This is the door to an inpatient psychiatric unit. It is locked at all times. Does this look like a place of healing? Why or why not? What does this environment say about the patients on this unit?

THE

OF MENTAL ILLNESS

Stigma

Families will say this, "Only illness in the world where you never get a covered dish." There is something about having a mental illness where everything falls away, and what you experience is fear and isolation rather than a sense of people coming towards you. (Joyce Burland)

What is stigma?

Original meaning: Bodily signs that indicate something about moral character of the person

What is stigma?

Coined by Goffman (1963) to refer to prejudices related to having a mental illness

In Greek society, stigmatizing attitudes about the mentally ill were already apparent

What is stigma?

As early as the 16th century, “madness” was seen as a “perverted will” and “symptoms of animal instincts”…. “a beast”

What is stigma?

AThe Scarlet Letter

What is stigma?

In The Scarlet Letter by Nathanial Hawthorne, Hester is made to wear an “A”, signifying her identify as an adulteress. The “A” is meant to be a symbol of shame, but instead it becomes a powerful symbol of identity to Hester. The letter’s meaning shifts as time passes. Originally intended to mark Hester as an adulterer, the “A” eventually comes to stand for “Able.” Finally, it becomes indeterminate: the Native Americans who come to watch the Election Day pageant think it marks her as a person of importance and status. The letter helps to point out the ultimate meaninglessness of the community’s system of judgment and punishment. More often than not, a symbol becomes a focal point for critical analysis and debate.

What is stigma?

In The Scarlet Letter, Hester is publicly shamed and forced by the people of Boston to wear a badge of humiliation, but she was not willing to leave the town. Hester’s behavior is premised on her desire to determine her own identity rather than to allow others to determine it for her. To her, running away or removing the letter would be an acknowledgment of society’s power over her: she would be admitting that the letter is a mark of shame and something from which she desires to escape. Instead, Hester stays, refiguring the scarlet letter as a symbol of her own experiences and character. Her past sin is a part of who she is; to pretend that it never happened would mean denying a part of herself. Thus, Hester very determinedly integrates her sin into her life.

What is stigma?

What does the story of The Scarlet Letter teach us about the stigma of mental illness?

What is stigma?

In place for centuries, the custodial, institution-based model of care for those with mental illness contributed to their stigmatization by segregation. The mentally ill were separated from the physically ill, who were treated in local hospitals in their own communities. The decision to send persons with mental illness to far-away institutions, although well intentioned in its origins, dislocated them from their communities. With time, they lost their connections with coworkers, friends, and relatives; ultimately, they lost their personal identity. At a system level, the institutional model also contributed to the banishment of mental illness, and also of psychiatry, from the general stream of medicine. The therapeutic nihilism that for centuries permeated most psychiatric work also contributed to the asylum mentality. The few-and-far-between therapeutic successes helped to reinforce the nihilism, in that the remaining conditions were considered incurable. With time, the stigma associated with mental conditions and mental health patients also extended to those in charge of caring for them, psychiatrists included.

What is stigma?

Labeling theory: Reactions of others of central significance in

experience of mental illness Involves an “exchange of meaning” about

what it means to have a mental illness

What is stigma?

Recognition of a differentiating “mark”

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Devaluation of the bearer of the “mark”

A relational and social construct

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What is stigma?

This static concept of stigma has been enlarged to encompass a social construct linked to values placed on social identities through a process consisting of 2 fundamental components: the recognition of the differentiating “mark” and the subsequent devaluation of the bearer. Stigma is therefore a relational construct based on attributes.

Consequently, stigmatizing conditions may change with time and among cultures

What is stigma?

Perspective

Reactions

Identity

Develops in a matrix of social relationships and interactions

The way stigma is perceived by the stigmatizer or by the person being stigmatized

Exists along a continuum from the entirely personal to group belongness

Cognitive, affective, and/or behavioral reactions to stigma and its consequences

What is stigma?

Visibility: how obvious the mark is Controllability: whether the mark is

under the bearer’s control Impact: if it instills fear by conveying

an element of danger

What is stigma?

Mental health patients who show visible signs of their conditions because of their

symptoms, or because medication side effects may make appear “different”,

are socially construed as being weak in character or lazy,

who display threatening behaviours usually score high on the dimensions of visability, controllability and impact. By a process of association and class identity, all persons with mental illness are equally stigmatized: regardless of impairment or disability level, the individual patient is lumped into a class, and belonging to that class reinforces the stigma against the individual.

Stigma—a definition

“Beliefs, attitudes and behaviours that result in social rejection or isolation of an individual based on any set of characteristics that are perceived by a group to be undesirable or threatening, regardless of whether exposure to the person with these characteristics would actually cause adverse consequences to others” (Van Dorn, 2005)

Types of stigma

Public Self

Public stigma….

Impacts on achieving essential life goals, particularly obtaining competitive employment and living safely and independently

Fosters criminalization People with mental illness are dealt with by the

police, courts and jails, instead of mental health system Related to inadequate funding for the mental health system

and “get tough”, policies People with S&S of mental illness are more likely than others

to be arrested (Teplin, 1984) People with mental illness tend to spend more time

incarcerated than people without mental illness (Steadman, McCarty and Morrissey, 1989)

Impacts utilization of health care system

Those affected by self-stigma experience…

Social isolation: people restrict their social networks in

anticipation of rejection Loss of self-esteem:

people believe that they are less valuable as people

Limited prospects for recovery

Other consequences of stigma include…

Impaired social adaptation Social isolation, exclusion from friendships Access to employment blocked

Non-adherence to medication treatment

Models of stigma

Cognitive models: stigma related processes formed and maintained at the psychological level. Stereotype:

