Families will say this, "Only illness in the worldwhere you never get a covered dish." There issomething about having a mental illnesswhere everything falls away, and what youexperience is fear and isolation rather than asense of people coming towards you. (JoyceBurland)
What is stigma? Original meaning: Bodily signs that indicate something about moral character of the person
What is stigma?Coined by Goffman (1963) torefer to prejudices related tohaving a mental illnessIn Greek society, stigmatizingattitudes about the mentally illwere already apparent
What is stigma?As early as the 16th century,“madness” was seen as a“perverted will” and“symptoms of animalinstincts”…. “a beast”
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 andforced by the people of Boston to wear a badge ofhumiliation, but she was not willing to leave the town.Hester’s behavior is premised on her desire to determineher own identity rather than to allow others to determineit for her. To her, running away or removing the letterwould be an acknowledgment of society’s power overher: she would be admitting that the letter is a mark ofshame and something from which she desires to escape.Instead, Hester stays, refiguring the scarlet letter as asymbol of her own experiences and character. Her pastsin is a part of who she is; to pretend that it neverhappened 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” + Devaluation of the bearer of the “mark” A relational and social construct
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? The way stigma is perceived by theDevelops in a matrix Perspective stigmatizer or by the person beingof social stigmatizedrelationships andinteractions Cognitive, Exists along affective, and/or a continuum behavioral from the reactions to Reaction Identity entirely stigma and its s personal to consequences group belongness
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)
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-stigmaexperience… 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 stigmainclude… Impaired social adaptation Socialisolation, 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 Those diagnosed with schizophrenia are particularly subject to negative attitudes and distancing behaviour Schizophreniais 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—structuralchange Affirmative actions: government approved activities focused on redressing historical disparities Prohibitionof 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? Ifpsychosis 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? Dosome 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)
Additional ReferencesArboleda-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). Familiaritywith and social distance from people who have serious mentalillness. 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 andPreventative Psychology, 11, 179-190.Jarvis, G. (2007). The social causes of psychosis in North AmericanPsychiatry: a review of a disappearing literature. The Canadian Journalof Psychiatry, 52 (5), 287-294.
Additional References 2Pilgrim, 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.