Stigma of mental illness Advances inAPT

Psychiatric Treatment
(2000), vol. 6, p. 65(2000), vol. 6, pp. 65–72

Stigma of mental illness

and ways of diminishing it
Peter Byrne

Stigma is defined as a sign of disgrace or discredit, The adaptive response to private and public
which sets a person apart from others. The stigma shame is secrecy. Commenting on the barriers to the
of mental illness, although more often related to management of depression, Docherty (1997) cites
context than to a person’s appearance, remains a both patients’ shame in admitting to, and phys-
powerful negative attribute in all social relations. icians’ reluctance to enquire about, depressive
Sociological interest in psychiatric stigma was given symptoms. Family and friends may endure a stigma
added vigour with the publication of Stigma – Notes by association, the so-called “courtesy stigma”
on the Management of Spoiled Identity (Goffman, 1963). (Goffman, 1963). In one study of 156 parents and
More recently, psychiatrists have begun to re- spouses of first-admission patients, half reported
examine the consequences of stigma for their making efforts to conceal the illness from others
patients. In 1989, the American Psychiatric Associ- (Phelan et al, 1998). Professionals are no different in
ation’s annual meeting’s theme ‘overcoming stigma’ this regard, and hide psychiatric illness in themsel-
was subsequently published as a collection of ves or a family member. Secrecy acts as an obstacle
articles (Fink & Tasman, 1992), and last year saw to the presentation and treatment of mental illness
the launch of the Royal College of Psychiatrists’ five- at all stages. So, unlike physical illness, when social
year Changing Minds anti-stigma campaign. resources are mobilised, people with mental disorders
are removed from potential supports. Poorer outcomes
in chronic mental disorders are likely when patients’
social networks are reduced (Brugha et al, 1993).
What stigma means The question arises as to just what all this shame
and secrecy is about. Negative cultural sanction and
Beyond any definition, stigma has become a marker
for adverse experiences (see Box 1). First among
these is a sense of shame. Mental illness, despite
centuries of learning and the ‘Decade of the Brain’, Box 1. The experience of stigma
is still perceived as an indulgence, a sign of
weakness. Self-stigmatisation has been described, Shame
and there are numerous personal accounts of Blame
psychiatric illness, where shame overrides even the Secrecy
most extreme of symptoms. In two identical UK The “black sheep of the family” role
public opinion surveys, little change was recorded Isolation
over 10 years, with over 80% endorsing the statement Social exclusion
that “most people are embarrassed by mentally ill Stereotypes
people”, and about 30% agreeing “I am embarrassed Discrimination
by mentally ill persons” (Huxley, 1993).

Peter Byrne is Senior Lecturer at East Kent NHS Community Trust (2 Radnor Park Avenue, Kent CT19 5HN). He completed all
his psychiatric training in Ireland: in Dublin, Waterford and Cork. He also lectures in Film Studies at University College Dublin.
He is a former chairman of the Public Education Committee of the Royal College of Psychiatrists in Ireland, and the current co-
chairman of media projects of the Changing Minds Committee. His research interests include stigma, the media, patient and
public education.

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APT (2000), vol. 6, p. 66 Byrne

