The 1999 report on mental health by the Surgeon General of the United States was regarded as a landmark document in the United Kingdom, as well as the United States. This was because of its straightforward identification of the stigma associated with mental illness as the chief obstacle to effective treatment of persons with mental disorders. Stigma (plural, stigmata) is a Greek word that in its origins referred to a kind of tattoo mark that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or morally polluted persons. These individuals were to be avoided or shunned, particularly in public places. The word was later applied to other personal attributes that are considered shameful or discrediting.
Social psychologists have distinguished three large classes, or categories, of stigma:
- Physical deformities. These include extremes of height and weight and such conditions as albinism and facial disfigurements or missing limbs. In the developed countries, this category also includes such signs of aging as gray hair, wrinkles, and stooped posture.
- Weaknesses or defects of individual character. This category includes biographical data that are held to indicate personal moral defect, such as a criminal record, addiction , divorce, treatment for mental illness, unemployment, suicide attempts, etc.
- Tribal stigma. This type of stigma refers to a person's membership in a race, ethnic group, religion, or (for women) gender that is thought to disqualify all members of the group.
The nature of stigma
One explanation for the origin of stigmata is that its roots in the human being's concern for group survival at earlier times in their evolutionary journey. According to this theory, stigmatizing people who were perceived as unable to contribute to the group's survival, or who were seen as threats to its well-being, were stigmatized in order to justify being forced out or being isolated.
The group survival theory is also thought to explain why certain human attributes seem to be universally regarded as stigmata, while others are specific to certain cultures or periods of history. Mental illness appears to be a characteristic that has nearly always led to the stigmatization and exclusion of its victims. The primary influences on Western culture, the classical philosophical tradition of Greece and Rome, and the religious traditions of Judaism and Christianity indicate that mental illness was a feared affliction that carried a heavy stigma. The classical philosopher's definition of a human being as a "rational animal" excluded him or her who had lost the use of reason and was no longer regarded as fully human; most likely he or she was under a divine curse. This attitude was summarized in the well-known saying of Lucretius, "Whom the gods wish to destroy, they first make mad."
In the Bible, both the Old and the New Testaments reflect the same fear of mental illness. In 1 Samuel 21, there is an account of David's pretending to be insane in order to get away from the king of a neighboring territory. "He changed his behavior before [the king's servants]; he pretended to be mad in their presence. He scratched marks on the doors of the gate, and let his spittle run down his beard." The king, who was taken in by an act that certainly fits the Diagnostic and Statistical Manual of Mental Disorders criteria for malingering , quickly sent David on his way. In the New Testament, one of Jesus' most famous miracles of healing (Mark 5:1-20) is the restoration of sanity to a man so stigmatized by his village that he was hunkered down in the graveyard (itself a stigmatized place) outside the village when Jesus met him. Mark's account also notes that the villagers had tried at different times to chain or handcuff the man because they were so afraid of him. One important positive contribution of Biblical heritage, however, is a sense of religious obligation toward the mentally ill. Among Christians, the New Testament's account of Jesus' openness to all kinds of stigmatized people—tax collectors, prostitutes, and physically deformed people, as well as the mentally ill—became the basis for the establishment of the first shelters and hospitals for the mentally ill.
The core feature of stigma in the modern world is defined by social psychologists as the possession of an attribute "that conveys a devalued social identity within a particular context." Context is important in assessing the nature and severity of stress that a person suffers with regard to stigma. Certain attributes, such as race or sex, affect an individual's interactions with other people in so many different situations that they have been termed "master status" attributes. These have become the classic identifying characteristic of the person who possesses them. Dorothy Sayers' essay, "Are Women Human?" is not only a witty satire on the way men used to describe a woman's job or occupation (with constant reference to feminine qualities), but a keen social analysis of the problems created by master status attributes for persons who are stigmatized.
Other forms of devalued social identity are relative to specific cultures or subcultures. In one social context, a person who is stigmatized for an attribute devalued by a particular group may find acceptance in another group that values the particular attribute. A common example is that of an artistically or athletically talented child who grows up in a family that values only intellectual accomplishment. When the youngster is old enough to leave the family of origin, he or she can find a school or program for other students who share the same interest. A less marked contrast, but one that is relevant to the treatment of mental illness, is the cultural differences with regard to the degree of response to certain symptoms of mental illness. A study conducted in the early 21st century assessed the reaction of family members to elderly people who were diagnosed with Alzheimer's disease (AD). Findings pointed to considerable variation across racial and ethnic groups. Asian Americans were most affected by feelings of shame and social stigma relative to the memory loss of a family member, while African Americans were the least affected.
