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:
http://akmhcweb.org/Articles/NYTForMentallyIllDeathandMisery.htm
http://akmhcweb.org/Articles/NYTHereLifeIsSqualorandChaos.htm
http://akmhcweb.org/Articles/NYTVoicelessDefenselessandaSourceofCash.htm
6. In your daily activities take note of how mental illness is stigmatized.
Discuss.
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/
