Advanced Search

Editorial | March 01, 2008

Stigma in Mental Health Care

Carol I. Ping Tsao; Aruna Tummala; Laura Weiss Roberts

Academic Psychiatry 2008;32:70-72.

View Article Information

Received November 28, 2007; accepted December 12, 2007. Drs. Tsao, Tummala, and Roberts are affiliated with the Departments of Psychiatry and Behavioral Health at the Medical College of Wisconsin in Milwaukee, Wis. Address correspondence to Carol I. Ping Tsao, M.D., Psychiatry and Behavioral Health, Medical College of Wisconsin, 5000 W. National Ave, Milwaukee, WI 53295; ctsao@mcw.edu (e-mail).

Article

References

text A A A

Stigma marks someone as different from others, leading to devaluation of that person. A social construction, stigma occurs within relationships. In his classic 1963 description, Goffman (¹) defines stigma as "an attribute that is deeply discrediting," where a person is diminished "from a whole and usual person to a tainted, discounted one." Shifting from a focus on individual traits, subsequent formulations have identified certain psychosocial processes that lead to stigmatization. These include labeling, stereotyping, separating, status loss, and discrimination in a context of power imbalance (²). Stigma affects people adversely. Academic achievement is lower for members of stigmatized groups as compared with nonstigmatized groups, and members of stigmatized groups are at greater risk for both mental and physical diseases (³).

Patients with mental illnesses are stigmatized and suffer adverse consequences such as increased social isolation, limited life chances, and decreased access to treatment (⁴—⁶). In addition to poorer social functioning as assessed by housing and employment status (⁷), those with the stigma of mental illness also encounter a significant barrier to obtaining general medical care (⁸) and to recovery from mental illness (⁹). As stated by Chin and Balon (¹⁰), "The added burden that stigma imposes on the struggle to recovery can alter behavior, generate anxiety, and ultimately cause isolation from the mainstream culture."

In this issue, several manuscripts make a case for increasing familial involvement in the care of patients with mental illnesses with the aims of improving social and health outcomes for patients and providing support to family members. Suggestions range from managing confidentiality while increasing family engagement in the treatment of distressed adolescents (¹¹) to optimizing the benefits of family money management (¹²) to inclusion of family across the spectrum of psychiatric clinical care (¹³) to more formalized reintegration of family therapy training in psychiatry residency programs (¹⁴) to making after-death calls to family members (¹⁵).

Stigma also affects family members of persons with mental illness. Referred to as "courtesy" (¹) or "associative" (¹⁶) stigma, its psychological impact can be quite deleterious. In a Swedish study, 18% of relatives of patients with severe mental illness reported that the patient would be better off dead (¹⁷). This figure increased to 40% in relatives who felt that the patient’s mental illness caused mental health problems in themselves (¹⁷).

In this issue, two articles report literature reviews on stigma of families with mental illness (¹⁸) and stigma associated with suicide (¹⁹). In the first article (¹⁸), parental stigmatization of children with mental illnesses and the stigmatization of children with parents who have mental illnesses are explored. Parents are often blamed for causing mental illness in their children through poor parenting. Children are often perceived as being somehow tainted by their parents’ mental illness. In the second article (¹⁹), three survivors of suicide report their experiences and make suggestions to further diminish stigma associated with suicide. Survivors of suicide, as compared with other bereaved persons, experience more guilt and less social support. Candid disclosure about the decedent’s struggle with mental illness and suicide being the cause of death, having someone to talk with openly about the loss, and/or participation in a suicide support group can provide significant comfort to familial survivors of suicide and may go some distance in decreasing stigma.

As a group, mental health professionals are no less susceptible to stigmatizing beliefs than the general population (²⁰—²²). And medical education has only a very limited benefit with regard to reducing stigmatizing beliefs (²³). In a study of resident physicians from an array of medical specialties, neither greater education nor additional experience nor choice of specialty exerted a positive influence on attitudes toward mental illness (¹⁰). Instead, stigmatizing attitudes were only lower when the resident physicians had family members with a psychiatric illness (¹⁰).