myths combine to ensure scapegoating in the wider frequently portrayed as victims, pathetic characters,
community (see Box 1). The reality of discriminatory or “the deserving mad” (Byrne, 1997). This parallels
practices supplies a very real incentive to keep the experience of physical disability, where
mental health problems a secret. Patients who sympathy is a pretext for social distance – the “Does
pursue the secrecy strategy and withdraw have a he take sugar?” strategy. The Royal College of
more insular support network. Discrimination Psychiatrists’ survey also recorded consistently high
occurs across every aspect of social and economic responses (ranging from 50–79%) in relation to six
existence (Fink & Tasman, 1992; Heller et al, 1996; common mental disorders, when the public was
Read & Reynolds, 1997; Byrne, 1997; Thompson & asked whether the sufferer was “hard to talk to”.
Thompson, 1997). A civilisation should be judged Most clinicians would instinctively encourage
by how it treats its mentally ill: discrimination is empathy not sympathy for their patients.
also about the conditions in which our patients live, In cinema and television, mental illness is the
mental health budgets and the priority which we substrate for comedy, more usually laughing at than
allow these services to achieve. By way of summary, laughing with the characters (Byrne, 1997). As part
Gullekson (in Fink & Tasman, 1992) writes about of the ‘them and us’ strategy, mental disorders have
her brother’s schizophrenia: also been conferred with highly charged negative
“For me stigma means fear, resulting in a lack of connotations of self-infliction, an excuse for laziness
confidence. Stigma is loss, resulting in unresolved and criminality. Hyler et al (1991) have written about
mourning issues. Stigma is not having access to a number of Hollywood films where the represen-
resources… Stigma is being invisible or being reviled, tations of mental illness are of “overprivileged,
resulting in conflict. Stigma is lowered family esteem oversexed narcissistic parasites”. But ‘pull yourself
and intense shame, resulting in decreased self-worth. together’ attitudes are not confined to fictional
Stigma is secrecy… Stigma is anger, resulting in screen representations, with one Northern Ireland
distance. Most importantly, stigma is hopelessness, general practitioner writing:
resulting in helplessness.”
“Yet they (‘neurotic patients’) take up far too much
of our time and energy – people complaining,
miserable, depressed, neurotically whining about how
Stereotypes unhappy they are, pouring out all their problems in
the surgery and dumping them on my doorstep. It
would be really unbearable if I was actually listening
to them” (Farrell, 1999).
Goffman (1963) commented that the difference
between a normal and a stigmatised person was a
question of perspective, not reality. Stigma (like
beauty) is in the eye of the beholder, and a body of
evidence supports the concept of stereotypes of
The process of stigmatisation
mental illness (Townsend, 1979; Philo, 1996; Byrne,
1997). Stereotypes are about selective perceptions
The history of stigma, culturally determined, is
that place people in categories, exaggerating
described elsewhere (Section 2 of Fink & Tasman,
differences between groups (‘them and us’) in order
1992; Warner in Heller et al, 1996). Some social
to obscure differences within groups (Townsend,
scientists believed stigma was a function of labelling
1979). As with racial prejudice, stereotypes make
by psychiatrists, citing benign public attitudes of
people easier to dismiss, and in so doing, the
stigmatiser maintains social distance. The media self-report studies and the observation that many
perpetuate stigma, giving the public narrowly patients were unaware of stigma: this is not
focused stories based around stereotypes. On a more supported by the evidence (Link et al in Fink &
positive note, the media are a useful location to begin
the search for negative representations and adverse
attitudes to mental illness, and ultimately the media
will be the means of any campaign that aims to Box 2. Stereotypes of mental illness
challenge and replace the stereotypes.
Philo (1996) measured violence as the central Psychokiller / maniac
element in television representations in 66% of items Indulgent, libidinous
about mental illness, an interesting figure in that it Pathetic sad characters
corresponds with the Royal College of Psychiatrists’ Figures of fun
1998 survey, where 70% believed that people with Dishonest excuse: hiding behind ‘psycho-
schizophrenia are violent and unpredictable. At the babble’ or doctors
other extreme, people with mental illness are

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Stigma of mental illness APT (2000), vol. 6, p. 67

