Stigma in Mental Illness: Causes and Impacts

This chapter will examine the term stigma and discuss the negative attitudes that the public hold towards mental health and mental illness and suggest why they may have adopted these views and attitudes. It will also address the media’s role in portraying these views and sustaining these attitudes towards mental illness. An enormous number of individuals are affected by mental illness worldwide: the World Health Organization (WHO) (2001) has estimated that 1 in 5 persons will suffer from a mental illness each year. A question that could be asked if mental illness is a dominant and prevalent issue within society today why do people still hold these negative views and attitudes within society? Finally the chapter will conclude by making some recommendations for practice, ways that stigma can be reduced and how mental health and mental illness can be portrayed in a more positive light.

To fully appreciate the views and attitudes towards mental illness it is important to understand the concept of stigma. Stigma is derived from the Greek for a mark branded on a slave or criminal (White, 1998). Goffman’s (1963) seminal work on stigmatization has, over the years, stimulated a great variety of educational discussion on the nature, sources, and effects of stigma (Link and Phelan, 2001). According to Goffman (1963) stigma is a physical or psychological mark of disgrace that makes an individual stand out from society. Three types of stigmatizing marks identified by Goffman include,

‘Abominations of the body, tribal stigma, and blemishes of individual character’ (Goffman, 1963, pg 14).

People who encompass these physical or psychological marks are often devalued and dehumanised which consequently leads to their position within society being corrupted by the distressing effects of stigmatization (Goffman, 1963). A definition that can be seen to encompass all aspects alongside Goffman is offered by Miles (1981) cited in Brunton (1997) who says,

‘Societal reaction which singles out certain attributes evaluates them as an undesirable and devalues the persons who possess them.’ (p. 892)

The suffering and loss of opportunities that seems to always come hand in hand with a diagnosis of mental illness can be seen to be connected to the psychiatric symptoms that can be observed e.g. talking to voices, the decrease in daily functioning, and the dip in a persons social functioning in society (Corrigan and Wassel, 2008). However, the loss of opportunities and the person with a mental illness devaluing their own self worth take place for the reason of the stigma that surrounds mental illness (Corrigan and Kleinlein, 2005).

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For the purposes of this dissertation ‘negative’ attitudes refers to discriminatory attitudes that are based on prejudice, stereotypes or inaccurate information. Stereotypes are firmly set judgements that are learnt throughout life and held firmly in our mind (Stier and Hinshaw, 2007). They are discriminating views or images related to members of particular groups (Corrigan and Wassel, 2008). Prejudice effects individuals in an emotional manner (Stier and Hinshaw, 2007) and occurs when people within society have the same opinion about a particular stereotype and affix this to a group of people making negative connotations towards that particular group (Corrigan and Wassel, 2008). Then again, Corrigan and Wassel (2008) state that discriminative behaviour can be seen as a direct result of prejudice. This involves a specific group being treated in a dissimilar way leading to that group not being able to access opportunities available to them or their rights being restricted (Stier and Hinshaw, 2007). Negative attitudes towards people with mental distress may be manifested by physical and verbal abuse, problems in the workplace or discrimination from people who provide services to people with a mental illness (Mind, 2010).

Negative attitudes are partly constructed in the language we use to describe mental illness. People with mental distress are often being described in derogatory terms. For example, perpetrators of acts of violence are often described as ‘Lunatics, mad person’ (Tudor, 1996), ‘schizos, nutters, psychos, fiends, monsters and maniacs’ (Twomley, 2007). This makes a clear link between violence and mental distress, it must be acknowledged though that not everyone who is violent necessarily has a mental illness. Angermeyer and Schulze (2001) suggest the general public view people with mental illness as bizarre, fear-provoking, impulsive, violent and lack self-discipline. From this, therefore, it could be suggested that people who have a mental illness are deviants or have deviant behaviour.

Becker (1963) defines deviance as ‘any trait or behaviour that was abnormal when compared to the average population’ (pg. ). If mental illness is classed as deviant then how bad does someone have to act or behave to be classed as deviant. This demonstrates that social rules that are made allow people to judge others as different or in this case deviant (Becker, 1963). This is further supported by Baumann (2007) who suggest that the individual’s picture of the world is created by comparatively constant norms, principles and expectations.

Angermeyer and Matschinger (2005) suggests a diagnosis of schizophrenia has, particularly, been found to be stigmatizing and linked with negative stereotypes such as violence and dangerousness. This shows that by mental health being medicalised it is profoundly unhelpful due to the diagnostic terms such as psychosis which can ‘shackle’ people to the mental health system (Watkins, 2007). In contrast Shepherd et al (2008) describe the recovery model  as taking ownership and responsibility for an illness and what can and can’t be done, focusing on the strengths and issues rather than a diagnosis. This is a reliable source provided by the Sainsbury Centre for Mental Health. The recovery model will be discussed more in-depth in chapter three.