In this issue, several articles explore medical students’ attitudes toward psychiatry in general and a career in psychiatry specifically. The psychiatric clerkship appears to have equivocal impact on changing medical students’ views toward psychiatry (²⁴). Medical students from the University of Nairobi, Kenya, generally had fairly favorable attitudes toward psychiatry, but few would consider psychiatry a viable career choice (²⁵). Even fewer medical students from Pakistan, where there is a shortage of psychiatrists, identified psychiatry as their career of choice (²⁶).

Interestingly, a recent article describes iatrogenic stigma, that is, stigma caused or perpetuated by mental health professionals (²⁷). The author argues that certain actions on the part of the psychiatrist themselves perpetuate stigma (such as diagnosing a person with mental illness, which in turn leads to labeling; cosmetic side effects of medications, which make a person easily identifiable as mentally ill). On the contrary, we believe that psychiatrists have a duty to reduce the stigma of mental illness at the individual, family, societal, and structural levels. Stigma involves problems with knowledge (ignorance), attitudes (prejudice), and behavior (discrimination). Of the three, reduction of discrimination against people with mental illness is most pressing (²⁸). Anti-stigma programs use three broad approaches: protest, education, and contact (²⁹). Protest campaigns work to have stigmatizing media messages withdrawn. Media has a powerful role to play in influencing public opinion as exemplified by the recent Virginia Tech shootings. Psychiatrists and mental health professionals need to collaborate actively with the local media to ensure that an appropriate social message is passed on. Education provides accurate information to the public about mental illness. Contact entails positive social interaction with persons with mental illness. All three approaches have been shown to reduce stigma (³⁰).

In this issue, two articles suggest that certain exposures, akin to contact, decrease stigma. Adolescent standardized patient training in psychiatric conditions reduces stigma in adolescent simulators (³¹). Advocacy groups have more positive impact on clinical as compared to preclinical medical trainees (³²).

In addition to actively engaging in the proven methods to decrease stigma, psychiatrists also need to actively combat structural discrimination. Structural discrimination is unjust treatment perpetuated by a social, political, and/or legal institution based on stigmatizing attitudes. A chief example of structural discrimination is the inequitable distribution of resources, resulting in poor quality of mental health services based on the stigmatizing belief that mental illness is incurable or that mental illness is not a real illness.

Finally, psychiatrists need to work within the medical community to bring about more candid dialogue about impaired physicians, including psychiatrists, psychologists, and nurses. Kay Redfield Jamison (³³) writes:

There is a very large group that I think of as the silent successful—people who get well from psychiatric illness but who are afraid to speak out. This reluctance is very understandable, very human, but it is unfortunate because it perpetuates the misperception that mental illness cannot be treated.

References

Goffman E: Stigma: Notes on the Management of Spoiled Identity. New York, Prentice Hall, Inc, 1963

Link BG, Phelan JC: Conceptualizing stigma. Annual Rev of Sociology 2001; 27:363—385

Major B, O’Brien LT: The social psychology of stigma. Annu Rev Psychol 2005; 56:393—421

Link B: Mental patient status, work, and income: an examination of the effects of a psychiatric label. Am Sociol Rev 1982; 47:202—215

Fink PJ, Tasman A: Stigma and Mental Illness. Washington, D.C., American Psychiatric Press, 1992

Rosenfield S: Labeling mental illness: the effects of received services and perceived stigma on life satisfaction. Am Sociol Rev 1997; 62:660—672

Corrigan PW: The impact of stigma on severe mental illness. Cogn Behav Pract 1998; 5:201—222

Liggins J, Hatcher S: Stigma toward the mentally ill in the general hospital: a qualitative study. Gen Hosp Psychiatry 2005; 27:359—364

Corrigan PW, Watson AC, Ottati V: From whence comes mental illness stigma? Int J Soc Psychiatry 2003; 49:142—157