Tasman, 1992). Mental illness stigma existed long intolerance of ambiguity, rigid authoritarian beliefs
before psychiatry, although in many instances the and a hostility towards other groups (ethnocentric-
institution of psychiatry has not helped to reduce ity). Other studies of the attributes of those who are
either stereotyping or discriminatory practices. more likely to produce negative evaluations of
Further, the ubiquity of stigma and the lack of stigmatised people found no relation to “conven-
language to describe its discourse have served to tionalism”, but did report an association with a
delay its passing: racism, fatism, ageism, religious “cynical world view” (Crandall & Cohen, 1994).
bigotry, sexism and homophobia are all recognised Knowing someone who has a mental illness is
descriptions for prejudiced beliefs, but there is no not associated with more enlightened attitudes
word for prejudice against mental illness. One (Wolff et al, 1996a), but Huxley (1993) identifies that
possible remedy to this would be the introduction the key factor is direct contact with people who have
of the term ‘psychophobic’ to describe any individ- had “helpful treatment for episodes of mental
ual who continues to hold prejudicial attitudes about illness”. The challenge, listed in the third section of
mental illness regardless of rational contrary evid- Box 3, is to confront the stigmatiser with his or her
ence. Despite inevitable objections from some, the irrational beliefs, in addition to enabling direct con-
rise of ‘politically correct’ language has been a key tact with “one of them”. This may seem an unrealistic
factor in the success of campaigns opposing discrim- aim, if the prototype stigmatiser conjures up images
ination based on gender, age, religion, colour, size of shaven-headed boot-boys, but any list of stig-
and physical disability (Thompson & Thompson, matisers includes landlords, employers, insurers,
1997). welfare administrators, housing officers, univer-
Negative attitudes to people with mental illness sities, health care professionals, lawyers, prison
start at playschool and endure into early adulthood: workers and teachers.
one cohort confirmed the same prejudices on re-
examination eight years later (Weiss, 1994). Green
et al (1987) measured consistently negative public
attitudes at five separate points over 22 years. These Levels of intervention
studies, and that quoted above from Huxley (1993),
directly contradict a recent claim (stated but
unreferenced) that “public perception of psychiatric The starting point for all target groups and at every
disorders will change: improved understanding of level is education: to date, the Changing Minds
the causes and mechanisms of disease is likely to campaign has succeeded in its requests to medical
reduce stigma” (McGuffin & Martin, 1999). Accep- journals to publish articles on stigma. These articles,
ting the low value most cultures attach to mental including the excellent Lancet series (Lancet, 1998)
disorders, are there any qualities in stigmatisers that have provoked discussion within professional
could be altered to reduce overall levels of stigma? circles, and beyond. Psychiatric Services and the UK-
Adorno et al (1950) have hypothesised about the based Journal of Mental Health have been major forums
likely make-up of prejudiced people: they have an for research and debate on this subject, and more

Box 3. Factors which influence the prejudice of stigmatisers

Factor type Example Likely to increase prejudice

Attribute of stigmatised Gender Male gender
Appearance Unkempt appearance
Behaviour Acute illness episode
Financial circumstances Homelessness

Assumptions about Perceived focus of illness Many deficits

the individual’s disorder Perceived responsibility Not responsible for actions
Perceived severity History of hospital admission

Knowledge base about Perceived origin Self-inflicted

particular disorder Perceived course Incurable/‘chronic’
Perceived treatments ‘Needs drugs’ to stay well
Perceived danger Criminality or violence

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APT (2000), vol. 6, p. 68 Byrne

recently the Psychiatric Bulletin has featured a ourselves and others, and pursue the ongoing task
number of key articles. Other professions – nursing, of unravelling the nature of prejudice. These three
occupational therapy and social work – have been separate tasks are summarised in the Changing
writing about these issues for far longer and in Minds slogan: “Stop, think, understand”.
greater depth than psychiatrists. Publications in the Closing the knowledge gap is only part of the
lay press circulate the arguments to a wider answer. Stigmatisers, as a rule, are unlikely to volun-
audience. The Internet is already a highly effective teer to attend educational packages. Even assuming
means of distributing information and specific anti- the message reaches all targets, education alone
stigma initiatives, and readers can access details of cannot change centuries of folklore and prejudice.
Changing Minds and other campaigns through The ‘carrot’ of education must be accompanied by
www.rcpsych.ac.uk. and www.irishpsychiatry.com. the ‘stick’ of challenges to media misrepresentations,
Stigma and its sequelae should achieve a prominent positive discrimination in the workplace, test cases
place on the curriculum of all health service profes- in the courts, and legal sanction through (for example)
sionals and their students. The latter group will be the Disability Rights Commission. In this regard,
the decision-makers of the next millennium and will lessons can be learned from AIDS foundations and
either initiate further social psychiatry research or the gay community, who met the challenge of initial
make the same mistakes as their predecessors. public antipathy to AIDS, and who have now
Wolff et al (1996a,b) have provided a practical achieved the dual goals of health promotion and
working model for interventions aimed at various major reductions in discriminatory practices
target groups (see Box 4). One aspect of this is to (Thompson & Thompson, 1997).
listen to the concerns of the people whose attitudes
you wish to change. Young couples with children
have specific fears that need to be addressed, and in
this group, reductions in levels of fear can be
Changing psychiatry first
achieved with educational interventions (Wolff et
al, 1996a). Other settings, for example schools,
workplaces and welfare services, will require Ask yourself the following questions: could you give
different information packages tailored to their a talk about stigma next week? What have you done
needs. The content of these interventions should to reduce stigma and discrimination against your
include the components of established psycho- patients? Is stigma on the undergraduate curriculum
education modules, the stigma–discrimination of your university, or something about which your
paradigm (a prototype presentation is available at trainees have formal teaching? It is not just that psy-
www.rcpsych.ac.uk) and information specific to the chiatry has a shameful history in its contributions
needs of the target group. to modern-day misconceptions about mental illness
Mental health professionals need to move beyond (see Box 6), but that it has also failed to address its
teaching psychoeducation in isolation (at the clinic) current deficiencies. None of the standard British
to full participation in planned programmes of psychiatry textbooks cites “stigma” in their indices.
public education (see Box 5). Every intervention There is a dearth of psychiatric research on stigma
must convince its target group of the importance of and discrimination, and a perennial resistance to
stigma/discrimination, challenge stereotypes in rocking the stigma boat. Wolff et al (1996a) described
their failure to achieve ethical approval for their
study in London, and also described staff precon-
ceptions that it would draw attention to the patients’
problems, making integration locally more difficult.
Many psychiatrists share the stereotypes des-
Box 4. Key suggestions for educational cribed above. Lewis & Appleby (1988) reported that
interventions: after Wolff et al (1996a)

