74 Stigma of Mental Illness

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. Try not to use these words, and encourage students not to use them. It is more appropriate to refer to “a person who has a mental illness” when speaking about someone.

“Mentally ill people are nuts, crazy, wacko.” “Mentally ill people are morally bad.” “Mentally ill people are dangerous and should be locked in an asylum forever.” “Mentally ill people need somebody to take care of them.” 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?

Stigmas are negative stereotypes about groups of people. Common stigmas about people who are mentally ill are

• Individuals who have a mental illness are dangerous.
• Individuals who have a mental illness are irresponsible and can’t make life decisions for themselves.
• People who have a mental illness are childlike and must be taken care of by parents or guardians.
• People who have a mental illness should just get over it.

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.

Stigmas against individuals who have a mental illness lead to injustices, including discriminatory decisions regarding housing, employment, and education. Overcoming the stigmas commonly associated with mental illness is yet one more challenge that people who have a mental illness must face. Indeed, many people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself. The stigmatizing attitudes toward mental illness held by both the public and those who have a mental illness lead to feelings of shame and guilt, loss of self-esteem, social dependence, and a sense of isolation and hopelessness. One of the worst consequences of stigma is that people who are struggling with a mental illness may be reluctant to seek treatment that, in most cases, would significantly relieve their symptoms.

Providing accurate information is one way to reduce stigmas about mental illness. Advocacy groups protest stereotypes imposed upon those who are mentally ill. They demand that the media stop presenting inaccurate views of mental illness and that the public stops believing these negative views. A powerful way of countering stereotypes about mental illness occurs when members of the public meet people who are effectively managing a serious mental illness: holding jobs, providing for themselves, and living as good neighbors in a community. Interaction with people who have mental illnesses challenges a person’s assumptions and changes a person’s attitudes about mental illness.

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. 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 18–24 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. “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.” His 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 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.2 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.3 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, using the United Press International database from 1983, found that 86 percent of all print stories dealing with former mental patients focused on violent crime.4 A 1997 British study found similarly skewed stories, and a 1999 German study concludes that selective reporting about mental illness causes audiences to distort their view of the “real world.”6 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. In an outstanding documentary for Dateline NBC, John Hockenberry followed for two years the uneven course of recovery of a young man with schizophrenia.

Feature stories about the achievements of individuals diagnosed with mental illness—such as Newsweek’s account of Tom Harrell,9 a jazz trumpet star; The San Diego Union-Tribune’s account of pro golfer Muffin Spencer-Devlin;10 and a New York Times business section feature about John Forbes Nash, Jr., the winner of a Nobel Prize for economics11—also help shatter stereotypes. A New York Times Magazine cover story, for example, brought new understanding to a highly publicized homicide when it chronicled a young man’s search for help in a crumbling mental health system. 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. In his 1999 landmark report to the Nation on mental illness and health, Surgeon General David Satcher called on America to tear down the barriers of prejudice that block access to services and recovery.13 Nothing short of a national commitment to de-stigmatize mental illness will achieve this goal.

The Roots of Stigma

Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Penn & Martin, 1998; Corrigan & Penn, 1999). It reduces patients’ access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its most overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society.

Explanations for stigma stem, in part, from the misguided split between mind and body first proposed by Descartes. Another source of stigma lies in the 19th-century separation of the mental health treatment system in the United States from the mainstream of health. These historical influences exert an often immediate influence on perceptions and behaviors in the modern world.

Public Attitudes About Mental Illness: 1950s to 1990s

Nationally representative surveys have tracked public attitudes about mental illness since the 1950s (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981). To permit comparisons over time, several surveys of the 1970s and the 1990s phrased questions exactly as they had been asked in the 1950s (Swindle et al., 1997).

In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as“mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981).

By 1996, a modern survey revealed that Americans had achieved greater scientific understanding of mental illness. But the increases in knowledge did not defuse social stigma (Phelan et al., 1997). The public learned to define mental illness and to distinguish it from ordinary worry and unhappiness. It expanded its definition of mental illness to encompass anxiety, depression, and other mental disorders. The public attributed mental illness to a mix of biological abnormalities and vulnerabilities to social and psychological stress (Link et al., in press). Yet, in comparison with the 1950s, the public’s perception of mental illness more frequently incorporated violent behavior (Phelan et al., 1997). This was primarily true among those who defined mental illness to include psychosis (a view held by about one-third of the entire sample). Thirty-one percent of this group mentioned violence in its descriptions of mental illness, in comparison with 13 percent in the 1950s. In other words, the perception of people with psychosis as being dangerous is stronger today than in the past (Phelan et al., 1997).

