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The Canadian Journal of Psychiatry

Volume 48 Ottawa, Canada, November 2003 Number 10

Guest Editorial

Considerations on the Stigma of Mental Illness


Julio Arboleda-Flórez, MD, FRCP(C), FAPA, DABFP, PhD1

tigma, prejudice, and discrimination are closely related with stigma’s negative consequences for persons with mental
S and tightly interwoven social constructs. These constructs
affect many, based on age, religion, ethnic origin, or socio-
illness and their families (3). Second, based on the review, it
comments on this issue’s papers on stigmatization and
economic status. However, a person can potentially move out discrimination.
of these groups, if not physically—as in age or ethnic back-
ground—then by moving up the social ladder, which makes Historical Elements
the affected person less of a target. Conversely, stigma, preju-
For the ancient Greeks, stizein, to tattoo or to brand, described
dice, and discrimination against those with mental illness cut
a distinguishing mark burned or cut into the flesh of slaves or
across all classes and social groups, and, to the extent that
criminals so that others would know who they were and that
many mental conditions are chronic and incapacitating, those
they were less-valued members of society. Although the term
affected can hardly migrate out of the grip of negative social
may not have been applied to mental illness, stigmatizing atti-
attitudes. The result is social annihilation that constricts the
tudes about the mentally ill were already apparent in Greek
lives of those with mental illness, preventing them from fully
society: as found in Sophocles’ Ajax or Euripedes’ The Mad-
reengaging in their communities and participating in the
ness of Heracles, mental illness was associated with concepts
social activities of their groups of reference.
of shame, loss of face, and humiliation (4).
The general public most frequently makes contact with mental
illness through the media or the movies. Unfortunately, the In the Christian world, the word stigmata is applied to peculiar
media often depict patients as unpredictable, violent, and dan- marks resembling the wounds of Christ that some individuals
gerous (1), and movies usually follow the popular “psycho- develop on their palms and soles. Paul, for example pro-
killer” plot (2) long exploited by the cinematographic claimed, “I bear in my body the stigmata of Christ” (5).
industry. Associating mental illness with violence helps to Although the roots of the term are the same, the religious con-
perpetuate stigmatizing and discriminatory practices against notation of stigmata is not the same as stigma: stigma is a
mentally ill persons; it is only one of many negative stereo- social construct indicating disgrace that, at the same time,
types and common prejudicial attitudes about them. identifies the bearer. Hawthorne exemplifies this in his novel
The Scarlet Letter (6). In this novel set in the puritanical New
This editorial has 2 purposes. It first reviews theoretical ele- England town of Salem, Massachusetts, a woman accused of
ments fundamental to stigma as a social construct, together being an adulteress is ordered to wear the letter “A” to signify
her sin and shame. The town of Salem is also famous for hav-
ing been the place of a mass execution of witches in 1662, a
The Canadian Psychiatric Association acknowledges support in part for
the In Review series courtesy of an unrestricted educational grant from period in which the Malleus Maleficarum (7) (Witches’ Ham-
mer) was still a highly regarded reference textbook for the
management of witches. The Inquisitorial approach to
witches, apart from being highly misogynous, also repre-
Mental Health Matters
sented a negative and condemning attitude toward mental ill-
ness; it may have been the origin of the stigmatizing attitudes

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The Canadian Journal of Psychiatry—Guest Editorial