Knowledge structures learned by most members of a social group; represent collectively agreed on ideas about groups people

Of mental illness: dangerousness, incompetence, character weakness

Prejudice Endorsement of negative stereotype, experience negative

emotional reactions Discrimination

Behavioural reaction, often angry, leading to hostile discrimination such as withholding care, or fearful, leading to discriminatory avoidance

Models of stigma

Motivational models: explain WHY people stigmatize, or the function it serves, although it is an incomplete picture Ego-justification

Stigma avoids potential threat to one’s physical or psychological self, by avoiding a socially perceived threat

Stigma rationalizes negative group based attitudes and discrimination

Group or system-justification: not satisfactory explanations

Models of stigma

Institutional models: Definition: rules, policies, and procedures

of private and public institutions in positions of power that intentionally restrict the rights and opportunities of the group affected

Examples: Legislation restricting rights and opportunities

of people with mental illness

Models of Stigma

Structural models: Relates to the effect rather than the intent

of an action, rule or law Group goals are not accomplished because

they seem to clash with dominant ideologies that maintain the status quo E.g.cost-effectiveness: funding for mental

health programs, insurance parity

Stigma and violence

Stigma

Those diagnosed with schizophrenia are particularly subject to negative attitudes and distancing behaviour Schizophrenia is seen to be associated with

dangerousness, violence and unpredictability

Majority express preference for social distancing-rates have increased over past 40 years

Fewer negative attitudes about depression

Van Dorn, Swanson, Elbogen, and Swartz (2005)

Research question What are the differences in how mental

health stakeholders (patients, families, clinicians) view people with schizophrenia as compared with general public?

What are the differences in desire for social distance?

Results

Little difference between stakeholder groups in desire for social distance

Family members and clinicians are less likely to see person as violent

Service users most strongly believed the person likely or very likely to be violent

All groups likely to endorse a biomedical model of causality

Family members and service users more likely than clinicians to endorse stressful circumstances as a cause

Significant association between belief that the person was likely to be violent and desire for social distance

Conclusions

Negative attitudes evident even in groups with close association to persons with schizophrenia

People’s beliefs about cause and treatment effectiveness seem to affect perceptions of potential for violence, thus reducing desire for social distance

Changing public stigma

Protest strategies Anecdotal evidence suggests that protest can

be effective as a punishing consequence to decrease the likelihood that people will repeat the behaviour

Asking people to suppress their prejudice about a group can promote a backlash and worsen attitudes as a result (Corrigan, etal 2001)

Educational approaches Produces short term improvements in attitudes

(Corrigan etal), those with greater prejudice are less likely to benefit from education

Changing public stigma

Interpersonal contact Most promising results Contact with promoted greater

improvement in attitudes than protest, education and controls

Improvements seem to be most pronounced when contact is with a person who moderately disconfirms stereotype (Reinke, etal 2004)

Targeted stigma change

Anti-stigma programs are more successful when they target specific groups of people rather than the general public

Specific prejudicial attitudes and discriminatory behaviours need to be targeted Behaviours are more likely to change when

strategies target attitudes that correspond to the behaviour

Power groups must be challenged in the setting in which they might discriminate

Targeted stigma change

Targets Landlords who fail to lease or make reasonable

accommodation Employers who fail to hire or make reasonable

accommodation Health care providers who withhold some services or

are unnecessarily coercive Criminal justice personnel who are unnecessarily

coercive and who fail to use mental health services Policy makers who allocate insufficient resources,

interpret regulations in an “unfriendly” manner The media who perpetually disseminate stigmatizing

images

Erasing public stigma—structural change

Affirmative actions: government approved activities focused on redressing historical disparities Prohibition of discrimination Requiring “reasonable accommodation”

Making changes to the work environment to assist the person to work

Fair housing

Food for thought

What is the relationship between how North Americans understand the etiology of psychosis and the experience of stigma? If psychosis was viewed as being caused by

social factors, would there be any difference in the experience of stigma?

More food for thought

Are psychiatric diagnoses a part of the problem or part of the solution? Do some aspects of anti-stigma campaigns

have a potentially negative impact on service users because they frame most psychosocial problems as a psychiatric diagnosis?

There’s a sea of dandelions, beautiful dandelions. What a beauty! Somewhere we were taught that dandelions are ugly, they’re weeds. Where did we get this stigma about the dandelions? And it just struck me how a lot of life can have stigma attached to it, just like mental illness. (Ruth Detweiler)

Arboleda-Florez, J. (2003). Considerations on the stigma of mental illness (Editorial). Canadian Journal of Psychiatry, 48 (10), 645-650.

Corrigan, P., Green, A., Lundin, R., Kubiak, M., & Penn, D. (2001). Familiarity with and social distance from people who have serious mental illness. Psychiatric Services, 52 (7), 953-958.

Corrigan, P., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: explanatory models and methods for change. Applied and Preventative Psychology, 11, 179-190.

Jarvis, G. (2007). The social causes of psychosis in North American Psychiatry: a review of a disappearing literature. The Canadian Journal of Psychiatry, 52 (5), 287-294.

Additional References

Additional References 2

Pilgrim, D. & Rogers, A. (2005). Psychiatrists as social engineers: a study of an anti-stigma campaign. Social Science and Medicine, 61, 2546-2556.

Rusch, N., Angermeyer, M., & Corrigan, P. (2005). Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European Psychiatry, (20), 529-539.

Van Dorn, R., Swanson, J., Elbogen, E., & Swartz, M. (2005). A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood go violence and desire for social distance. Psychiatry, 68 (2), 152-163.