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Guest Editorial

Considerations on the Stigma of Mental Illness

Julio Arboleda-Flrez, MD, FRCP(C), FAPA, DABFP, PhD1

Stigma, prejudice, and discrimination are closely related

and tightly interwovensocial constructs. These constructsaffect many, based on age, religion, ethnic origin, or socio-

economic status. However, a person can potentially move out

of these groups, if not physicallyas in age or ethnic back-

groundthen by moving up the social ladder, which makes

the affected person less of a target. Conversely, stigma, preju-

dice, and discrimination against those with mental illness cut

across all classes and social groups, and, to the extent that

many mental conditions are chronic and incapacitating, those

affected can hardly migrate out of the grip of negative social

attitudes. The result is social annihilation that constricts the

lives of those with mental illness, preventing them from fully

reengaging in their communities and participating in the

social activities of their groups of reference.

The general public mostfrequently makescontact withmental

illness through the media or the movies. Unfortunately, the

media often depictpatients as unpredictable, violent, and dan-

gerous (1), and movies usually follow the popular psycho-

killer plot (2) long exploited by the cinematographic

industry. Associating mental illness with violence helps to

perpetuate stigmatizing and discriminatory practices against

mentally ill persons; it is only one of many negative stereo-

types and common prejudicial attitudes about them.

This editorial has 2 purposes. It first reviews theoretical ele-ments fundamental to stigma as a social construct, together

with stigmas negative consequences for persons with mental

illness and their families (3). Second, based on the review, itcomments on this issues papers on stigmatization and

discrimination.

Historical Elements

For the ancient Greeks,stizein, to tattoo or to brand, described

a distinguishing mark burned or cut into the flesh of slaves or

criminals so that others would know who they were and that

they were less-valued members of society. Although the term

may not have been applied to mentalillness, stigmatizingatti-

tudes about the mentally ill were already apparent in Greek

society: as found in Sophocles Ajax or Euripedes The Mad-ness of Heracles, mental illness was associated with concepts

of shame, loss of face, and humiliation (4).

In theChristian world,the word stigmatais applied to peculiar

marks resembling the wounds of Christ that some individuals

develop on their palms and soles. Paul, for example pro-

claimed, I bear in my body the stigmata of Christ (5).

Although the roots of the term are the same, the religious con-

notation of stigmata is not the same as stigma: stigma is a

social construct indicating disgrace that, at the same time,

identifies the bearer. Hawthorne exemplifies this in his novel

The Scarlet Letter(6). In this novel set in the puritanical New

England town of Salem, Massachusetts, a woman accused of

being an adulteress is ordered to wear the letter A to signify

her sin and shame. The town of Salem is also famous for hav-

ing been the place of a mass execution of witches in 1662, a

period in which theMalleus Maleficarum (7) (Witches Ham-

mer) was still a highly regarded reference textbook for the

management of witches. The Inquisitorial approach to

witches, apart from being highly misogynous, also repre-

sented a negative and condemning attitude toward mental ill-

ness; it may have been the origin of the stigmatizing attitudes

Can J Psychiatry, Vol 48, No 10, November 2003 W 645

The Canadian Journal of Psychiatry

Volume 48 Ottawa, Canada, November 2003 Number 10

Mental Health Matters

The Canadian Psychiatric Association acknowledges support in part for

the In Review series courtesy of an unrestricted educational grant from


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toward those with mentalillness that have existed in Christian

cultures from the rise of rationalism in the 17th century to the

present (8). Madness has long been held among Christians to

be a form of punishment inflicted by God on sinners (9).

Stigmatizing and discriminatory attitudes against those with

mental illness have also been reported and are known to exist

in many other cultures.

Theoretical Considerations

Goffman thought of stigma as an attribute that is deeply dis-

crediting. According to Goffman, stigmatized persons are

regarded as being of less value and spoiled by thestigmatiz-

ing effects of 3 conditions: abominations of the body, such

as physical deformities; tribal identities, such as ethnicity,

sex, or religion; and blemishes of individual character, such

as mental disorders or unemployment (10).This static concept

of stigma has now been enlarged to encompass a social con-

struct linked to values placed on social identities through a

process consistingof 2 fundamental components: the recogni-

tion of thedifferentiating markand the subsequent devalua-

tion of the bearer. Stigma is therefore a relational construct

based on attributes. Consequently, stigmatizing conditions

may change with time and among cultures (11).

