Stigma occurs when society labels someone as tainted or less desirable. Stigma involves three elements; a lack of knowledge (ignorance), negative attitudes (prejudice) and people behaving in ways that disadvantage the stigmatised person (discrimination) (1). Several health conditions are associated with stigma including some cancers, HIV, AIDS and skin conditions such as psoriasis. However the stigma related to mental health problems is particularly severe and widespread. This article discusses mental health stigma, its consequences and what can be done to reduce it.
Stigma and its consequences
Two main types of stigma occur with mental health problems, social stigma and self-stigma. Social stigma, also called public stigma, refers to negative stereotypes of those with a mental health problem. These stereotypes come to define the person, mark them out as different and prevent them being seen as an individual. Social stigma is associated with discrimination. For example a person with a mental health problem may find that others, including friends and colleagues, avoid them. They may also find it harder to gain housing, obtain employment and access healthcare and may find that their account is less likely to be believed by the police if they report a crime. A 2011 survey found that almost nine out of ten mental health service users in England had experienced discrimination (2). The consequences of discrimination, for example unemployment and social isolation, can stigmatise a person further. Self-stigma occurs when a person internalises negative stereotypes. This can cause low self-esteem, shame and hopelessness. Both types of stigma can lead a person to avoid seeking help for their mental health problem due to embarrassment or fear of being shunned or rejected. When this happens the underlying problem can go untreated causing unnecessary suffering. A delay in receiving treatment can worsen the outlook of some conditions as can the stress and anxiety caused by experiencing stigma. Family members can become stigmatised by a relative having a mental health problem, so called courtesy stigma.
It has been argued that certain diagnostic labels cause stigma. Although it is true that certain diagnoses, for example schizophrenia, carry more negative connotations than other diagnoses, for example depression, stigma cannot be attributed to diagnosis alone. Stigma and discrimination have been associated with mental health problems throughout history, across cultures and long before modern diagnostic categories were established.
Lack of knowledge and negative attitudes
The level of knowledge among the public regarding mental health problems is poor and negative beliefs and attitudes are widespread (3). Both are key elements of stigma. One of the most common and damaging misperceptions is that people with schizophrenia are violent and a danger to others. This view has been perpetuated by misleading media reports. Research shows that although schizophrenia is associated with violent behaviour this accounts for less than 10% of violent crime in society (4). A person with schizophrenia is far more likely to be the victim of violence than to be violent to another person (5). They are also more likely to be the victim of violence than a person in the general population (6). If a person with schizophrenia becomes aggressive this is often related to the use of excessive alcohol or street drugs which is similar to the situation seen with people who do not suffer from schizophrenia but become aggressive.
Public surveys show that eating disorders and problematic use of alcohol and other drugs are frequently seen as an individual’s own fault (3). People with these disorders, and also depression and anxiety, are often viewed as needing to ‘pull themselves together’. Such views would rarely be associated with cancer or heart disease. In reality the cause of most mental health problems, like most physical health problems, is complex and multiple risk factors contribute. Some factors can be modified which is important as it gives people some control over their health, for example eating a healthy diet to reduce the risk of heart disease or ensuring a sensible work/life balance to reduce the risk of depression. However many risk factors for physical and mental health problems are beyond an individual’s control, for example inheriting an increased vulnerability to develop heart disease, depression or some other medical condition. Another example of a risk factor, beyond the control of the sufferer, is childhood abuse and neglect which increases the risk for developing depression, problematic use of alcohol and other drugs, eating disorders, personality disorder and psychosis in later life.
Other misperceptions include the view that mental health problems are uncommon, that sufferers seldom recover and that treatment is ineffective. Mental health problems are common; one in four adults will suffer from a mental health problem in any given year and mental health problems account for about one third of all general practitioner (GP) consultations. However these disorders have a far better outcome than many people realise. For example half of those affected with a depressive illness recover within three months. Long term studies show that many people diagnosed with schizophrenia are functioning well and at least one in ten people who experience a first psychotic episode will not experience a further episode. A minority of people with mental health problems have severe, long-term symptoms and experience significant disability but this is no different to the situation with many physical illnesses. Most people who are treated for a mental health problem receive all their care from their GP and other staff in primary care with about 10% receiving additional help from specialist psychiatric services such as community mental health teams. Treatment depends on the nature of the problem and the individual. However, in general both talking treatments, such as cognitive behavioural treatment (CBT), and medication are reasonably effective. Many mental health problems can be treated successfully with talking treatments alone but medication is an important part of the treatment for many more severe problems. When medication is given it should always be accompanied by psychological and social approaches. The effectiveness of psychiatric drugs in a range of psychiatric conditions is similar to the effectiveness of medical drugs in a range of physical health disorders including migraine, heart failure, chronic obstructive pulmonary disease and high blood pressure (7).
Negative views of mental health problems are held by people in all walks of life and of all ages. People with mental health problems can experience stigma and discrimination from family members, friends, teachers, work colleagues and health professionals including GPs, psychiatrists and psychiatric nurses.
Education campaigns can help reduce stigma. Most are targeted at the general public but they can also focus on specific groups, for example teachers, the police or medical students. ‘Time to Change’ is England’s largest mental health anti-stigma campaign and was launched in 2009. It is led by the mental health charities Mind and Rethink Mental Illness and is funded by the Department of Health, the Big Lottery Fund and Comic Relief. Education campaigns often involve individuals with a mental health problem telling their personal story, either through film clips or face to face in workshops, with an emphasis on hope and recovery. Such ‘social contact intervention’ is an effective way to reduce stigma. Providing accurate information and key messages is also important. Examples of key messages include that mental health problems are common and affect people of all ages, backgrounds and cultures but are not a barrier to living a fulfilling and successful life as shown by the many famous people who have suffered from depression and other psychiatric problems.