There is no doubt that the media plays a part in reinforcing the attitudes towards mental health and mental illness. In everyday life the public come into contact with the media by newspapers, TV and radio on a daily basis. The way people with a mental illness are viewed as dangerous can be seen to be fuelled by tabloid media publicity about ‘psycho-killers’ (Tudor, 1996). Examples of this are included in the appendix.

The report, Screening for madness, by Byrne (2009) reveals that films representations of people with experience of mental health problems have become more harmful, he suggests that,

‘Mental health stereotypes have not changed over a century of cinema. If anything, the comedy is crueler and the deranged psycho killer even more demonic.’ (pg. 4)

‘One flew over the Cuckoo’s Nest’ can be seen as the film most remembered for depicting someone with a mental illness acting strangely or violently (reference). Even though this was released 35 years ago it shows the influence of movie stereotypes on attitudes and how these can last generations. This is also demonstrated with the recent film ‘Batman-the Dark Knight’ depicting mental illness with violence which more or less is based around the mental illness schizophrenia (Byrne, 2009). This would suggest that ignorance and lack of understanding of mental illness are still very prominent in society today.

It must be acknowledged there are some exceptions to this, of more recent films that have portrayed a less sensational and more insightful picture of mental illness. For instance, ‘A Beautiful Mind’, in 2002, depicted the true story of a maths genius who had a diagnosis of schizophrenia, while ‘Shine’, in 1996, was the story of a brilliant pianist who had a diagnosis of bipolar disorder. Nevertheless, the more positive portrayals can represent mental distress as ‘exotic’, ‘dramatic’ or ‘romantic’ in ways that bear little resemblance to real-life experiences (Lott, 2006).

Likewise, media portrayals of mental health have been far from flattering and largely sensationalized. A survey undertaken in 2000 by MIND found that 73% of people with mental health problems felt that the reporting of mental health issues were unjust, biased and pessimistic (MIND, 2000 cited in Rethink, 2006).

In addition a study by Chopra and Doody (1997) looked at 98 newspaper articles and found there was no significant difference in the portrayal of schizophrenia. They did find overall that 36.1% of articles were negative in tone, 56.7% were neutral and 7.2% were positive. The word ‘schizophrenic’ is often used in tabloid stories in conjunction with violent events, somehow suggesting that the diagnosis can justify why the violence happened in the first place (Twomey, 2007). In reality, the person who happens to have a diagnosis of schizophrenia may have acted in such a way due to taking illegal drugs or may have a violent personality, we need to look at all aspect of what led to a violent situation happening and not just that someone was mentally ill.

The media can often be seen to be responsible for stigmatizing stereotypes of mental illness (Byrne, 1997),however, if the media was used to its potential it can challenge prejudice, enlighten and instigate discussions, helping to reduce the stigma that is so often experienced by people with a mental illness (Salter and Byrne, 2000). It is still evident through reporting on mental health that a diagnosis of a mental illness is linked to violence. There is however, some evidence of positive change where The Sun newspaper was made to remove a headline of ‘Bonkers Bruno locked up’ which was reporting on the sectioning of the boxer frank Bruno under the Mental Health Act (MIND, 2010). In 2006, the Press Complaints Commission (PCC) published a code of practice, which banned the use of stigmatising language around mental illness which reduced the use of the terms such as ‘schizo’ and ‘nutter’ (PCC, 2006). This gives an example of just how much the media has moved on over the years and that there are some strategies to prevent harm being done to people with mental health problems.

Becker (1963) concludes that people who are mentally ill are blamed for things that happen in society therefore you would think they would be punished or persecuted. It must be acknowledged that there are extensive resources devoted to the benevolent care and support of those with an enduring mental illness. Even though this is an old source it is relevant even today and apparent how services are developing for people with mental health problems. Nevertheless, people suffering from a mental illness are still feared and excluded from society (Becker, 1963 and Watkins, 2007). When people have acute mental health problems they can appear to the public to be frightening and exhibit odd behaviours which can often lead to police involvement (Taylor, 2008). At such times they can commit criminal acts, often escaping prosecution due to their mental illness at the time (Bowers, 1998; Taylor, 2008). Therefore, it could be argued that the public hold these views due to such examples where people are excused from their actions on the basis of some ‘supposed illness’. It could be suggested that they should be held accountable for their actions as anyone else would be (Bowers, 1998). It can be argued that these attitudes towards mental illness can be seen in a direct parallel to racism (Bowers, 1998). So why do people continue showing negative attitudes and views towards mental health as much work has been done in helping to combat racism, can the same not be done for people with mental illness.

