mental health stigma in research

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• > European Psychiatry
• > Volume 20 Issue 8
• > Mental illness stigma: Concepts, consequences, and...

Article contents

• What is stigma?
• Public and self-stigma
• Different conceptualizations of stigma
• The consequences of stigma
• Ways to reduce the stigma towards mental illness
• Conclusions

Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma

Published online by Cambridge University Press:  16 April 2020

Persons with mental illness frequently encounter public stigma and may suffer from self-stigma. This review aims to clarify the concept of mental illness stigma and discuss consequences for individuals with mental illness. After a conceptual overview of stigma we discuss two leading concepts of mental illness stigma and consequences of stigma, focussing on self-stigma/empowerment and fear of stigma as a barrier to using health services. Finally, we discuss three main strategies to reduce stigma - protest, education, and contact – and give examples of current anti-stigma campaigns. Well-designed anti-stigma initiatives will help to diminish negative consequences of mental illness stigma.

Persons with mental illness often have to struggle with a double problem. First, they have to cope with the symptoms of the disease itself; depending on the particular mental disorder they may have problems such as recurrent hallucinations, delusions, anxiety, or mood swings. These symptoms can make it difficult for someone with a mental illness to work, live independently or achieve a satisfactory quality of life. Second, the misunderstandings of society about the various mental disorders result in stigma. Some persons who manage their mental illness well enough to work still have tremendous difficulties finding a job because employers discriminate against them. Thus, mental illness results not only in the difficulties arising from the symptoms of the disease but also in disadvantages through society's reactions. As a further complication, some people with mental illness may accept the common prejudices about mental illness, turn them against themselves, and lose self-confidence. The latter is referred to as ‘self-stigma’ and will be discussed further below.

In this paper we want to give a conceptual background of public and self-stigma, discuss how stigma of mental illness interferes with empowerment of persons with mental illness and with service use, review strategies to reduce stigmatization of persons with mental illness and give examples of current initiatives. We believe that it is important to review conceptually relevant work in the field of mental illness stigma to provide a framework for a better interpretation of various empirical findings. Therefore, in this review we wish to summarize conceptually driven work and research on mental illness stigma from different countries. We focussed on two concepts that have been most relevant in research on mental illness stigma: Stigma as conceptualised by Link and Phelan Reference Link and Phelan [63] and the concept of Corrigan and coworkers Reference Corrigan [28] . In this paper, we will first conceptualise stigma using an integrative conceptualisation, combining the two mentioned concepts. We will then discuss differences between these two concepts and their consequences for research and interpretation of results.

This review may be of help to readers from different backgrounds: It may be useful for researchers as a framework to generate and test hypotheses; for clinicians who work with people with mental illness to recognise public stigma and self-stigma more easily and help people with mental illness to cope with the consequences; for mental health professionals to question their own possibly stigmatising attitudes towards people with mental illness; for teachers and students to establish educational and other anti-stigma initiatives in their schools or universities; last not least for people with mental illness to better understand stigma and self-stigma and to actively fight stigma and its consequences in their environment.

1. What is stigma?

Stigmatizing attitudes contain some core assumptions. Media analyses of film and print have identified three common misconceptions about people with mental illness: they are homicidal maniacs who should be feared; they are rebellious, free spirits; or they have childlike perceptions of the world that should be marveled [40,50,103] . Independent factor analyses from Canada, England and Germany confirm these findings by identifying the following factors: First, fear and exclusion: persons with severe mental illness are to be feared and, therefore, kept out of communities; second, authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others; and third, benevolence: persons with severe mental illness are childlike and need to be cared for [7,11,101] . Although stigmatizing attitudes are not confined to mental illness, the general public seems to disapprove of persons with psychiatric disabilities more than of persons with physical illness [83,97,105] . Persons with mental illness are more likely to be seen as responsible for causing their illness [22,105] . This assumption of responsibility is less pronounced for schizophrenia than for substance addiction and eating disorders Reference Angermeyer and Matschinger [4] . These attitudes lead to corresponding discriminatory behavior. Citizens are less likely to hire persons with mental illness Reference Bordieri and Drehmer [9] , less likely to rent them apartments Reference Page [79] , and more likely to falsely press charges for violent crimes [98,99] .

As an example of a person suffering from stigma, consider what happened to Anne. Anne is 25years old and has been hospitalised several times with acute symptoms of schizophrenia. For two years, she had been symptom-free, living on her own, working in a local tourist information office and enjoying an active social life. Recently though, she had a relapse of her mental illness. She again was hospitalised and it took her two months to recover and to get ready to go back to work again. However, after recovery she realised that getting over the symptoms of her disease did not suffice: Her employer discharged her because he believed she could have a dangerous outburst in the office due to her mental illness. In addition, her family convinced her that it was too risky to live on her own and made her move back to her parents’ home. Since her family lived in another town, that made her lose her friends. In summary, despite a good recovery from the symptoms of her mental illness, within a month after discharge from the mental hospital Anne had lost her job, appartment and friends. Imagine in comparison a person with a chronic somatic illness like diabetes. Similar to schizophrenia, diabetes can lead to severe relapses and hospitalisations. However, unlike a person with schizophrenia, a person with diabetes is unlikely to encounter comparably consequential public stigma related to her illness.

2. Public and self-stigma

2.1. a social cognitive model of public stigma.