Educational campaigns often target the media to try and ensure a more balanced and accurate coverage of mental health issues. This is crucial as the media can perpetuate negative stereotypes through inaccurate and distorted reporting of news stories. Surveys of newspapers in England find that just under half of articles with a mental health theme are stigmatising, for example they use pejorative language or emphasise the risk of violence to others (8).
The fictional portrayal of people with mental health problems in cinema and television is often misleading and stigmatising. A recent report identified four main cinematic stereotypes of people with mental health problems; objects of fun and ridicule, fakers, people to be pitied or violent individuals (9). The last portrayal is closely linked to cinematic portrayals of psychosis. The media reflect society’s existing prejudices and cannot be blamed for the existence of stigma but these representations have been described as a ‘reservoir’ that perpetuates damaging stereotypes. On the other hand some depictions of mental illness, particularly in several recent television dramas, are accurate, positive and can help reduce stigma and increase public understanding.
Tackling stigma is not only the responsibility of those organising large scale education campaigns. A ‘bottom up’ approach is also needed. People who have suffered from a mental health problem, family members, health care professionals and the general public need to feel confident to challenge negative stereotypes that they encounter, whether at work or socially. An example of this occurring on a large scale was in 2003 when the Sun newspaper reported on the former world heavyweight champion boxer Frank Bruno being admitted to a psychiatric ward with the headline ‘Bonkers Bruno Locked Up’. There was an immediate outcry by members of the public and mental health charities and the paper was forced to change the headline to the more sympathetic ‘Sad Bruno In Mental Home’ for the second edition.
Another way to combat stigma is through anti-discrimination policy and legislation. This approach has proven successful in reducing discrimination experienced by people on grounds of gender, race and sexual orientation. The Equality Act 2010 made it unlawful in Great Britain to discriminate directly or indirectly against someone who has a disability in work, education, public services and several other specified situations. The Act defines a disability as a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on a person’s ability to carry out normal day-to-day activities. Long-term means the disorder has lasted a year, or is likely to last at least a year, or is likely to be recurrent. As such the definition could include people with a wide range of mental health problems such as learning difficulties, depression, schizophrenia and bipolar disorder. The Act also requires employers to make reasonable adjustments in the work place if a person’s disability puts them at a disadvantage compared to others.
Signs of progress
Progress has been made in reducing mental health stigma. Mental health is discussed far more openly than in the past as shown by the many magazine articles, books and radio and television programmes on this subject. One of the most successful current plays in the West End, ‘The Curious Incident of the Dog in the Night-time’, is the sympathetic fictional account of a young man with Asperger’s Syndrome. In the 1990s the award winning author William Styron wrote about his depressive illness in the book ‘Darkness Visible’ as did the biologist Lewis Wolpert in a book entitled ‘Malignant Sadness’. The current Time to Change anti-stigma and discrimination campaign in England has been supported by celebrities and high profile figures, including Stephen Fry, Frank Bruno and Alastair Campbell, who have discussed their experience of suffering from a mental health problem.
The Time to Change campaign has been accompanied by a decrease in stigma. Between 2008, the year before the campaign was launched, and 2011 there was a significant fall in the level of discrimination experienced by people using mental health services in England and a small increase in the proportion of people who reported experiencing no discrimination (2). Over the same period there was an increase in the proportion of anti-stigmatising newspaper articles (8). Unfortunately the proportion of stigmatising articles remained constant with the change being due to a decrease in the proportion of mixed or neutral articles. Between 2003 and 2013 there has been a small improvement in public attitudes to people with mental illness in England (10). A report published in 2014 concluded that television dramas were moving away from negative stereotypes towards a more accurate and sympathetic portrayal of people with mental health problems and that script writers were aware of mental health stigma and discrimination (11).
Despite the progress that has been made, mental health stigma remains widespread. Much of the reduction in stigma has centred on depression, bipolar disorder and other mood disorders while psychosis and schizophrenia remain highly stigmatised. A range of approaches are needed to tackle stigma. Reducing stigma can improve the quality of life of those with a mental health problem and is a major priority.
The authors wish to thank the various service users and professionals who made helpful comments on earlier drafts of this article.
- Thornicroft G, Rose D, Kassam A, Sartorius N. Stigma: ignorance, prejudice or discrimination. British Journal of Psychiatry 2007; 190: 192-3.
- Corker E, Hamilton S, Henderson C et al. Experiences of discrimination among people using mental health services in England 2008-2011. British Journal Psychiatry 2013; 202 (suppl 55):s58-s63
- Crisp A, Gelder MG, Goddard E, Meltzer H. Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry 2005; 4:106-113.
- Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal Psychiatry 2002; 180:490-5.
- Brekke JS, Prindle C, Bae SW, Long JD. Risks for individuals with schizophrenia who are living in the community. Psychiatr Serv. 2001; 52(10):1358-66.
- Walsh E, Scott C, McKenzie K et al. Prevalence of violent victimisation in severe mental illness. British Journal of Psychiatry 2003; 183: 233-238.
- Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. British Journal Psychiatry 2012; 200(2):97-106.
- Thornicroft A, Goulden R, Shefer G et al. Newspaper coverage of mental illness in England 2008-2011. British Journal Psychiatry 2013; 202 (suppl 55):s64–s69.
- Screening Madness; A century of negative move stereotypes of mental illness. Peter Byrne. Time to Change (2009).
- Evans-Lacko S, Corker E, Henderson C and Thornicroft G. Effect of the Time to Change anti-stigma campaign on trends in mental-illness-related public stigma among the English population in 2003—13: an analysis of survey data. The Lancet Psychiatry 2014; 1:121 – 128
- Making a drama out of a crisis. Time to Change Campaign 2014.