The 1996 survey also probed how perceptions of those with mental illness varied by diagnosis. The public was more likely to consider an individual with schizophrenia as having mental illness than an individual with depression. All of them were distinguished reasonably well from a worried and unhappy individual who did not meet professional criteria for a mental disorder. The desire for social distance was consistent with this hierarchy (Link et al., in press).

Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past (Phelan et al., 1997).

This finding begs yet another question: Are people with mental disorders truly more violent? Research supports some public concerns, but the overall likelihood of violence is low. The greatest risk of violence is from those who have dual diagnoses, i.e., individuals who have a mental disorder as well as a substance abuse disorder (Swanson, 1994; Eronen et al., 1998; Steadman et al., 1998). There is a small elevation in risk of violence from individuals with severe mental disorders (e.g., psychosis), especially if they are noncompliant with their medication (Eronen et al., 1998; Swartz et al., 1998). Yet the risk of violence is much less for a stranger than for a family member or person who is known to the person with mental illness (Eronen et al., 1998). In fact, there is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder. Because the average person is ill-equipped to judge whether someone who is behaving erratically has any of these disorders, alone or in combination, the natural tendency is to be wary. Yet, to put this all in perspective, the overall contribution of mental disorders to the total level of violence in society is exceptionally small (Swanson, 1994).

Because most people should have little reason to fear violence from those with mental illness, even in its most severe forms, why is fear of violence so entrenched? Most speculations focus on media coverage and deinstitutionalization (Phelan et al., 1997; Heginbotham, 1998). One series of surveys found that selective media reporting reinforced the public’s stereotypes linking violence and mental illness and encouraged people to distance themselves from those with mental disorders (Angermeyer & Matschinger, 1996). And yet, deinstitutionalization made this distancing impossible over the 40 years as the population of state and county mental hospitals was reduced from a high of about 560,000 in 1955 to well below 100,000 by the 1990s (Bachrach, 1996). Some advocates of deinstitutionalization expected stigma to be reduced with community care and commonplace exposure. Stigma might have been greater today had not public education resulted in a more scientific understanding of mental illness.

Stigma and Seeking Help for Mental Disorders

Nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). Stigma surrounding the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment (Sussman et al., 1987; Cooper-Patrick et al., 1997). Concern about stigma appears to be heightened in rural areas in relation to larger towns or cities (Hoyt et al., 1997). Stigma also disproportionately affects certain age groups, as explained in the chapters on children and older people.

The surveys cited above concerning evolving public attitudes about mental illness also monitored how people would cope with, and seek treatment for, mental illness if they became symptomatic. (The term “nervous breakdown” was used in lieu of the term “mental illness” in the 1996 survey to allow for comparisons with the surveys in the 1950s and 1970s.) The 1996 survey found that people were likelier than in the past to approach mental illness by coping with, rather than by avoiding, the problem. They also were more likely now to want informal social supports (e.g., self-help groups). Those who now sought formal support increasingly preferred counselors, psychologists, and social workers (Swindle et al., 1997).

Stigma and Paying for Mental Disorder Treatment

Another manifestation of stigma is reflected in the public’s reluctance to pay for mental health services. Public willingness to pay for mental health treatment, particularly through insurance premiums or taxes, has been assessed largely through public opinion polls. Members of the public report a greater willingness to pay for insurance coverage for individuals with severe mental disorders, such as schizophrenia and depression, rather than for less severe conditions such as worry and unhappiness (Hanson, 1998). While the public generally appears to support paying for treatment, its support diminishes upon the realization that higher taxes or premiums would be necessary (Hanson, 1998). In the lexicon of survey research, the willingness to pay for mental illness treatment services is considered to be“soft.” The public generally ranks insurance coverage for mental disorders below that for somatic disorders (Hanson, 1998).

Reducing Stigma

There is likely no simple or single panacea to eliminate the stigma associated with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved. Knowledge of mental illness appears by itself insufficient to dispel stigma (Phelan et al., 1997). Broader knowledge may be warranted, especially to redress public fears (Penn & Martin, 1998). Research is beginning to demonstrate that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Overall approaches to stigma reduction involve programs of advocacy, public education, and contact with persons with mental illness through schools and other societal institutions (Corrigan & Penn, 1999).