toward those with mental illness that have existed in Christian class, and belonging to that class reinforces the stigma against
cultures from the rise of rationalism in the 17th century to the the individual.
present (8). Madness has long been held among Christians to
Describing the characteristics of stigma—or what it is and
be a form of punishment inflicted by God on sinners (9).
how it develops—begets the question why it develops.
Stigmatizing and discriminatory attitudes against those with
Unfortunately, little literature on the subject exists, but the
mental illness have also been reported and are known to exist
hypothesis has been advanced that 3 major elements are
in many other cultures.
required for stigmatizing attitudes to happen: an original
“functional impetus” that is accentuated through “perception”
Theoretical Considerations and, subsequently, consolidated through “social sharing” of
Goffman thought of stigma as an attribute that is “deeply dis- information. The sharing of stigma becomes an element of a
crediting.” According to Goffman, stigmatized persons are society that creates, condones, and maintains stigmatizing
regarded as being of less value and “spoiled” by the stigmatiz- attitudes and behaviours. According to Stangor and Crandall
ing effects of 3 conditions: “abominations” of the body, such (13), the most likely candidate for the initial “functional impe-
as physical deformities; “tribal identities,” such as ethnicity, tus” is the goal of avoiding a threat to the self (Table 1).
sex, or religion; and “blemishes of individual character,” such Threats can be either “tangible,” if they threaten a material or
as mental disorders or unemployment (10). This static concept concrete good, or “symbolic,” if they threaten the beliefs, val-
of stigma has now been enlarged to encompass a social con- ues, and ideologies upon which the group ordains its social,
struct linked to values placed on social identities through a political, or spiritual domains.
process consisting of 2 fundamental components: the recogni-
tion of the differentiating “mark” and the subsequent devalua- Table 1 The origins of stigmaa
tion of the bearer. Stigma is therefore a relational construct
· Functional impetus: initial perception of tangible or symbolic
based on attributes. Consequently, stigmatizing conditions threat
may change with time and among cultures (11). · Perception: perceptual distortions that amplify group
differences
Stigma develops within a social matrix of relationships and · Social sharing: consensual sharing of threats and
perceptions
interactions and has to be understood within a 3-dimensional
a
axis. The first of these dimensions is perspective; that is, the Adapted from Stangor and Crandall (13, p 73).
way stigma is perceived by the person who does the stigmatiz-
ing (perceiver) or by the person who is being stigmatized (tar- Cultural perceptions of mental illness may be associated with
get). The second dimension is identity, defined along a tangible threats to the health of society because mental illness
continuum from the entirely personal at one end to engenders 2 kinds of fear: fear of physical attack and fear of
group-based identifications and group belongingness at the contamination (that is, that we may also lose our sanity). To
other. The third dimension is reactions; that is, the way the the extent that persons with mental illness are stereotyped as
stigmatizer and the stigmatized react to the stigma and its con- lazy, unable to contribute, and a burden to the system, mental
sequences. Reactions can be measured at the cognitive, affec- illness may also be seen as posing a symbolic threat to the
tive, and behavioural levels. The stigmatizing mark also has 3 beliefs and values shared by members of the group.
major characteristics: visibility, or how obvious the mark is;
controllability, or whether the mark is under the bearer’s con- In place for centuries, the custodial, institution-based model
trol; and impact, or how much those who do the stigmatizing of care for those with mental illness contributed to their stig-
fear the stigmatized (12). Stigmatizing attitudes get worse if matization by segregation. The mentally ill were separated
the mark is very visible, if it is perceived to be under the from the physically ill, who were treated in local hospitals in
bearer’s control, and if it instills fear by conveying an element their own communities. The decision to send persons with
of danger. mental illness to far-away institutions, although well inten-
tioned in its origins, dislocated them from their communities.
Mental health patients who show visible signs of their condi- With time, they lost their connections with coworkers,
tions because either their symptoms or medication side effects friends, and relatives; ultimately, they lost their personal iden-
make them appear strange, who are socially construed as tity. At a system level, the institutional model also contributed
being weak in character or lazy, and who display threatening to the banishment of mental illness, and also of psychiatry,
behaviours usually score high on any of these 3 dimensions. from the general stream of medicine. The therapeutic nihilism
By a process of association and class identity, all persons with that for centuries permeated most psychiatric work also con-
mental illness are equally stigmatized: regardless of impair- tributed to the asylum mentality. The few-and-far-between
ment or disability level, the individual patient is lumped into a therapeutic successes—such as the discovery of the cause and

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Considerations on the Stigma of Mental Illness