Stigma develops within a social matrix of relationships and

interactions and has to be understood within a 3-dimensional

axis. The first of these dimensions is perspective; that is, the

waystigma is perceived by theperson whodoes thestigmatiz-

ing (perceiver) or by the person who is being stigmatized (tar-

get). The second dimension is identity, defined along a

continuum from the entirely personal at one end to

group-based identifications and group belongingness at the

other. The third dimension is reactions; that is, the way the

stigmatizer and the stigmatized react to the stigmaand itscon-

sequences. Reactions can be measured at the cognitive, affec-

tive, and behavioural levels. The stigmatizing mark also has 3

major characteristics: visibility, or how obvious the mark is;

controllability, or whether the mark is under the bearers con-

trol; and impact, or how much those who do the stigmatizing

fear the stigmatized (12). Stigmatizing attitudes get worse if

the mark is very visible, if it is perceived to be under the

bearers control, and if it instills fear by conveying an elementof danger.

Mental health patients who show visible signs of their condi-

tions because either their symptoms or medication side effects

make them appear strange, who are socially construed as

being weak in character or lazy, and who display threatening

behaviours usually score high on any of these 3 dimensions.

By a process of association and class identity,all persons with

mental illness are equally stigmatized: regardless of impair-

ment or disability level, the individual patient is lumped into a

class, and belonging to that class reinforces the stigmaagainst

the individual.

Describing the characteristics of stigmaor what it is and

how it developsbegets the question why it develops.

Unfortunately, little literature on the subject exists, but the

hypothesis has been advanced that 3 major elements are

required for stigmatizing attitudes to happen: an original

functional impetus that is accentuated through perception

and, subsequently, consolidated through social sharing of

information. The sharing of stigma becomes an element of a

society that creates, condones, and maintains stigmatizing

attitudes and behaviours. According to Stangor and Crandall

(13), themost likelycandidate forthe initial functional impe-

tus is the goal of avoiding a threat to the self (Table 1).

Threats can be either tangible, if they threaten a material or

concrete good, or symbolic, if they threaten the beliefs, val-

ues, and ideologies upon which the group ordains its social,

political, or spiritual domains.

Table 1 The origins of stigmaa

Functional impetus: initial perception of tangible or symbolicthreat

Perception: perceptual distortions that amplify groupdifferences

Social sharing: consensual sharing of threats andperceptions

aAdapted from Stangor and Crandall (13, p 73).

Cultural perceptions of mental illness may be associated with

tangible threats to the health of society because mental illnessengenders 2 kinds of fear: fear of physical attack and fear of

contamination (that is, that we may also lose our sanity). To

the extent that persons with mental illness are stereotyped as

lazy, unable to contribute, and a burden to the system, mental

illness may also be seen as posing a symbolic threat to the

beliefs and values shared by members of the group.

In place for centuries, the custodial, institution-based model

of care for those with mental illness contributed to their stig-

matization 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 inten-

tioned in its origins, dislocated them from their communities.

With time, they lost their connections with coworkers,

friends, and relatives;ultimately, theylost theirpersonal iden-

tity. At a systemlevel, the institutional model also contributed

to the banishment of mental illness, and also of psychiatry,

from the general streamof medicine.The therapeutic nihilism

that for centuries permeated most psychiatric work also con-

tributed to the asylum mentality. The few-and-far-between

therapeutic successessuch as the discovery of the cause and

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W Can J Psychiatry, Vol 48, No 10, November 2003

The Canadian Journal of PsychiatryGuest Editorial


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treatment of mental conditions like general paresis and

pellagraonly 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.

Stigma and DiscriminationBased on social distance measurements that show acceptance

of mental patients and on findings that the behaviour and not

the label is stigmatizing, some researchers have argued that

persons with mentalillnessare notstigmatized(14). They also

argue that mental health patients themselves are rarely able to

report concrete instances of rejection (15). However, findings

denying the pernicious effects of stigma have been refuted

based on the poor methodology of these studies (16).