Specific target groups, with prior identific-

ation of their attitudes
No evidence of community backlash Box 5. From psychoeducation to public
Flexible public education packages education
Small groups work better
Several interventions over time exceed the Patient Person
sum of their parts Family Target group
Continuing contact with the group (keyworker) Network Community
maintains momentum Advocate group Society

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Stigma of mental illness APT (2000), vol. 6, p. 69

psychiatrists reacted to vignettes differently if the

person had been given the diagnosis of a personality Practical stigma management
disorder: once labelled, primary diagnoses differed
and value judgements (e.g. “manipulative”, “does
not merit NHS time”, “unlikely to improve”, “likely If every psychiatrist left rehabilitation to the rehab-
to annoy”) appeared more frequently. Antipathies ilitation team, there would be no rehabilitation.
to psychiatry and psychiatrists are widespread Equally, if every psychiatrist leaves ‘the stigma issue’
among the medical profession, but perhaps the real to the Changing Minds campaign, there will be no
issue is that the majority of psychiatrists fail to enduring change. Psychiatrists should address
challenge these prejudices. This failure to respond, stigma as a separate and important marker in its
be it acquiescence or resignation, cannot continue. own right. Because of the nature of stigma, patients
The impetus to challenge ageism did not come from are unlikely to bring it directly to the attention of the
medical gerontology, but was later championed by mental health team. Clinicians should ask about the
that speciality. Radical action within and outside nature of adverse experiences, discrimination, the
psychiatry is now required. extent of social networks, self-image, etc., and
Dubin & Fink (in Fink & Tasman, 1992) describe incorporate these issues into the treatment plan.
how psychiatrists perpetuate many concepts Acknowledging the existence of prejudice is an
underlying biased and stigmatising attitudes, and essential first step, and is no more ‘dangerous’ than
suggest that the way in which psychiatry is struc- enquiry into suicidal ideation. There may be a
tured maintains the status quo. Eisenberg (1995) has specific focus of adverse experiences (bullying at
criticised the highly charged ‘either/or’ discourse work or school, family difficulties), or ways in which
that mental diseases are either biological/’no one’s the patient can alter others’ reactions to him- or
fault’ or psychological/’caused by’ parents, spouses herself (see Box 3). The patient needs to construct
or patients. Silence on these issues is no longer these stigmatising experiences as part of a general-
tenable: for all aspects of stigma and discriminatory ised prejudice in society, allowing the possibility of
practices, psychiatrists need to complain more often overcoming his or her own difficulties. Alongside
and more effectively – media coverage is a good this, the clinician will gain in adding to his or her
starting point (Hart & Philipson, 1999). For psy- existing knowledge of the patient’s social context
chiatrists, the debate goes beyond stigma. It includes and learning more about stigma.
the quality and structure of existing services, and Schizophrenia presents unique challenges. Lack
the barriers that deny access to them (Thompson & of insight is always problematic, but an affective
Thompson, 1997). Compliance is one example where component can be associated with denial of
both a concept, and the theories underlying it, are in symptoms or rejection of treatment at key points in
need of a radical change in mind set. Brandon (in the illness. The life events model contains many
Read & Reynolds, 1996) has provided a number of events that could be precipitated by stigma-led
suggestions for change among psychiatrists, experiences: losing a job, a home or a friendship. It
principally abandoning the ‘them and us’ mentality. is about humiliating and devaluating experiences,
Crepaz-Keay (in Read & Reynolds, 1996) sums up and these play an important part in relapses of
the (stereotypical) psychiatrist’s reactions to depression. Equally, the central roles of vulnerability,
advocates: “But you’re not like my clients” or “Who destabilisation and restitution factors have a bearing
do you represent?”. on outcome. Pessimism in the profession may also
negatively affect patient perceptions here: for years,
the chronic social breakdown syndrome of long-stay
patients was seen as an integral part of schizo-
Box 6. A history of dumb ideas in psychiatry phrenia (Eisenberg, 1995). Given that at least 50%
of people with schizophrenia have significant social
Moon (lunatic) and womb (hysteria) theories skills deficits, any programme must include improv-
Technique of persuasion ing interpersonal skills. A symptom-focused approach
Epileptic personalities that includes stigma management can be incorpor-
Mental and moral defectives ated into an existing cognitive–behavioural model
Eugenics (Ernst Rubin) of treatment (Enright, 1997). A comprehensive list of
Insulin coma treatment social obstacles to successful de-institutionalisation
Frontal lobotomy has also been described (Farina et al, in Fink &
Momism, schizophrenogenic mothers, Schism Tasman, 1992).
& Schew families With the possible exception of some patients with
Treatments for homosexuality Alzheimer’s dementia, patients need to know their
diagnosis and what the problems are and are likely

