The Stigmatization of Mental Illnesses

This In Review is intended to provide a statement about the stigmatization of mental illnesses from 2 different but complementary perspectives: one from the vantage of public stereotypes, particularly those expressed by mental health and health providers'; and the other from the vantage of self-stigma, which occurs when an individual internalizes negative stereotypes and experiences a range of negative psychosocial and interpersonal consequences.2 Both papers identify key issues and offer strategies that can be used to reduce the stigma caused by a mental illness. The theoretical literature dealing with stigma and discrimination is vast and dates to the middle of the last century with the seminal work of Goffman,3 who examined stigma from the perspective of spoiled social identity and who recognized that mental illnesses were among the most deeply discredited of all stigmatized conditions. In Asylums, Goffman4 was highly critical of the mental hospitals of the day for their antitherapeutic and stigmatizing effects. Along with contemporaries, such as Scheff and Szasz,6 these writers reinforced the concept that the negative and debilitating consequences of mental illnesses were more a result of the way in which psychiatry was organized rather than the illnesses themselves. In modern times, despite having replaced asylums with general hospital psychiatric units and an array of community supports and services, people who have a mental illness still experience society's negative response to them as more devastating, disabling, and life-limiting than the illness itself.7 The paper by Dr Patrick W Corrigan and Dr Deepa Rao2 highlights the insidious process of self-stigmatization that may occur and describes novel approaches that have been used to reduce internalized stigma and to improve self-esteem and empowerment. While these smaller, focused efforts are not intended to improve public perceptions or behaviours, they do hold considerable promise for an individual's personal recovery. Dr Julio Arboleda-Florez and I' also include stigma selfmanagement as 1 of 6 approaches that may be used to disrupt the stigmatization process. From the original focus on stigma as a by-product of the social organization of psychiatry and psychiatric services, much of the subsequent theory has pertained to the social psychology of stigma, outlining the cognitive and attitudinal components necessary to create and maintain stigmatized world views. From this vast array of research, it is clear that one of the most fundamental characteristics of stereotypes is that, once established, they are highly resistant to change.8 This suggests that we will need powerful multi-level strategies that address stigma at individual, interpersonal, and social-structural levels. It also suggests that it will be important for antistigma activists to begin work early, before stereotypes have crystallized. In addition, to be successful, interventions must become a routine part of our institutionalized response to stigmatization. Short-lived bursts of activity are unlikely to create the level of sustained change that will be required to improve quality of life for people who have a mental illness and for their family members. Therefore, stigma reduction must be viewed as a transgenerational challenge. Quantitative researchers have spent considerable time documenting the scope and content of public stigma. For example, in their review of the literature between 1990 and 2004, Angermeyer and Dietrich9 identified 33 national studies and 29 local and regional studies, most of which were conducted in Europe. Among these, only 6 were attempts to evaluate population-based interventions, and 4 of these focused on depression - 1 of the disorders demonstrated in population surveys to be the least negatively viewed.10 No study examined whether changes in attitudes corresponded to changes in behaviour - arguably, the most important end point for antistigma programming. …

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