What can be done to overcome the stigma of mental illness? Because stigma is generally understood as a concatenation of negative attitudes and beliefs, community mental health education designed to change people’s minds seems to be what is needed. But there is another way to think about stigma – in terms of its consequences. Stigma results in a number of troubling problems including housing and job discrimination, lack of welcome in the mainstream community, social isolation, difficulty getting good medical care, and even difficulty participating in religious life, not to mention low self-esteem and reluctance to ask for help. If the problem of stigma is understood in terms of these kinds of barriers to well-being, barriers that come in the wake of stigma, then overcoming stigma can be thought of not just as changing attitudes and beliefs but also as opening and creating opportunities that are largely closed to people with serious mental illness.
There are two different approaches to “overcoming” stigma: (1) Changing attitudes and beliefs mostly through broad-based community mental health education; and (2) changes designed to bring about increased community access for people with mental illness in specific ways such as rights to housing, anti-discrimination measures, programs that create opportunities for people with mental illness such as employment programs, Housing First, psychosocial clubs, etc.
Changing Minds
“The stigma of mental illness” refers to the common perception in our society, and in most human societies, that it is shameful to be mentally ill. This attitude links to a number of common myths about mental illness – that people with mental illness are dangerous, that mental illness reflects a failure of moral character, that people with mental illness need supervision and protection, and so forth.
Stigma also links to a variety of troubling images of people with mental illness:
- of a mentally ill man pushing a woman to her death in front of a subway,
- of a bedraggled homeless person sleeping on a heating grate in the cold of winter,
- of a person cut off from reality and lost listening to inner voices,
- of a person immobilized by depression,
- of a person pursuing impossibly grandiose visions.
Images of this kind have hung over people with serious mental illness for all of human history. In modern times they have been frequently reinforced by the media – in lurid headlines, in films about deranged killers, in TV shows in which people you’d never guess are the villains kill for bizarre reasons. Even movies and TV shows that are sympathetic to the plight of people with mental illness tend to exaggerate their suffering and their inability to lead satisfying lives.
What to do? The answer seems clear. Develop broad-based community education efforts that focus on dispelling the myths about mental illness. This includes working with the media to present more realistic images of mental illness. They need to understand that yes, some people with mental illness are dangerous, but very few. They are more likely to be victims of crime than perpetrators. Yes, some people with mental illness are homeless or live in isolation and squalor but many live quietly with their families and friends or independently in decent housing. Yes, some people with mental illness are cut off from reality and highly dysfunctional, but relatively few. About 20% of the American population has a mental illness in any given year, and 50% will have a mental illness in their lifetime. The vast majority of them lead apparently normal lives most of the time. They work, go to school, live as part of families, have friends, have interests. Their suffering is often quiet and unnoticeable to almost everyone. Their illness often disrupts functioning to some extent, but most are able to carry on. Even people with severe and persistent psychiatric disabilities can have lives that they find personally satisfying and meaningful.
Community education efforts also focus on the effectiveness of treatment and rehabilitation. Sadly, of course, few of them get good treatment, not only because there isn’t enough available but also because the stigma they, their families, and their communities carry with them keeps them from seeking professional help.
Creating Opportunities
The good news is that it appears that stigma is less widespread than it used to be. The bad news is that despite decades of community education and pressure on the media to create more realistic images, stigma is still very much alive and very damaging. It continues to have dreadful consequences for people with mental illnesses and their families.
- As a result of stigma, some people with mental illness often feel dreadful about themselves, a kind of inner shame, and a need to hide their illness from the world or themselves.
- As a result of stigma, many people do not seek help.
- As a result of stigma, family members sometimes feel that they are to blame or that they are tainted by their family member’s illness.
- As a result of stigma, it is difficult for people known to have a mental illness to get a job, to get into college, to get housing, and even to be a fully accepted member of a religious congregation.
- As a result of stigma, some children with serious emotional disturbances are excluded from mainstream education and recreational activities.
- As a result of stigma, it is exceedingly difficult to defeat the sentiment of “not in my backyard” that blocks the development of housing and other programs for people with mental illnesses in the community.
- As a result of stigma, there is a persistent belief that people with serious mental illness need protection and supervision and that many, many more of them should be confined in hospitals for long periods of time.
What Can Be Done to Address the Consequences of Stigma?
First and foremost is insisting on respect for the rights of people with mental illness. This has been done with anti-discrimination legislation such as The Fair Housing Act and the Americans with Disabilities Act. It has also been done with judicial rulings such as the Donaldson Decision in 1975 and the Olmstead Decision in 1999.
In addition, there have been policy and legal changes and program developments to address the consequences of stigma. People with mental illness have difficulty getting access to decent housing in the community; therefore, develop housing programs and develop legal tools to override community resistance. People with mental illness have trouble getting jobs; therefore, create vocational rehabilitation and jobs programs for them. People with mental illness tend to be socially isolated; therefore, create psychosocial clubs; young adults with mental illness cannot get into college; therefore, create supported education programs. People with serious mental illness have difficulty getting good medical care; therefore, develop health care programs designed for them.
These are examples of creating opportunities for people with mental illness that have been substantially closed due to stigma. All have been put into practice over the past 40+ years to some extent. More such programs are needed, of course.
In addition, there are program possibilities that so far as I know have not yet been pursued. One that I think could be very useful is a community chaplaincy program. In hospitals, chaplains are available to help patients to get the religious experiences that many of them seek. There is no counterpart in the community where, sadly, many houses of worship do not welcome people with serious mental illnesses. A community chaplain could help win acceptance of people with mental illness in the religious community.
Progress Addressing Stigma
Over the past 60 years, much has been done to help people understand that mental illness is an expectable part of human life, that treatment can be effective, that mental anguish need not be a part of one’s life, and that even people with the most severe mental illnesses can recover – can, that is, create lives of personal meaning and satisfaction.
Has stigma been overcome? Not by a long shot. But we have made some progress; and with greater investment in public education, with continued vigilance about the rights of people with mental illness, the growth of effective programs, and the development of new ways to open opportunities for people with mental illness, I am confident that we can make much more.
Michael B. Friedman is an Adjunct Associate Professor at The Columbia University School of Social Work. He can be reached at mf395@columbia.edu.