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APT (2000), vol. 6, p. 70 Byrne

to be. Just as adverse public attitudes endure over negative media coverage of mental health
time, the adverse effect of stigma on individuals’ issues
well-being persists from entry into treatment up until l a parent’s description of services as “supermarket
a year after successful treatment (Link et al, 1997). psychiatry”
Cognitive–behavioural therapy (CBT) is now of l a man who had recovered from an episode of
proven efficacy across the spectrum of mental depression, objecting to a public education
disorders (Enright, 1997): its core strategy is campaign that would include schizophrenia
disseminating information about the illness. Holmes and depression together: “Why drag depres-
& River (1998) have outlined a CBT approach to sion down to the level of the gutter?”
combating stigma in individuals. Their article is one l a consultant psychiatrist, on hearing an
of seven similar articles in the Winter 1998 (vol. 5) articulate account of schizophrenia from a
issue of Cognitive Behavioural Practice. woman living with the illness, “Then she
The next step in management is to transform the couldn’t be schizophrenic”.
person from patient to advocate. Part of coping with
stigma is fighting stigma. A recent Royal College of
Psychiatrists’ Council Report lists many different Future directions
kinds of advocacy: self, peer-group, legal, carer and
citizen (Royal College of Psychiatrists, 1999). In
joining an advocate group, the dangers of a ‘them It is difficult to predict the progress over time of a
and us’ situation arise. Certainly, not everyone who variety of existing anti-stigma initiatives. Media
experiences mental illness needs the companion- coverage of these interventions will be essential to
ship and validation of others who have had similar disseminate positive mental health messages, while
experiences. But if the advocate group includes challenging current misrepresentations. Regardless
contacts with partners, friends and families, along of the means (education, legal remedies, health ser-
with community groups, civil rights activists, cam- vice changes), the end is to promote social inclusion
paigners, even (sic) mental health professionals, then and reduce discrimination. The nature of that
it will be a valuable experience. The College, in the discrimination will change as the practices of
same report, issues a formal policy directive on discrimination are successfully challenged: the task
advocacy, broadly welcoming it, and recommending is to identify prejudice in whatever context.
early exposure to it for its trainees. Fisher (1994) Examination of the achievements of other anti-
identifies empowerment as essential to recovery from discrimination movements leaves mental illness
chronic disability. The relationship between psy- stigma as one of the last prejudices. A prerequisite
chiatry and the advocacy movement is not a one- must be to continue listing discriminatory practices
way street. In the past three years, these are the from different perspectives. In some instances, for
learning experiences that the author has encoun- example the current practice of psychiatric assess-
tered at advocates’ meetings: ment of candidates for organ transplantation,
l an architect objecting to her work colleagues’ psychiatrists are already part of the discriminatory
constant references to a psychiatric unit they culture, and must rely on others to highlight injus-
were designing as a “nut house” or “psycho tice. Double discrimination, the coincidence of
depot” mental illness and ethnic minority status, is another
l an insurance executive, with a remote history area where psychiatry on its own will not effect
of mental illness, challenging the loading of change (Browne in Heller et al, 1996). Psychiatry in
his insurance policy – by his own firm these and other areas must collaborate with other
l a nurse, following an episode of depression, fields in identifying problems and effecting enduring
insisting on returning to the intensive care unit solutions.
and not, as suggested, to a convalescence ward All available evidence confirms the value of local
l a medical student challenging the Dean to initiatives, and that means your active participation.
show the same flexibility with mental illness Which would be worse – the widespread reduction
as he had previously shown with physical of prejudice against people with mental illness
disability without the participation of our speciality, or
l a teacher with bipolar disorder encouraging the maintenance, through disinterest, of the status
the schools’ board to include information on quo?
this illness on the curriculum
l a footballer insisting his team play the local Please send new ideas for combating stigma to: Liz
psychiatric unit Cowan, Changing Minds Campaign Administrator,
l a newsagent offering to keep newspaper Royal College of Psychiatrists, 17 Belgrave Square,
cuttings to facilitate a local initiative on London SW1X 8PG.