Forthe stigmatized,stigma is a feeling of being negatively dif-

ferentiated owing to a particular condition or state. Stigma is

related to negative stereotyping and prejudicial attitudes that

in turn lead to discriminatory practiceswhich deprive the stig-

matized person from legally recognized entitlements. Stigma,

prejudice, and discrimination are therefore inextricably

related. Unlike prejudice, however, stigma involves defini-

tions of character and class identification. Consequently, it

has larger implications and impacts.

Prejudice often stems from ignorance or unwillingness to find

the truth.For example, a study conducted by theOntario Divi-

sion of the Canadian Mental Health Association in

19931994 found that the most prevalent misconceptions

about mental illness include the belief that mentalpatients aredangerous and violent (88%); that they have a low IQ or are

developmentally handicapped (40%); that they cannot func-

tion, hold a job, or have anything to contribute (32%); that

they lack willpower or are weak and lazy (24%); that they are

unpredictable (20%); and finally, that they are to be blamed

for their own condition and should just shape up (20%)

(17). Similarly, a survey among first-year university students

in the US found that almosttwo-thirds believed multipleper-

sonalities to be a common symptom of schizophrenia, and a

poll among the general public found that 55% did not believe

that mental illness exists, with only 1% acknowledging that

mental illness is a major health problem (18). Some of thesemyths also surfaced in a study conducted in Calgary during

the pilot phase of the World Psychiatric Association (WPA)

project Open the Doors (19). Respondents to this study

believedthat persons with schizophrenia cannotwork in regu-

lar jobs (72%), have a split personality (47%), and are danger-

ous to the public because of violent behaviour (14%) (20).

Outright discriminatory policies leading to abuses of human

and civil rights and denial of legal entitlements can often be

traced to stigmatizing attitudes or plain ignorance about the

facts of mental illness. These policies and abuses are not the

preserve of any country. In developed countries, health insur-

ance companies openly discriminate against persons who

acknowledge that they have had a mental problem. Life insur-

ance and income-protection policies make it a veritable ordeal

to collect payments when temporary disability has been caused

by mental conditions such as anxiety or depression. Manypatients see their payments denied or their policies discontin-

ued. Government policies sometimes demand that mental

health patients be registered in special files before pharmacies

can dispense needed psychiatric medications. More broadly,

the national research budgets in many developed countries pro-

vide only a modicum of funds for research in mental conditions.

In Canada, for example, mental health research commands less

than 5% of all the research health budgets, yet mental illness

affects directly 20% of Canadians (21).

In developing countries, archaic beliefs about the nature of

mental conditions, sometime enmeshed with religious beliefs

and cultural determinants, stigmatize patients, who are denied

access to treatment opportunities, and stigmatize their fami-

lies when, forexample,daughters in an affected familycannot

marry because it is feared that they are contaminated (22). In

some countries, patients languish in institutions for so long

that they lose all contacts and, owing to poor records, even

their names are forgotten. Obviously, the loss of personal

identity deprives them of their civic and political rights.

Violence and Mental Illness

Few popular notions and misconceptions areso pervasive and

stigmatizing as the belief that persons with mental illness areunpredictable and dangerous. This beliefso central to stig-

matization and discrimination against those affectedcannot

be easilydiscounted when hardly a month goes by without the

media reporting the sad story of yet another horrendous crime

allegedly committed by a patient with mental illness. This

type of news, even when reported conscientiously and accu-

rately, arouses fear and apprehension and pushes the public to

demand measures to prevent further crimes. Those with men-

tal illness in general bear the brunt of impact from the actions

of the few. Unfortunately, the media do not inform the public

that only a very small minority of mental health patients com-

mitserious crimesand that thepercentage of violence attribut-able to mentalillnessas a portion of thegeneral violence in the

community is also very small (23).

Sensational media reports (24,25) reinforce beliefs instilled

by movies that depict mental health patients as uncontrolla-

ble killers. Relatives of the mentally ill assert that the way

they are depicted in movies is the most important contributor

to stigmatization (26). Movies have stigmatized not only

those with mental illness but also psychiatrists, often extend-

ing negative stereotypes to portray them as libidinous lechers,




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eccentric buffoons, and evil-minded, vindictive, and repres-

sive agents of the social systemand in the case of female

psychiatrists, as loveless and sexually unfulfilled (27).