One additional complicating feature of stigma is the issue of overlapping stigmata. Many people belong to several stigmatized groups or categories, and it is not always easy to determine which category triggers the unkind or discriminatory treatment encountered. For example, one study of the inadequate medical treatment that is offered to most HIV-positive Native Americans noted that the stigma of Acquired Immune Deficiency Syndrome (AIDS) provides a strong motivation for not seeking treatment. The study protocol, however, did not seek to investigate whether young Native American men are afraid of being stigmatized for their sexual orientation, their race, their low socioeconomic status, or all three.
Stigma and mental illness
Stigma and specific disorders
The stigma that is still attached to mental illness in the developed countries does not represent a simple or straightforward problem. Public health experts who have studied the stigmatization of mental illness in recent years have noted that the general public's perception of mental illness varies, depending on the nature of the disorder. While in general the stigma of mental illness in contemporary society is primarily associated with the second of the three categories of stigma listed above,— supposed character failings—it also spills over into the first category. Mental disorders that affect a person's physical appearance—particularly weight gain—are more heavily stigmatized than those that do not.
The stigma related to certain types of mental disorders has declined since the 1950s, most notably in regard to depression and the anxiety disorders. It is thought that the reason for this change is that people are more likely nowadays to attribute these disorders to stress, with which most people can identify. On the other hand, the stigma associated with psychotic disorders appears to be worse than it was in the 1950s. Changes in public attitude are also reflected in age-group patterns in seeking or dropping out of treatment for mental disorders. One study demonstrated that older adults being treated for depression were more likely than younger adults to drop out of treatment because they felt stigmatized. The difference in behavior is related to public attitudes toward mental illness that were widespread when the older adults were adolescents.
In 2002, the types of mental disorders that carry the heaviest stigma fall into the following categories:
- Disorders associated in the popular mind with violence and/or illegal activity. These include schizophrenia , mental problems associated with HIV infection, and substance abuse disorders.
- Disorders in which the patient's behavior in public may embarrass family members. These include dementia in the elderly, borderline personality disorder in adults, and the autistic spectrum disorders in children.
- Disorders treated with medications that cause weight gain or other visible side effects.
The role of the media
The role of the media in perpetuating the stigmatization of mental illness has received increasing attention from public health researchers, particularly in Great Britain. In 1998, the Royal College of Psychiatrists launched a five-year campaign intended to educate the general public about the nature and treatment of mental illness. Surveys conducted among present and former mental patients found that they considered media coverage of their disorders to be strongly biased toward the sensational and the negative. One-third of patients said that they felt more depressed or anxious as a result of news stories about the mentally ill, and 22% felt more withdrawn. The main complaint from mental health professionals, as well as patients, is that the media presented mentally ill people as "dangerous time bombs waiting to explode" when in fact 95% of murders in the United Kingdom are committed by people with no mental illness. The proportion of homicides committed by the mentally ill has decreased by 3% per year since 1957, but this statistic goes unreported. Much the same story of unfair stigmatization in the media could be told in the United States, as the Surgeon General's report indicates.
Physicians' attitudes toward mental illness
Physicians' attitudes toward the mentally ill are also increasingly recognized as part of the problem of stigmatization. The patronizing attitude of moral superiority toward the mentally ill in the early 1960s, specifically in mental hospitals, has not disappeared. This was reported by Erving Goffman in his classic study. A Canadian insurance executive told a conference of physicians in May 2000 that they should look in the mirror for a picture of the ongoing stigmatization of the mentally ill. The executive was quoted as saying, "Stigma among physicians deters the detection of mental disorders, defers or pre-empts correct diagnosis and proper treatment and, by definition, prolongs suffering." An American physician who specializes in the treatment of substance addicts cites three reasons for the persistence of stigmatizing attitudes among his colleagues: their tendency to see substance abuse as a social issue, rather than a health issue; their lack of training in detecting substance abuse; and their mistaken belief that no effective treatments exist. A similar lack of information about effective treatments characterizes many psychiatrists' attitudes toward borderline personality disorder.
Stigma as cause of mental illness
It is significant that researchers in the field of social psychology have moved in recent years to analyzing stigma in terms of stress. Newer studies in this field now refer to membership in a stigmatized group as a stressor that increases a person's risk of developing a mental illness. The physiological and psychological effects of stress caused by racist behavior, for example, have been documented in African Americans. Similar studies of obese people have found that the stigmatization of obesity is the single most important factor in the psychological problems of these patients. To give still another example, the high rates of depression among postmenopausal women have been attributed to the fact that aging is a much heavier stigma for women than for men in contemporary society.