treatment of mental conditions like general paresis and facts of mental illness. These policies and abuses are not the
pellagra—only helped to reinforce the nihilism, in that the preserve of any country. In developed countries, health insur-
remaining conditions were considered incurable. With time, ance companies openly discriminate against persons who
the stigma associated with mental conditions and mental acknowledge that they have had a mental problem. Life insur-
health patients also extended to those in charge of caring for ance and income-protection policies make it a veritable ordeal
them, psychiatrists included. to collect payments when temporary disability has been caused
by mental conditions such as anxiety or depression. Many
Stigma and Discrimination patients see their payments denied or their policies discontin-
Based on social distance measurements that show acceptance ued. Government policies sometimes demand that mental
of mental patients and on findings that the behaviour and not health patients be registered in special files before pharmacies
the label is stigmatizing, some researchers have argued that can dispense needed psychiatric medications. More broadly,
persons with mental illness are not stigmatized (14). They also the national research budgets in many developed countries pro-
argue that mental health patients themselves are rarely able to vide only a modicum of funds for research in mental conditions.
report concrete instances of rejection (15). However, findings In Canada, for example, mental health research commands less
denying the pernicious effects of stigma have been refuted than 5% of all the research health budgets, yet mental illness
based on the poor methodology of these studies (16). affects directly 20% of Canadians (21).
For the stigmatized, stigma is a feeling of being negatively dif- In developing countries, archaic beliefs about the nature of
ferentiated owing to a particular condition or state. Stigma is mental conditions, sometime enmeshed with religious beliefs
related to negative stereotyping and prejudicial attitudes that and cultural determinants, stigmatize patients, who are denied
in turn lead to discriminatory practices which deprive the stig- access to treatment opportunities, and stigmatize their fami-
matized person from legally recognized entitlements. Stigma, lies when, for example, daughters in an affected family cannot
prejudice, and discrimination are therefore inextricably marry because it is feared that they are contaminated (22). In
related. Unlike prejudice, however, stigma involves defini- some countries, patients languish in institutions for so long
tions of character and class identification. Consequently, it that they lose all contacts and, owing to poor records, even
has larger implications and impacts. their names are forgotten. Obviously, the loss of personal
Prejudice often stems from ignorance or unwillingness to find identity deprives them of their civic and political rights.
the truth. For example, a study conducted by the Ontario Divi-
sion of the Canadian Mental Health Association in Violence and Mental Illness
1993–1994 found that the most prevalent misconceptions Few popular notions and misconceptions are so pervasive and
about mental illness include the belief that mental patients are stigmatizing as the belief that persons with mental illness are
dangerous and violent (88%); that they have a low IQ or are unpredictable and dangerous. This belief—so central to stig-
developmentally handicapped (40%); that they cannot func- matization and discrimination against those affected—cannot
tion, hold a job, or have anything to contribute (32%); that be easily discounted when hardly a month goes by without the
they lack willpower or are weak and lazy (24%); that they are media reporting the sad story of yet another horrendous crime
unpredictable (20%); and finally, that they are to be blamed allegedly committed by a patient with mental illness. This
for their own condition and should just “shape up” (20%) type of news, even when reported conscientiously and accu-
(17). Similarly, a survey among first-year university students rately, arouses fear and apprehension and pushes the public to
in the US found that almost two-thirds believed “multiple per- demand measures to prevent further crimes. Those with men-
sonalities” to be a common symptom of schizophrenia, and a tal illness in general bear the brunt of impact from the actions
poll among the general public found that 55% did not believe of the few. Unfortunately, the media do not inform the public
that mental illness exists, with only 1% acknowledging that that only a very small minority of mental health patients com-
mental illness is a major health problem (18). Some of these mit serious crimes and that the percentage of violence attribut-
myths also surfaced in a study conducted in Calgary during able to mental illness as a portion of the general violence in the
the pilot phase of the World Psychiatric Association (WPA) community is also very small (23).
project Open the Doors (19). Respondents to this study Sensational media reports (24,25) reinforce beliefs instilled
believed that persons with schizophrenia cannot work in regu- by movies that depict mental health patients as “uncontrolla-
lar jobs (72%), have a split personality (47%), and are danger- ble killers.” Relatives of the mentally ill assert that the way
ous to the public because of violent behaviour (14%) (20). they are depicted in movies is the most important contributor
Outright discriminatory policies leading to abuses of human to stigmatization (26). Movies have stigmatized not only
and civil rights and denial of legal entitlements can often be those with mental illness but also psychiatrists, often extend-
traced to stigmatizing attitudes or plain ignorance about the ing negative stereotypes to portray them as libidinous lechers,

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The Canadian Journal of Psychiatry—Guest Editorial

