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STIGMA, MENTAL
ILLNESS, AND CULTURE
Dr. Patricia Sherman
April 3, 2007
Why is it when we
talk to God, we’re
said to be praying,
but when God talks
to us, we’re said to
be schizophrenic?
Origins of Stigma
• Ancient Greece – means “mark;”
marks were placed on slaves to
identify their position in the social
structure and indicate they were of
lesser value
• People have always needed to
determine where they are in relation
to others
• Reassuring to believe that someone
is beneath you in the “pecking order”
Erving Goffman (1963)
• Suggested that stigma had two major
components: public one (reaction of
general public to people with mental
illness) and self-stigma (prejudice that
people with mental illness tend to turn
towards themselves
• Stigma comes in three forms
–Overt or external deformations
–Deviations in personal traits (mental
illness)
–Tribal stigmas – traits of a race,
nation, or religion that deviate from
the normative race, nationality or
religion
• The more visible the stigmatizing
mark or condition, the more society
believes the individual should be able
to control it and the greater the
negative impact of not being able to
do so
• List ten groups that are stigmatized
• When have you been stigmatized?
• When have you stigmatized someone
else?
Response to stigma
• Try to get rid of what is stigmatizing
• Make special efforts to compensate
• Refuse to accept societal norms
Glossary of Terms
• Labeling – the act of giving a name
with a social meaning to a state or
characteristic
• Deviance – behavior which is socially
abnormal and usually regarded as
unacceptable
• Primary deviance – the original
deviance, which in the context of
illness behavior, is that caused by the
illness itself
• Secondary deviance – the abnormal
behavior which results from the social
reaction to the primary deviance
• Stigma – the negative value given to
a characteristic which means that a
person is spoiled in some way and
liable to social rejection
• Stereotyping – the act of labeling a
person with one characteristic (often
stigmatized) on the basis of their
possession of another characteristic
• Discreditable – a state where a
person has a stigmatized
characteristic, but this is not generally
known. There is therefore a potential
to be discredited or rejected if the
characteristic becomes apparent
• Discredited – the state where the
stigmatized condition has become
visible
• Enacted stigma – the social rejection
that has taken place as a result of
being discredited
• Felt stigma – the perceived social
rejection of the stigmatized condition
• Complete Attitude Scale for Mental
Illness
• What was difficult to answer?
• What do you wish you could have
answered differently?
Four components of stigma
• Labeling people with a condition
• Stereotyping people with that
condition
• Creating a division – “us” and “them”
• Discriminating against people based
on their label
Why is mental illness
stigmatized?
• Its name implies it is different from
physical illness
• Sounds as if it’s “all in one’s head”
• Some people believe it results from
poor choices
• Belief that people with mental
illnesses are dangerous and
unpredictable, less competent, unable
to work, should be institutionalized,
can never get better
Some Health and Social
Consequences of Stigma
• Mental illness and addiction are
common, but only 1/3 of those
needing treatment seek it due to fear
of discrimination
• People deny painful symptoms and
are reluctant to seek help at an early,
more treatable stage of illness
• The drop-out rate for psychiatric
treatment is high because people do
not want to be seen attending
psychiatric clinics.