Stigma has a secondary effect on rates of mental illness in that members of stigmatized groups have less access to educational opportunities, well-paying jobs, and adequate health care. They are therefore exposed to more environmental stressors in addition to the stigma itself.
Stigma as effect
Stigma resulting from mental illness has been shown to increase the likelihood of a patient's relapse. Since a mental disorder is not as immediately apparent as race, sex, or physical handicaps, many people with mental disorders undergo considerable strain trying to conceal their condition from strangers or casual acquaintances. More seriously, the stigma causes problems in the job market, leading to stress that is related to lying to a potential employer and fears of being found out. Erving Goffman reported in the 1960s that a common way around the dilemma involved taking a job for about six months after discharge from a mental institution, then quitting that job and applying for another with a recommendation from the first employer that did not mention the history of mental illness.
The stigmatization of the patient with mental illness extends to family members, partly because they are often seen as the source of the patient's disorder. A recent editorial in the Journal of the American Medical Association tells the story of two sets of parents coping with the stress caused by other people's reactions to their children's mental illness, and the different responses they received when the children's disorders were thought to be a physical problem. The writer also tells of the problems encountered by the parents of an autistic child. The writer stated that family excursions were difficult, and continued, "My friend's wife was reprimanded by strangers for not being able to control her son. The boy was stared at and ridiculed. The inventive parent, fed up with the situation, bought a wheelchair to take the child out. The family was now asked about their child's disability. They were praised for their tolerance of his physical hardship and for their courage; the son was commended for his bravery. Same parents, same child, different view."
The results of stigma
The stigmatization of mental disorders has a number of consequences for the larger society. Patients' refusal to seek treatment, noncompliance with treatment, and inability to find work has a high price tag. Disability related to mental illness accounts for fully 15% of the economic burden caused by all diseases in developed countries.
Stigmatization of mental illness is an important factor in preventing persons with mental disorders from asking for help. This factor affects even mental health services on university campuses; interviews with Harvard students following a 1995 murder in which a depressed student killed a classmate, found that students hesitated to consult mental health professionals because many of their concerns were treated as disciplinary infractions, rather than illnesses. The tendency to stigmatize mental disorders as character faults is as prevalent among educators as among medical professionals. In addition, studies of large corporations indicate that employees frequently hesitate to seek treatment for depression and other stress-related disorders for fear of receiving negative evaluations of job performance and possible termination. These fears are especially acute during economic downturns and periods of corporate downsizing.
Compliance with treatment
Another connection between mental disorders and stigma is the low rates of treatment compliance among patients. To a large extent, patient compliance is a direct reflection of the quality of the doctor-patient relationship. One British study found that patients with mental disorders were likely to prefer the form of treatment recommended by psychiatrists with whom they had good relationships, even if the treatment itself was painful or difficult. Some patients preferred electroconvulsive therapy (ECT) to tranquilizers for depression because they had built up trusting relationships with the doctors who used ECT, and perceived the doctors who recommended medications as bullying and condescending. Other reasons for low compliance with treatment regimens are related to stigmatized side effects. Many patients, particularly women, discontinue medications that cause weight gain because of the social stigma attached to obesity in females.
Social and economic consequences
As already mentioned, persons with a history of treatment for mental disorders frequently encounter prejudice in the job market and the likelihood of long periods of unemployment; this can result in lower socioeconomic status, as well as loss of self-esteem. These problems are not limited to North America. A recent study of mental health patients in Norway, which is generally considered a progressive nation, found that the patients had difficulty finding housing as well as jobs, and were frequently harassed on the street as well as being socially isolated. In 1990, the Congress of the U.S. included mental disorders (with a few exceptions for disorders related to substance abuse and compulsive sexual behaviors) in the anti-discriminatory provisions of the Americans with Disabilities Act (ADA). As of 2002, mental disorders constitute the third-largest category of discrimination claims against employers.
Stigmatization of mental disorders also affects funding for research into the causes and treatment of mental disorders. Records of recent Congressional debates indicate that money for mental health research is still grudgingly apportioned as of 2002.
The stigma of mental illness will not disappear overnight. Slow changes in attitudes toward other social issues have occurred in the past three decades, giving hope to the lessening of stigma toward people with mental illness. However, limitations on indefinite economic expansion are an reason for concern. As the economic "pie" has to be divided among a larger number of groups, causing competition for public funding, persons with mental disorders will need skilled and committed advocates if their many serious needs are to receive adequate attention and help.
See also Stress
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National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA22201. (800) 950-6264. <www.nami.org> .
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Rebecca J. Frey, Ph.D.