to apply what social psychologists have learned
about prejudice and stereotypes in general to the stigma related to mental
illness. We have made progress in understanding the dimensions of mental illness
stigma, and the processes by which public stereotypes are translated into
discriminatory behavior. At the same time, we are beginning to develop models
of 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 also
learning about stigma change strategies. Contact in particular seems to be
effective for changing individual attitudes. Researchers need to examine whether
changes resulting from anti-stigma interventions are maintained over time. All of the research discussed in this paper examines stigma at the individual
psychological level. For the most part, these studies have ignored the fact
that stigma is inherent in the social structures that make up society. Stigma
is evident in the way laws, social services, and the justice system are structured
as well as ways in which resources are allocated. Research that focuses on
the social structures that maintain stigma and strategies for changing them
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STIGMA