• People with mental illness often hold
the same beliefs as society at large
and blame themselves for their illness
• The major way people cope with
stigma is to withhold information from
those who could help them
• Consumers expect to be rejected by
the community and, therefore, are
reluctant to engage with others
• The effects of stigma and its resultant
social withdrawal may have a greater
impact on an individual than the
illness
• Family members are also harmed by
stigma and may be blamed for
causing or contributing to the illness
• Community attitudes can negatively
affect recovery rate
• Mental health professionals are also
often stigmatized, holding a
diminished status in the eyes of other
health care professionals and making
recruitment challenging
• Many mental health professionals
share negative attitudes towards
people with mental illness
• The diminished attitude towards
consumers is applied to self-help and
peer-support programs, negatively
affecting the number of referrals
• People with mental illness are less
likely to be appropriately diagnosed
and treated for co-morbid medical
conditions
• Institutions, governments, and policy
makers contribute to stigma by
systematically under-funding mental
health services
• Discrimination towards people with
mental illness leads to diminished
employment opportunities, lack of
career advancement, and hostility in
the workplace
• Stigma contributes to the persistent
under-funding of research and
treatment services
• 74% of people with a mental illness
reported they had experienced stigma
in the last year
• 16% reported stigma in the workplace
• 13% from staff in a health service
(SANE, Australia, 2006)
• The elderly experience the double
stigma of being old and mentally ill
and are less likely to seek help; their
illnesses may not be detected
because of the belief that anxiety and
depression are a normal part of aging
• Other groups also experience a
double or triple stigma – LGBT,
people of color, women (“The gay
community stigmatizes us for being
mentally ill, and the mental health
community stigmatizes us for
being gay”)
• Discrimination is experienced through
a loss of human rights, including
forced treatment, finding or keeping
housing, the right to parent, access to
loans, immigration, denial of
insurance coverage, and overrepresentation in the criminal justice
system
•
Adapted from Mood Disorders Society of Canada’s Stigma and Discrimination Research
Workshop, Ottowa, ON – 10/2-4/06.
• Complete Family Scale
• Discuss in small groups
• Report out to larger group
Some Facts About Mental
Illness and Recovery
• Mental disorders fall along a
continuum of severity. Even though
mental disorders are widespread in
the population, the main burden of
illness is concentrated in a much
smaller proportion — about 6 percent,
or 1 in 17 Americans — who suffer
from a serious mental illness. It is
estimated that mental illness affects 1
in 5 families in America.
• Most mental illnesses are biologically
based brain disorders. They cannot
be overcome through "will power" and
are not related to a person's
"character" or intelligence.
• The World Health Organization has
reported that four of the 10 leading
causes of disability in the US and
other developed countries are mental
disorders. By 2020, Major Depressive
illness will be the leading cause of
disability in the world for women and
children.
• Mental illnesses usually strike
individuals in the prime of their lives,
often during adolescence and young
adulthood. All ages are susceptible,
but the young and the old are
especially vulnerable.
• Without treatment the consequences
of mental illness for the individual and
society are staggering: unnecessary
disability, unemployment, substance
abuse, homelessness, inappropriate
incarceration, suicide, and wasted
lives. The economic cost of untreated
mental illness is more than 100 billion
dollars each year in the United
States.
• The best treatments for serious
mental illnesses today are highly
effective; between 70 and 90 percent
of individuals have significant
reduction of symptoms and improved
quality of life with a combination of
pharmacological and psychosocial
treatments and supports.
• With appropriate effective medication
and a wide range of services tailored
to their needs, most people who live
with serious mental illnesses can
significantly reduce the impact of their
illness and find a satisfying measure
of achievement and independence.
• Early identification and treatment is of
vital importance. By ensuring access
to the treatment and recovery
supports that are proven effective,
recovery is accelerated and the
further harm related to the course of
illness is minimized.
Mental Illness Across
Cultures
• The expression of mental illness in
many cultures is in bodily terms –
headache, trouble sleeping, fatigue,
stomachache, etc.
