Lesson Plan One
Stigma and Chronic Mental Illness

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Stigma and Chronic Mental Illness

Sociologist Erving Goffman is generally credited for making stigma a topic for social science research. In his oft-cited essay, published in 1962, Goffman defined stigma as “an attribute that is deeply discrediting” and excludes an individual from full social participation. He suggested that stigmatized conditions could be found in three basic types: physical deformities, blemishes on personal characteristics, and membership in human groups that are associated with particular religions, nationalities, or ethnicities.

The notion of stigma has come to be a central concern in the area of public health and mental health. Indeed, two recent major reports, Mental Health: A Report of the Surgeon General and World Health Report 2001, Mental Health: New Understanding, New Hope, both identified stigma as an important barrier to the treatment and care of persons suffering from mental disorders. The following is from the first chapter of the Surgeon General’s report:

“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. It reduces patients’ access to resources and opportunities (e.g., housing, and 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.”

In a paper presented at the conference Stigma and Global Health: Developing a Research Agenda, Bruce Link and Jo Phelan of Columbia University offered an overview of the public health consequences of stigma. We recommend that students read this paper so they will have a more in-depth background with which to answer the questions below. We will also summarize some of the main points of the paper, available at http://www.stigmaconference.nih.gov/LinkPaper.htm
Link and Phelan offer the following definition of stigma:

“Stigma exists when the following interrelated components converge. In the first component, people distinguish and label human differences. In the second, dominant cultural beliefs link labeled persons to undesirable characteristics - to negative stereotypes. In the third, labeled persons are placed in distinct categories so as to accomplish some degree of separation of ‘us’ from ‘them.’ In the fourth, labeled persons experience status loss and discrimination that lead to unequal outcomes. Stigmatization is entirely contingent on access to social, economic and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories and the full execution of disapproval, rejection, exclusion and discrimination. Thus we apply the term stigma when elements of labeling, stereotyping, separation, status loss and discrimination co-occur in a power situation that allows them to unfold.”

Key Aspects of Stigma According to Link and Phelan

Component #1: On Distinguishing and Labeling Differences

Most human differences are overlooked and do not matter socially. However, some differences are identified and “selected for social salience.” The fact that these characteristics are socially selected is often ignored since people tend to simply accept that these differences must be important.

Component #2: On Associating Human Differences with Negative Attributes

Stigma involves the linking of undesirable attributes with the identified characteristic.

Component #3: On Separating “Us from Them”

Distinguishing “us” from “them” allows individuals to assign negative attributes to those who are labeled, set them apart as not fully human, and treat them in negative ways without remorse.

Component #4: Status Loss and Discrimination

According to this component, when individuals are labeled and given negative attributes they “experience status loss and discrimination.”

The Dependence of Stigma on Power

“Stigma is entirely dependent on social, economic and political power . . .[power] is essential to the social production of stigma.” Those with relatively little power have limited ability to discriminate against others.

Types of Discrimination Connected with Stigma

Link and Phelan identify three different types of discrimination associated with stigma and discuss the persistence of stigma as a result of these forms of discrimination.

1. Direct discrimination -- Individuals who hold stereotypical beliefs about the mentally ill often directly discriminate against them.

2. Structural discrimination -- In this form of discrimination, social environments and the systems in which people live may expose the person with mental illness “to a host of untoward circumstances.” Examples given include: inadequate funding for research and treatment; treatment facilities located in isolated or dangerous communities which in turn expose individuals to higher rates of crime, poor health care, and disease.

3. Internalized discrimination – Through socialization, people learn from a young age about the negative attributes assigned to those who are mentally ill, and form expectations about what it means to be mentally ill. As a result, individuals who experience mental illness may be reluctant to identify their symptoms and to seek early treatment for fear that they will be devalued and rejected. Once labeled, they may believe what they have learned and, for example, reduce their social networks and take fewer risks, expecting themselves to fail, as well as be ridiculed by others.


1. In the film Jay said “I wish that people could know my brother in his own words and see how full of life and tenderness and frustration and love he was.”

a. What were your reactions to Robert when you first saw him?
b. What do you think interferes with people really getting to know Robert?

2. How does socialization shape our understanding of chronic mental illness?

a. What are the terms/expressions used to denote persons suffering from severe mental illness?
b. What did Robert mean when he says of Creedmoor “It’s a birdy house?” What other names/expressions are used for psychiatric institutions?
c. Jay said “The worst thing you could say to somebody, parents would say it to their kids: If you don’t behave yourself, I’ll send you to Creedmoor. You belong in Creedmoor.” Discuss the impact of such threats.
d. How are persons with mental illness portrayed on television and in the movies? Compare and contrast a portrayal that you think is positive and one that you think is negative.
e. How are mental health professionals portrayed on television and in the movies? Compare and contrast a portrayal that you think is positive and one that you think is negative.
f. In d and e above, consider whether or not positive portrayals are necessarily accurate and destigmatizing and whether or not negative portrayals are necessarily inaccurate and stigmatizing.

3. How has Robert been the object of discrimination? Be sure to identify which forms of discrimination (direct, structural, internalized) he has experienced.

4. What are other ways that persons with severe mental illness have been discriminated against? Give examples.

5. Explain how life chances for the severely mentally ill may be limited as a result of discrimination. Give examples.

6. How can stigma adversely affect physical and mental health?

7. What is the impact of labeling a person “a schizophrenic,” rather than “a person with schizophrenia?”

8. What interventions do you think would be most effective in reducing the stigma of severe mental illness? Consider interventions for each of the three forms of discrimination identified in the Link and Phelan paper.

9. Over the years the New York Times has included demeaning references to the mentally ill in their crossword puzzles. For example, the answer to the clue "fruitcake" was “loony” and the answer to the clue "candidate for a psych ward" was "sicko." What is your reaction?


1. Where does the term "bedlam" come from? What does it mean?

2. What is meant by "self-fulfilling prophecy?" How does this concept relate to the discussion of stigma above?

3. Research findings have shown that persons with severe mental illness have increased rates of morbidity and mortality. What types of illness most affect them? Examine suicide rates.

4. How effective have previous attempts been to reduce stigma? Consult such references as:

Carter, R. (1998). Helping someone with mental illness. New York: Random House.

Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765-776.

5. Find out where in your community persons with chronic mental illness are treated and where they reside. If there are halfway houses/residences in your community, where are they located? Use newspapers, minutes of city council meetings, etc. to find out whether there were controversies when these residences were first proposed. Read the New York Times exposés about homes for the mentally ill in New York state. They are available at:


6. In your daily activities take note of how mental illness is stigmatized. Discuss.


Students can become advocates for persons with mental illness in a variety of ways:

1. Students can volunteer to work in programs for people who are mentally ill.

2. Based on the examples of stigma they identified above, students can be asked to design and carry out an anti-stigma campaign.

3. Students can join the National Alliance for the Mentally Ill’s (NAMI) StigmaBuster’s Stigma Alert Listing: www.nami.org/campaign/stigmabust.html and take part in the current anti-stigma campaigns.


Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York: Simon & Schuster.

Link, B. G., & Phelan, J. C. (2001, 5-7 September). On stigma and its public health implications. Paper presented at the conference Stigma and Global Health: Developing a Research Agenda, Bethesda, MD. The complete proceedings of the conference are available at: http://www.stigmaconference.nih.gov/

Mental health: A report of the Surgeon General. (1999). Rockville, MD: U.S. Department of Health and Human Services, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. Available at: http://www.surgeongeneral.gov/library/mentalhealth/home.html

World health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization. Available at: http://www.who.int/whr/

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