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Stigma of mental illness APT (2000), vol. 6, p. 71

Wolff, G., Pathare, S., Craig, C., et al (1996a) Public education

for community care. A new approach. British Journal of
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APT (2000), vol. 6, p. 72 Byrne

4. With respect to stigma and the course of the illness b attitudes to people with individual mental
and its treatment: illnesses have shown more understanding as
a social isolation is associated with a longer knowledge increased, alongside phased
duration of depression community care
b general practitioners do not perceive c ‘psychiatrists’ are held in equally high esteem
themselves as being involved in the care of to ‘doctors’
their patients with serious mental illness, d to be an ‘ex-mental patient’ carries a number
particularly if they are Black African, Black of low positive ratings
Caribbean, or male e stereotypical beliefs, such as “dangerous”,
c studies of people who had contact with “worthless”, “weak” and “foolish”, have
psychiatric institutions (USA), compared to persisted to the same degree over 22 years.
controls, show median ages of death of 66 and
76 respectively
d measuring the attitudes of health
professionals, patients with anorexia were
seen as significantly “less likeable” than
patients with schizophrenia, and as being
responsible for their illness MCQ answers
e since the publication of Goffman’s Stigma in
1963, psychiatrists have been at the forefront 1 2 3 4 5
in campaigns to identify and abolish stigma. a F a F a F a T a T
b F b T b T b T b F
5. Research on community attitudes to mental c T c T c T c T c F
illness (Green et al, 1987) show: d T d F d F d T d T
a little or no change over 22 years in negative e F e F e T e F e T
attitudes to mental illness

Royal College of Psychiatrists

Faculty of General & Community Psychiatry and

The Collegiate Trainees Committee Joint Annual Meeting
9th – 10th March 2000, Kensington Town Hall, London
Sessions to be held on:
n Community Psychiatry n Psychiatry and Primary Care
n Psychiatry in the A&E Department n Epidemiological Studies in Psychiatry
n Neuropsychiatry and Neuropharmacology

Also to include:
THE WILLIAM SARGANT LECTURE
‘Psychopharmacotherapy in the context of culture and ethnicity’
Professor Keh-Ming Lin, UCLA School of Medicine, NIMH Research Center
on the Psychobiology of Ethnicity, USA

If you require further details on the above meeting please contact the
Conference Office at The Royal College of Psychiatrists on 020 7235 2351
ext. 168, or by fax on 020 7259 6507.
http://www.rcpsych.ac.uk

https://doi.org/10.1192/apt.6.1.65 Published online by Cambridge University Press