• Hallucinations and delusions will be
culturally relevant
• Need to assess level of acculturation
• Mental illness compounded by
immigration experience, conditions
leading to immigration, poverty, lack
of health insurance, language
difficulties, loss of support system,
lack of access to traditional healers
• Asian Indians and Pacific Islanders –
very few receive treatment (1/6 of
those who need it)
• Deep-rooted stigma prevents many
from acknowledging their illness
• Stigma extends to families
• Fear of not being able to marry
• Psychiatric illnesses are considered
curse from God, punishment for sins
in past lives, or manifestations of evil
spirits
• Latino/a culture has expectation that
people will be able to solve problems
on their own
• Serious stigma regarding mental
illness
• 75% of family members in Ethiopia
report being stigmatized
• Chinese use traditional medicine and
healers
• Tend to hide feelings; loss of face
• Emphasis on family involvement
• May use term for sadness that is
translated as “congested”
• In traditional Japan, suicide is
valorized – it’s a way of maintaining
honor by accepting responsibility
• Japanese changing name for
schizophrenia from seishi buntetsu
byo (split-mind disorder) to togo
shiccho sho (loss of coordination
disorder)
• African Americans tend to access
treatment later – fearful it will make
them look weak and not spiritual
enough
• Religious preoccupation may not be
symptom of mental illness
• In Poland, over 70% indicated that
people with mental health disorders
are called “crazy,” “loony,” “idiot,”
“abnormal”
• 3/5 Scots believed someone with
mental illness would not be able to
look after children
• Zimbabwe – high rate of depression,
especially among women, typically
present with multiple physical
symptoms
• Many somatic complaints, especially
related to the heart and head are
metaphors for grief or fear
• Afro-Caribbean immigrants often
believe in obeah – a form of witchcraft
containing elements of Christianity,
animism, and folk medicine
• Based on belief that it is possible to
influence the health or well-being of
another person from a distance
• Iraqis deny mental illness exists in
their country; women will not be able
to marry if they are mentally ill
• Kenya – stigma against being a
psychiatrist – “Are you alright
upstairs?”
• In many parts of the world, spirit
possession is common. This may be
a way for disadvantaged people to
gain status; lose status if symptoms
are due to a chemical imbalance
• Could be misdiagnosed as
schizophrenia
• The cultures that patients come from
shape their mental health and affect
the kinds of mental health services
they use. Likewise the cultures of the
clinicians and the service system
affect diagnosis, treatment, and the
organization and financing of services
• Complete Scale of Social Distance
• Complete Attitude Towards Seeking
Professional Psychological Help
The media
• People with mental illness:
–Are homicidal maniacs who need to
be feared
–Have childlike perceptions of the
world and need to be taken care of,
or
–Are responsible for their illness due
to weak character and should be
blamed
• Show scene from 12 Monkeys
• Show scene from Me, Myself, and
Irene
• Discuss
• Newspapers and TV stations can
print or broadcast statements about
those with mental illness that would
not be tolerated if they were said
about any other minority group.
Stigma insinuates itself into policy
decisions, access to care, health
insurance, employment
discrimination, and in research
allocation and priorities.
• 9/11 terrorists characterized as
“crazy” or “mad”
• GM Super Bowl ad – robot jumping
off bridge
• Wendy’s – multiple personality eating
disorder
• Vermont Teddy Bear – “Crazy for You
Bear”
• Fox-TV – “Unanimous” – Richard
became an outcast after it was
discovered he had a psychiatric
hospitalization
• Readers’ Digest – “How do crazy
people go through the forest?”
Some Ways to Fight Mental
Illness Stigma
• Avoid prejudging those with mental
illness on the basis of media and
societal stereotypes
• Learn more about mental illness
• Learn more about mental illness
stigma and discrimination
• Speak up about mental illness stigma
• Listen to people who have
experienced mental illness
• Watch your language – talk about
people first, then their illness
• Talk openly about mental illness,
especially your own or that of a loved
one
• Provide support for organizations that
fight mental illness stigma
Some Ways to Cope With
and End Stigma AS A
CONSUMER
• Get appropriate treatment
• Surround yourself with supportive
people
• Make your expectations known
• Don’t equate yourself with your illness
• Share your own experiences
• Monitor the media
• Join an advocacy group
In Our Own Voice (IOOV)
• NAMI initiative in which two trained
presenters give personal testimony
about their journeys with mental
illness
• Listen to PSA’s
Advocacy Websites
• http://community2.webtv.net/stigmanet/LINKSAntiStigma/
• http://www.stigmaresearch.org/
• http://mentalhealth.samhsa.gov/publication
s/allpubs/sma06-4176/
• http://www.nami.org/template.cfm?section
=fight_stigma
• http://uhaweb.hartford.edu/owahl/resource
s.htm
• http://www.stampoutstigma.org/
• http://www.mentalhealthstigma.com/
• http://www.adscenter.org/
• Read Kay Redfield Jamison’s
statement
Action plan
• What will you do to combat stigma in
your professional and/or personal
life?
– Goal:
• Objective #1
• Objective #2
• Objective #3