Chin SH, Balon R: Attitudes and perceptions toward depression and schizophrenia among residents in different medical specialties. Acad Psychiatry 2006; 30:262—263

Stanley N, Manthorpe J, Gillespie L: Family physicians’ interventions with young people in distress and their parents: managing confidentiality and levels of engagement. Acad Psychiatry 2008; 32:92—97

Elbogen E, Wilder C, Swartz M, Swanson J: Caregivers as money managers for adults with severe mental illness: how treatment providers can help. Acad Psychiatry 2008; 32:104—110

Berman E, Heru A, Rolland J, Sargent J, McDaniel S: Family-oriented patient care through the residency training cycle. Acad Psychiatry 2008; 32:111—118

Rait D, Glick I: Reintegrating family therapy training in psychiatric residency programs: making the case. Acad Psychiatry 2008; 32:76—80

LoboPrabhu S, Molinari V, Pate J, Lomax J: The after-death call to family members: academic perspectives. Acad Psychiatry 2008; 32:132—135

Mehta SI, Farina A: Associative stigma: perceptions of the difficulties of college-aged children of stigmatized fathers. J Soc Clin Psychol 1988; 7:192—202

Ostman M, Kjellin L: Stigma by association: psychological factors in relatives of people with mental illness. Br J Psychiatry 2002; 181:494—498

Larson J, Corrigan P: The stigma of families with mental illness. Acad Psychiatry 2008; 32:87—91

Sudak H, Maxim K, Carpenter M: Suicide and stigma: a review of the literature and personal reflections. Acad Psychiatry 2008; 32:136—142

Farrell M, Lewis G: Discrimination on the grounds of diagnosis. Br J Addict 1990; 85:883—890

Sriram TG, Jabbarpour YM: Are mental health professionals immune to stigmatizing beliefs? Psychiatr Serv 2005; 56:610

Lauber C, Nordt C, Braunschweig C, Rossler W: Do mental health professionals stigmatize their patients? Acta Psychiatr Scand Suppl 2006; Supp:51—59

Ay P, Save D, Fidanoglu O: Does stigma concerning mental disorders differ through medical education? A survey among medical students in Istanbul. Soc Psychiatry Psychiatr Epidemiol 2006; 41:63—67

Fischel T, Manna H, Krivoy A, et al: Does medical students’ clerkship in psychiatry contribute to changing their attitude towards psychiatry? Acad Psychiatry 2008; 32:147—150

Ndetei D, Khasakhala L, Ongecha-Owuor F, Kuria M, Mutiso V, Syanda J, Kokonya D: Attitudes toward psychiatry: A survey of medical students at the University of Nairobi, Kenya. Acad Psychiatry 2008; 32:154—159

Syed E, Siddiqi M, Dogar I, et al: Attitudes of Pakistani medical students towards psychiatry as a prospective career: a survey. Acad Psychiatry 2008; 32:160—164

Sartorius N: Iatrogenic stigma of mental illness. Br Med J 2002; 324:1470—1471

Thornicroft G, Rose D, Kassam A, et al: Stigma: ignorance, prejudice or discrimination? Br J Psychiatry 2007; 190:192—193

Corrigan PW, Penn D: Disease and discrimination: two paradigms that describe severe mental illness. J Ment Health 1997; 6:355—366

Corrigan PW: Don’t call me nuts: an international perspective on the stigma of mental illness. Acta Psychiatr Scand 2004; 109:403—404

Hanson M, Johnson S, Niec A, et al: Does mental illness stigma contribute to adolescent standardized patients’ discomfort with simulations of mental illness and adverse psychosocial experiences? Acad Psychiatry 2008; 32:98—103

Davydow D, Bienvenu O, Lipsey J, et al: Factors influencing the choice of a psychiatric residency program: a survey of applicants to the Johns Hopkins residency program in psychiatry. Acad Psychiatry 2008; 32:143—146

Jamison KR: The many stigmas of mental illness. Lancet 2006; 367:533—534