Negative attitudes towards individuals with mental illness is widespread and can be capable of creating a significant barrier to treatment (Piner and Kahle, 1984). It has been established that negative attitudes can be individually the most significant obstruction to integration of people with a mental illness in to society (Piner and Kahle, 1984). Negative attitudes towards mental health can influence the path and result of their mental illness (Bowers, 1998). This can also lead to self-stigma which occurs when an individual with a mental health illness internalizes the stigma and believes they are of less value (Halter, 2004; Corrigan, 2007). This may result in low self-worth, loss of dignity, and lead to feelings of hopelessness (Campbell and Deacon, 2006). People who experience a mental illness often see no potential for them to undertake full time employment due to internalizing these negative attitudes that are held about the psychiatric system (Watkins, 2007). If we don’t help people recover from mental illnesses it is inevitable that it may become an enduring illness. An analogy given compares it to having a broken leg; if you don’t rest it then it won’t heal properly, the same could be said for the mind. Maybe if people were more positive towards mental health and mental illness then people with mental health problems would be encouraged to flourish in the community and not be seen as deviant. This is supported by Sayce (2000) who suggests that being part of the social foundations of the community is necessary for our psychological well being.

Generally most people would like to think they are compassionate and have inclusive attitudes towards people who experience a breakdown in their mental health (Ross and Read, 2004). Except, discrimination is still communicated in everyday social situations in subtly distancing, condescending exchanges, flippant outlooks or obvious hostility leaving people feeling socially isolated (Watkins, 2007). This could be due to the fact that mental illness shows how fragile human nature is therefore people’s/societies anxieties and fears about mental health may be due to seeing the potential that any one of us could develop a mental health disorder (Becker, 1963).

From my practice to date the following example really brought home to me the level of stigma and negative attitudes people have towards mental illness. When listening to an account from a service user it made me realise how public attitudes towards people with mental health difficulties is still a big issue and a real challenge for health care professionals. Mary explained that when taking a taxi to give a talk to students about living with mental illness she got talking to the taxi driver. At first he thought she was a lecturer but when she explained what she was going to do he became very quiet and stopped conversation with her. She found this a very ignorant and closed way of dealing with the situation and became quite upset about it.

Having examined the concepts of stigma, discussed the negative attitudes that the public hold towards mental health and mental illness, suggested why they may have adopted these views and attitudes and addressed the media’s role in portraying these views and sustaining these attitudes towards mental illness. It is now important to draw some recommendations and challenges that can help reduce the stigma of mental illness and promote a more positive picture to members of the public. These recommendations include education and public contact.

Firstly, education of the public both at school and after (Murphy et al 1993; Penn et al 1994) about mental health and its prevalence among every one of us is really important. Education is widely approved for influencing prejudice and discrimination (Corrigan and Wassel, 2008). Corrigan and Wassel (2008) ask the important question,

‘If people had the correct knowledge or effective problem solving skills, would they be able to give up public stigma and handle associated concerns more directly?’ (pg. 45)

Education can generate small effects on attitudes; unfortunately, this kind of change in attitude is seen to not be maintained over time (Corrigan et al, 2001). This demonstrates the need to continually re-educate people to reinforce the message. Challenging the public is most effective when it targets people who frequently interact with individuals with mental illness: landlords, employers, GPs, police officers etc (Corrigan and Wassel, 2008).

Secondly, most importantly the media needs to comply with their code of practice (2006). If something does appear in the media that appears stigmatising people should protest against it not accept it and reiterate that it won’t be tolerated. As nurses we need to encourage that positive things surrounding mental health of mental health are promoted in the media.

Lastly, the public need more contact with people who are experiencing mental health difficulties. This type of contact can provide the most healthy and positive findings toward changing public stigma (Penn et al,1994; Pettigrew and Tropp, 2000). It can be something as small as someone speaking about their mental illness in a group situation to co-workers learning of someone coping with a mental illness. The effectiveness of utilising contact can be improved when the person with a mental illness is seen by society as in the same social class as them (Gaertner et al, 1996). In Link and Cullen’s (1986) study they found people who had contact with someone who had a mental illness showed much lower anxiety around danger compared to those who had no contact. Murphy et al’s (1993) study contradicted this as they found having contact with someone with a mental illness did not impact on their attitude. However, they did establish that people who spoke of having knowledge of mental illness showed a reduced anxiety and fear of mental illness.

Finally, the prevalence of mental illness in society cannot be underestimated. As previously alluded to with 1 in 5 people suffering from a mental illness (WHO, 2001) we cannot afford to ignore the impact of stigma, all health care professionals especially nurses need to advocate for clients and work with others to promote and protect the health and wellbeing of those in their care, their families and carers, and the wider community (Nursing and Midwifery Council, 2008).

Having discussed the views and attitudes that the public hold towards mental illness and those experiencing mental health difficulties it is now important, in the next chapter, to examine the views and attitudes of general nurses. Many will come into contact with people with mental health problems particularly in accident and emergency (a and e) and a medical setting.