eccentric buffoons, and evil-minded, vindictive, and repres- handicapping condition (36). In the same study, the Alberta
sive agents of the social system—and in the case of female group found that greater knowledge was associated with
psychiatrists, as loveless and sexually unfulfilled (27). less-distancing attitudes but that exposure to persons with men-
tal illness was not correlated with knowledge or attitudes (37).
The association between mental illness—specifically, schizo-
These findings confirm findings from other authors regarding
p h r e n ia— a n d v io le n c e , a lth o u g h c o n f ir med
the split between knowledge and attitudes among the general
epidemiologically (28), remains unclear. It seems to flow not
public (38). In different findings, the Alberta group also con-
so much through direct links of causality as through a series of
cluded that broad approaches to increase mental health literacy,
confounders and covariating causes, such as comorbidities
as defined by Jorm (39), may not be as effective among already
with alcohol and substance abuse (not unlike that which
highly educated population groups (40) as would specifically
drives violence among individuals without mental illness) and
focused interventions among small groups such as high school
psychopathic personality. In addition, not every act of vio-
students or clinical workers. This conclusion supports Corri-
lence committed by a mental health patient should be cata-
gan’s and Penn’s findings in regard to targeting specific groups
logued as resulting from the mental condition, in that the
and targeting specific beliefs about mental illness held by
context, such as taunting or victimization of the affected per-
ethnic minorities (41).
son, could be the main determinant for the violent reaction
(29). Further, if a person with past mental illness commits a A major issue identified by the Calgary group was the need for
violent act, it should not be assumed automatically that the an instrument to measure “felt stigma” among persons with
past mental illness is associated with the present violence. mental illness to provide an epidemiologic measure of levels,
From a public health perspective, the risk of violence from frequency, and degrees of stigmatization. In this regard, Cor-
those with mental illness should be measured via the attribut- rigan advises that stigma research should examine 3 issues:
able risk accrued to mental illness, compared with all other 1) “signaling events” such as labelling, physical appearance,
sources of violence in the community (30). These other and behaviour; 2) knowledge structures to bridge information
causes, and not persons with mental illness, are the true threats about controllability attributions and public attitudes about
to community security (31). Unfortunately, one single case of dangerousness and self-care; and 3) ways in which those
violence is usually sufficient to counteract the gains already knowledge structures lead to emotional reactions or behav-
made in community reintegration of mental health patients. ioural responses (42).
The stigmatization of mental illness impacts negatively, not The 3 papers included in this issue’s In Review section present
only on the level of services provided but also on the quality of research efforts on stigma from Canada and Germany that fol-
these services; it compromises access to care because pol- low Corrigan’s agenda to a large extent. Focusing on empiri-
icy-makers and the public believe that persons with mental ill- cal research into interventions for stigma and evaluations of
ness are dangerous, lazy, unreliable, and unemployable (32). their effectiveness, they make a cohesive set. The Canadian
paper, by Dr Heather Stuart (43), deals with the problem of
Research on the Stigma of Mental Illness media reporting. It evaluates a media-intervention program
Although there does not seem to be a one-to-one relation carried out in Calgary within the activities of the Open the
between exposure to environmental stressors, such as stigma Doors pilot program, which aimed to combat stigma and dis-
and discrimination, and adaptational outcomes, research on crimination toward persons with schizophrenia. This paper
stigma has demonstrated that it has negative outcomes on highlights both the importance of media reporting on sensa-
physical health and self-esteem (33). Persons with mental ill- tional crimes supposedly committed by persons with mental
ness often experience prejudice similar to that experienced by illness and how broader social situations can influence media
those who suffer racial or ethnic discrimination, but the practi- reporting. A conclusion to be drawn from this paper is that,
cal effects are complex and affected by several factors, such as while the media have a responsibility to inform the public,
age, sex, and the degree of self-stigmatization (34). mental health service providers, relatives, and consumers
It has often been confirmed that stigmatization and prejudice alike also have a responsibility to ensure that patients are
are the reasons why many persons do not seek assistance or properly treated and adhere to acceptable treatment protocols
postpone seeking assistance until too late (35). Recent research to minimize or eliminate violent incidents caused by mentally
has also demonstrated that the fear of mental illness is not ill persons. One single case of violence is enough to under-
related just to the behaviour sometimes demonstrated by mine any good work to combat stigma and discrimination.
affected persons. It is also related to the label itself and to the The paper by Dr Wolfgang Gaebel and Dr Anja Baumann (44)
consequences that flow from the illness. Thus, in the Alberta deals with the effects and effectiveness of antistigma
pilot site of the Open the Doors program, the Edmonton respon- interventions within the framework of the Open the Doors
dents rated “loss of mind” as more disabling than any other program in Germany. It is interesting that this paper already

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Considerations on the Stigma of Mental Illness

provides some results of comparison data between Alberta, Conclusions


Canada, and 6 cities in Germany. In these data, the figures for Successful treatment and community management of mental
social distance are practically the same for both countries. The illness relies heavily on the involvement of many levels of
rather unexpected negative effects from one type of inter- government, social institutions, clinicians, caregivers, the
vention in Germany—viewing a film—are similar to the public at large, consumers, and their families. Successful
unexpected negative effects of media intervention in Calgary, community reintegration of mental health patients and the
which underscores 3 issues: that a very narrow line should be acceptance of mental illness as an inescapable element of our
walked when mounting interventions against stigma, that fear social fabric can only be achieved by engaging the public in a
of violence from persons with mental illness remains a com- true dialogue about the nature of mental illnesses, their devas-
mon denominator to understanding stigma, and that any inter- tating effects on individuals and communities, and the prom-
ventions regarding stigma should be accompanied by a ise of better treatment and rehabilitation alternatives. An
thorough evaluation component to gauge their effectiveness enlightened public, working in unison with professional asso-
and types of impact. ciations and with lobby groups on behalf of persons with men-
tal illness, can leverage national governments and health care
Finally, the second paper from Germany, by Dr Matthias organizations to provide equitable access to treatment and to
Angermeyer, Dr Michael Beck, and Dr Herbert Matschinger, develop legislation against discrimination. With these tools,
enters into more detail on the matter of social distance and its communities can enter into a candid exchange of ideas about
determinants (45). The paper examines whether labelling and the causes of stigma and the consequences of stigmatizing
beliefs about the causes and prognosis of schizophrenia are at attitudes in their midst. Only these concerted efforts will even-
the root of the social distance that most people seem to express tually dispel the stigma associated with mental illness.
regarding those who suffer from this mental condition.
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