The association between mental illnessspecifically, schizo-

p h re n ia a nd v io le n ce , a lt ho u gh c o nf ir me d

epidemiologically (28), remains unclear. It seems to flow not

so much through directlinks of causalityas through a seriesofconfounders and covariating causes, such as comorbidities

with alcohol and substance abuse (not unlike that which

drives violence among individuals without mental illness) and

psychopathic personality. In addition, not every act of vio-

lence committed by a mental health patient should be cata-

logued as resulting from the mental condition, in that the

context, such as taunting or victimization of the affected per-

son, could be the main determinant for the violent reaction

(29). Further, if a person with past mental illness commits a

violent act, it should not be assumed automatically that the

past mental illness is associated with the present violence.

From a public health perspective, the risk of violence from

those with mental illness should be measured via the attribut-

able risk accrued to mental illness, compared with all other

sources of violence in the community (30). These other

causes, andnot persons with mentalillness, arethe true threats

to communitysecurity (31). Unfortunately, one single case of

violence is usually sufficient to counteract the gains already

made in community reintegration of mental health patients.

The stigmatization of mental illness impacts negatively, not

only on thelevelof services provided butalso on thequality of

these services; it compromises access to care because pol-

icy-makers and the publicbelieve that persons with mentalill-

ness are dangerous,lazy, unreliable, and unemployable (32).

Research on the Stigma of Mental Illness

Although there does not seem to be a one-to-one relation

between exposure to environmental stressors, such as stigma

and discrimination, and adaptational outcomes, research on

stigma has demonstrated that it has negative outcomes on

physical health and self-esteem (33). Persons with mental ill-

ness often experience prejudice similar to that experienced by

those whosuffer racialor ethnicdiscrimination,but thepracti-

caleffects arecomplex andaffectedby several factors, such as

age, sex, and the degree of self-stigmatization (34).

It has often been confirmed that stigmatization and prejudice

are the reasons why many persons do not seek assistance or

postpone seeking assistance until too late (35). Recent research

has also demonstrated that the fear of mental illness is not

related just to the behaviour sometimes demonstrated by

affected persons. It is also related to the label itself and to the

consequences that flow from the illness. Thus, in the Alberta

pilot site of theOpen theDoors program, theEdmontonrespon-

dents rated loss of mind as more disabling than any other

handicapping condition (36). In the same study, the Alberta

group found that greater knowledge was associated with

less-distancing attitudes but that exposure to persons with men-

tal illness was not correlated with knowledge or attitudes (37).

These findings confirm findings from other authors regarding

the split between knowledge and attitudes among the general

public (38). In different findings, the Alberta group also con-cluded that broad approaches to increase mental healthliteracy,

as defined by Jorm (39), may not be as effective among already

highly educated population groups (40) as would specifically

focused interventions among small groups such as high school

students or clinical workers. This conclusion supports Corri-

gans and Penns findings in regard to targeting specific groups

and targeting specific beliefs about mental illness held by

ethnic minorities (41).

A major issue identified by theCalgary group was theneed for

an instrument to measure felt stigma among persons with

mental illness to provide an epidemiologic measure of levels,

frequency, and degrees of stigmatization. In this regard, Cor-

rigan advises that stigma research should examine 3 issues:

1) signaling events such as labelling, physical appearance,

and behaviour; 2) knowledge structures to bridge information

about controllability attributions and public attitudes about

dangerousness and self-care; and 3) ways in which those

knowledge structures lead to emotional reactions or behav-

ioural responses (42).

The3 papersincludedin this issues In Reviewsectionpresent

research efforts on stigmafrom Canada and Germany that fol-

low Corrigans agenda to a large extent. Focusing on empiri-

cal research into interventions for stigma and evaluations oftheir effectiveness, they make a cohesive set. The Canadian

paper, by Dr Heather Stuart (43), deals with the problem of

media reporting. It evaluates a media-intervention program

carried out in Calgary within the activities of the Open the

Doors pilot program, which aimed to combat stigma and dis-

crimination toward persons with schizophrenia. This paper

highlights both the importance of media reporting on sensa-

tional crimes supposedly committed by persons with mental

illness and how broader social situations can influence media

reporting. A conclusion to be drawn from this paper is that,

while the media have a responsibility to inform the public,

mental health service providers, relatives, and consumersalike also have a responsibility to ensure that patients are

properly treated and adhere to acceptable treatment protocols

to minimize or eliminateviolent incidents caused by mentally

ill persons. One single case of violence is enough to under-

mine any good work to combat stigma and discrimination.

