Mental Health Stigma
By Drs. Thomas Ungar and Rivian Weinerman
Mental health stigma remains one of the only areas of socially accepted discrimination, often so inherent that it goes unnoticed. While significant progress has been made in decreasing stigma and discrimination based on gender, race, sexual orientation, and religion, stigma against people with mental illness and psychiatric issues remains prevalent in society.
Think for a moment if you would go to visit a friend in a hospital, who is there because of a physical health condition. Now think if this person had a mental health problem. Would you visit? Would you tell others if you had a mental health problem?
The growing area of anti-stigma activities includes: work by the Opening Minds group of the Mental Health Commission of Canada; several national mental health awareness campaigns; a recent anti-stigma position statement by the Canadian Psychiatric Association; and Canada’s first nationally accredited continuing education module “Combating Stigma for Physicians and Other Health Professionals,” launched in 2012 (www.cma.ca/antistigma). The University of Toronto’s Department of Psychiatry has identified anti-stigma activities as a key pillar in its strategic priorities and held the inaugural Mindfest public forum at Hart House in the spring of 2013.
What is Stigma?
Stigma is a complex social process that is the culmination of prejudice and discrimination. Social stigma is severe social disapproval of or personal discontent with a person on the grounds of their unique characteristics, which distinguish them from others in society. The ancient Greek symbol “stigma” was tattooed, burned, or branded into the skin of people that society wanted to easily identify as outsiders, different, and easily distinguishable from others in society. Stigma has been defined as “a mark of disgrace” by which persons were socially shunned. Stigmatized individuals “possess (or are believed to possess) some attribute or characteristic that conveys a social identity that is devalued in a particular social context” and separates “us” from “them.”
Almost all stigma is based on a person differing from social or cultural norms. Erving Goffman defined stigma as “the process by which the reaction of others spoils normal identity,” and thought that stigmatized individuals possess “an attribute that is deeply discrediting and reduces the bearer from a whole and usual person to a tainted, discounted one.”
The 3 forms of stigma recognized by Goffman include: the experience of a mental illness (or the imposition of such a diagnosis); a physical form of deformity or an undesired differentness; or an association with a particular race, religion, belief, etc. Goffman’s theory has been criticized to associate blame with the individual. Power imbalance has been identified as a likely prerequisite, and “in many instances power differences are so taken for granted as to seem unproblematic.”
Self-stigma is the term used when people internalize public attitudes of prejudice and discrimination with many negative effects to themselves.
Courtesy stigma or stigma by association is a phenomenon that occurs when people who provide care or services to vulnerable populations are also stigmatized by association with the group receiving care.
Structural stigma and discrimination refers to “institutional accumulated practices that work to the disadvantage of mental health patients even in the absence of individual prejudice or discrimination. This ‘disabling environment’ is created by the barriers to participation in receiving care that reside in the architecture or structures we have constructed.”
The Impact of Stigma
Stigma is one of the major barriers preventing people from seeking help. Many people with mental health conditions report feeling ashamed, unworthy, and undeserving, don’t tell others about what is going on, and report that the stigma is often worse than their illness. As a result, they often keep mental health issues secret. Survey statistics demonstrate that 40% of Canadian parents would not tell anyone if their child had a mental illness. Only 1 child in 6 who is diagnosed with a mental health problem gets help. One third of the news stories about mental health focus on murder and violent crimes, sensationalizing and misrepresenting the facts.
This has a negative effect on primary care, as there is a relatively high prevalence of mental health issues in the general population. One in 10 people in Canada struggle with mental illness in a given year, and 1 in 5 in a lifetime.8 In Canada, mental health conditions are the leading cause of workplace disability, and economic costs are estimated at $6 billion annually. In 2020, depression will be the single leading cause of global disease burden, surpassing both cancer and heart disease.
The adverse effects of stigma include delays in seeking medical treatment, early treatment discontinuation, difficulties in obtaining housing, adverse economic effects, poor quality of care, and increased mortality. Within health care, stigma has been described as the primary barrier to treatment and recovery.
Stigma Intervention Strategies
Protest initiatives to change offensive language or behaviour have demonstrated limited benefit and can backfire. Traditional education focusing on improving literacy, help-seeking, as well as social marketing campaigns aimed to improve awareness and attitudes have shown modest benefit. One of this paper’s authors has created a public multi-media social marketing and information website at www.mentalhealthminute.com.
Contact-based education involves interaction and contact with a person with mental health condition in recovery and has amongst the best evidence to improve attitudes. Structural change intervention includes both legislative and policy changes aimed to improve equity and social justice, and it is also an evidence-based recommendation. Structural change is informed by the Social Justice Model of autonomy, civil rights, and a right to health, as outlined in the UN convention on the Rights of Persons with Disabilities (2007) and the Canadian Charter of Rights and Freedoms (1982).
Strategies targeting physicians and health care providers include a benchmark online-accredited Continuing Education module “Combating Stigma for Physicians and Other Health Professionals” (www.cma.ca/stigma), created by this paper’s authors by using the Cognitive Behavioural Interpersonal Skills (CBIS) manual to introduce clinical skills enhancement to family physicians, shown to increase mastery and combat avoidance.
A current debate about anti-stigma interventions is whether to share biologic disease state information about mental illness. This can worsen stigma for the public and lead to the incorrect conclusion that mental health disorders are permanent brain damage. But health providers may have a different paradigm for biology, so teaching the biology of mental illness may be as useful as an intervention to legitimize mental illness and improve quality of care.
Future efforts will likely embrace the human right to health, social justice advocacy, with policy and legislative change, and contact-based education.13 The Recovery and Hope movements increasingly perceive stigma as a social problem and advocate for an individual’s autonomy, responsibility, and participation in their own recovery. For scientists, scholars, and advocates looking for maximal impact of their work, anti-stigma studies is rich with opportunity.
Thomas Ungar MD, MEd, CCFP, FCFP, FRCPC, DABPN
Associate Professor of Psychiatry,
University of Toronto
Chief of Psychiatry and Medical Director Mental Health Program,
North York General Hospital
Rivian Weinerman MD, BSc (Med), FRCPC
Associate Clinical Professor,
University of British Columbia
Regional Head Division of Collaborative Care Psychiatry,
Vancouver Island Health Authority
Collaborative Care Psychiatrist, Collaborative Care Services,
Victoria, British Columbia
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