Ironically, these examples also illustrate a more unsettling consequence: that the mental health field was adversely affected when causes and treatments were identified. As advances were achieved, each condition was transferred from the mental health field to another medical specialty (Grob, 1991). For instance, dominion over syphilis was moved to dermatology, internal medicine, and neurology upon advances in etiology and treatment. Dominion over hormone-related mental disorders was moved to endocrinology under similar circumstances. The consequence of this transformation, according to historian Gerald Grob, is that the mental health field became over the years the repository for mental disorders whose etiology was unknown. This left the mental health field “vulnerable to accusations by their medical brethren that psychiatry was not part of medicine, and that psychiatric practice rested on superstition and myth” (Grob, 1991).

These historical examples signify that stigma dissipates for individual disorders once advances render them less disabling, infectious, or disfiguring. Yet the stigma surrounding other mental disorders not only persists but may be inadvertently reinforced by leaving to mental health care only those behavioral conditions without known causes or cures. To point this out is not intended to imply that advances in mental health should be halted; rather, advances should be nurtured and heralded. The purpose here is to explain some of the historical origins of the chasm between the health and mental health fields.

Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises to be an effective antidote. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate. Still, fresh approaches to disseminate research information and, thus, to counter stigma need to be developed and evaluated. Social science research has much to contribute to the development and evaluation of anti-stigma programs (Corrigan & Penn, 1999). As stigma abates, a transformation in public attitudes should occur. People should become eager to seek care. They should become more willing to absorb its cost. And, most importantly, they should become far more receptive to the messages that are the subtext of this report: mental health and mental illness are part of the mainstream of health, and they are a concern for all people.

Violence and Mental Illness: The Facts

The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public, according to the U.S. Surgeon General (DHHS, 1999). The belief that persons with mental illness are dangerous is a significant factor in the development of stigma and discrimination (Corrigan, et al., 2002). The effects of stigma and discrimination are profound. The President’s New Freedom Commission on Mental Health found that, “Stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders—especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).”

This link is often promoted by the entertainment and news media. For example, Mental Health America, (formerly the National Mental Health Association) reported that, according to a survey for the Screen Actors’ Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence. Also most news accounts portray people with mental illness as dangerous (Mental Health America, 1999). The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al., 2002). Inaccurate and stereotypical representations of mental illness also exist in other mass media, such as films, music, novels and cartoons (Wahl, 1995).

Most citizens believe persons with mental illnesses are dangerous. A longitudinal study of Americans’ attitudes on mental health between 1950 and 1996 found, “the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.” Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).

As a result, Americans are hesitant to interact with people who have mental illnesses. Thirty-eight percent are unwilling to be friends with someone having mental health difficulties; sixty-four percent do not want someone who has schizophrenia as a close co-worker, and more than sixty-eight percent are unwilling to have someone with depression marry into their family (Pescosolido, et al., 1996).

But, in truth, people have little reason for such fears. In reviewing the research on violence and mental illness, the Institute of Medicine concluded, “Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small,” and further, “the magnitude of the relationship is greatly exaggerated in the minds of the general population” (Institute of Medicine, 2006). For people with mental illnesses, violent behavior appears to be more common when there’s also the presence of other risk factors. These include substance abuse or dependence; a history of violence, juvenile detention, or physical abuse; and recent stressors such as being a crime victim, getting divorced, or losing a job (Elbogen and Johnson, 2009).

In addition:

• “Research has shown that the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994).”
• “. . . [T]he absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994).”
• In a 1998 study that compared people discharged from acute psychiatric inpatient facilities and others in the same neighborhoods, researchers found that “there was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse (Steadman, Mulvey, Monahan, Robbins, Applebaum, Grisso, Roth, and Silver, 1998).”

People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). Researchers at North Carolina State University and Duke University found that people with severe mental illnesses—schizophrenia, bipolar disorder or psychosis—are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al., 1999).

People with mental illnesses can and do recover. People with mental illnesses can recover or manage their conditions and go on to lead happy, healthy, productive lives. They contribute to society and make the world a better place. People can often benefit from medication, rehabilitation, talk therapy, self help or a combination of these. One of the most important factors in recovery is the understanding and acceptance of family and friends.

Most people who suffer from a mental disorder are not violent—there is no need to fear them. Embrace them for who they are—normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support.

—Grohol, 1998