Thepaperby Dr Wolfgang Gaebeland Dr Anja Baumann (44)

deals with the effects and effectiveness of antistigma

interventions within the framework of the Open the Doors

program in Germany. It is interesting that this paper already

648




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provides some results of comparison data between Alberta,

Canada, and 6 cities in Germany. In these data, the figures for

socialdistance arepracticallythe same forboth countries. The

rather unexpected negative effects from one type of inter-

vention in Germanyviewing a filmare similar to the

unexpected negative effects of media intervention in Calgary,

which underscores 3 issues: that a very narrow line should bewalked when mounting interventions against stigma, that fear

of violence from persons with mental illness remains a com-

mon denominator to understanding stigma, and that any inter-

ventions regarding stigma should be accompanied by a

thorough evaluation component to gauge their effectiveness

and types of impact.

Finally, the second paper from Germany, by Dr Matthias

Angermeyer, Dr Michael Beck, and Dr Herbert Matschinger,

enters into more detail on the matter of social distance and its

determinants (45). The paper examines whether labelling and

beliefs about the causes and prognosis of schizophrenia are attheroot of thesocial distance that most peopleseem to express

regarding those who suffer from this mental condition.

Findings presented in this paper reinforce the hypothesis that

perceiving the mentally ill as dangerous and unpredictable is

thebasis of most stigmatizingattitudes and is a major determi-

nant of levels of social distance felt by many among the gen-

eral public. Unfortunately, high levels of knowledge can

coexist with high levelsof prejudiceand negative stereotypes.

As pointed out in this paper, teaching the public the biological

model of schizophrenia may increase knowledge of the state

of the art of psychiatric research and improve mental health

literacy, but it may not increase understanding of persons suf-

fering from this disorder and may, rather, intensify social

distance.

The lesson to be drawn from these papers is simple: helping

persons with mental illness to limit the possibilities that they

may become violent, via proper and timely treatment and

management of their symptoms and preventing social situa-

tions that might lead to contextual violence, could be the sin-

gle most important way to combat the stigma that affects all

those with mental illness. While most myths about mental ill-

ness can be tracedto prejudice and ignorance of thecondition,

enlightened knowledge does not necessarily translate into less

stigmaunless both thetangibleand symbolic threats that men-

tal illness poses are also eradicated. This can only be done

through better education of the public and of mental health

service consumers about the facts of mental illness and vio-

lence, together with consistent and appropriate treatment to

prevent violent reactions. Good medication management

should also aim to decrease the visibility of symptomsamong

patients (that is, consumers) and to provide better public edu-

cation programs on mental health promotionand prevention.

ConclusionsSuccessful treatment and community management of mental

illness relies heavily on the involvement of many levels of

government, social institutions, clinicians, caregivers, the

public at large, consumers, and their families. Successful

community reintegration of mental health patients and the

acceptance of mental illness as an inescapable element of oursocial fabric can only be achieved by engaging the public in a

true dialogue about the nature of mentalillnesses, their devas-

tating effects on individuals and communities, and the prom-

ise of better treatment and rehabilitation alternatives. An

enlightened public, working in unison with professional asso-

ciations and with lobby groups on behalfof persons with men-

tal illness, can leverage national governments and health care

organizations to provide equitable access to treatment and to

develop legislation against discrimination. With these tools,

communities can enter into a candid exchange of ideas about

the causes of stigma and the consequences of stigmatizing

attitudesin their midst.Onlytheseconcerted efforts will even-tually dispel the stigma associated with mental illness.

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1Professor and Head, Department of Psychiatry, Queens University,

Kingston Ontario.Address for correspondence: Dr J Arboleda-Flrez, Department of Psychia-try, BrockV, Room 546, Hotel Dieu Hospital,166BrockStreet,KingstonONK7L 5G2e-mail: [email protected]

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