Public stigma comprises reactions of the general public towards a group based on stigma about that group. Although we are used to distinguishing between groups in society and to label these groups with different attributes, this is not a self-evident process. Most human differences are mainly ignored and socially irrelevant in Western societies of our time. For example, the color of one's car or the size of one's shoes do not matter for most people under most circumstances. However, other personal features like skin-color, sexual orientation or income are often relevant to one's social appearance. There is obviously a social selection of which human qualities matter socially and which do not.

It is often taken for granted to distinguish between different groups in society and to label human differences accordingly. However, every demarcation of groups requires an oversimplification. Even with obvious attributes like skin-color, there is no clear demarcation line between, for example, 'black' and 'white'. Even more so, there is no sharp line between mental health and mental illness Reference Link and Phelan [63] .

That cultural attitudes to behavior and (mental) illness change substantially over time is another aspect of the social selection of human differences in creating groups Reference Conrad and Schneider [13] . Whether patterns of behavior, thinking and feeling are being noticed at all and if so, whether they are described in moral, psychosocial or medical terms is influenced by societal discourse and usually varies over time. Attention deficit hyperactivity disorder is an example of a label that was unknown a few decades ago and is likely to change again Reference Seidler [95] .

It is further important to note that labeling often implies a separation of 'us' from 'them'. This separation easily leads to the belief that 'they' are fundamentally different from 'us' and that 'they' even are the thing they are labelled. 'They' become fundamentally different from those who do not share a negative label, so that 'they' appear to be a completely different sort of people Reference Link and Phelan [63] . Our use of language is revealing regarding the use of labels to distinguish 'us' from 'them'. For example, it is common to call someone a 'schizophrenic' instead to call her or him a person with schizophrenia. For physical illness, things are often handled differently and people usually say, a person has cancer. The person afflicted with cancer remains one of 'us' and has an attribute, while the 'schizophrenic' becomes one of 'them' and is the label we affix to the person Reference Link and Phelan [63] . In this way, language can be a powerful source and sign of stigmatization.

Given this background of distinguishing between groups, labeling and separating 'us' from 'them', social psychology has identified different cognitive, emotional and behavioral aspects of public stigma: stereotypes, prejudice, and discrimination (see Table 1 ). It is important for both theoretical research and practical initiatives to understand these components. Stereotypes are knowledge structures known to most members of a social group [48,53] . Stereotypes are an efficient way to categorize information about different social groups because they contain collective opinions about groups of persons. They are efficient in the sense that they quickly generate impressions and expectations of persons who belong to a stereotyped group Reference Hamilton, Sherman, Wyer, RS and Srull [45] .

Table 1 Components of Public and Self-Stigma

People do not necessarily agree with the stereotypes they are aware of Reference Jussim, Nelson, Manis and Soffin [54] . Many persons may, for example, be aware of stereotypes of different ethnic groups but do not think these stereotypes are valid. Prejudiced persons, on the other hand, endorse these negative stereotypes (“That's right! All persons with mental illness are violent“) and have negative emotional reactions as a consequence (“They all scare me“) [35,36,48] . Prejudice leads to discrimination as a behavioral reaction Reference Crocker, Major, Steele, Gilbert and Fiske [32] . Prejudice that yields anger can lead to hostile behavior. In the case of mental illness, angry prejudice may lead to withholding help or replacing health care with the criminal justice system Reference Corrigan [28] . Fear leads to avoidant behavior. For example, employers do not want persons with mental illness around them so they do not hire them. This association between perceived dangerousness of persons with mental illness, fear, and increased social distance has been validated for different countries, including Germany Reference Angermeyer and Matschinger [3] , Russia Reference Angermeyer, Buyantugs, Kenzine and Matschinger [1] and the United States Reference Corrigan [15] .

Stereotypes and prejudice alone are not sufficient for stigma. In addition, social, economic and political power is necessary to stigmatize. For example, if individuals with mental illness form stereotypes and prejudices against staff in a mental health service, this staff is unlikely to become a stigmatized group because the persons with mental illness simply do not have the social power to put serious discriminatory consequences against the staff into practice Reference Link and Phelan [63] .

In summary, public stigma consists of these three elements - stereotypes, prejudice and discrimination - in the context of power differences and leads to reactions of the general public towards the stigmatised group as a result of stigma.

2.2. A social cognitive model of self-stigma

Self-stigma refers to the reactions of individuals who belong to a stigmatized group and turn the stigmatizing attitudes against themselves Reference Corrigan and Watson [25] . Like public stigma, self-stigma comprises of stereotyping, prejudice and discrimination ( Table 1 ). First, persons who turn prejudice against themselves agree with the stereotype: “That's right; I am weak and unable to care for myself!” Second, self-prejudice leads to negative emotional reactions, especially low self-esteem and self-efficacy Reference Wright, Gronfein and Owens [106] . Also self-prejudice leads to behavior responses. Because of their self-prejudices, persons with mental illness may fail to pursue work or independent living opportunities. If they fail to reach this goal this is often not due to their mental illness itself but due to their self-discriminating behavior Reference Link, Cullen, Struening and Shrout [66] . How can self-stigma arise? Many persons with mental illness know the stereotypes about their group such as the belief that people with mental illness are incompetent Reference Hayward and Bright [47] . But, as in public stigma, knowledge alone does not necessarily lead to stigma, if persons are aware of the stereotypes but do not agree with them Reference Crocker and Major [33] . Thus, fortunately for many persons with mental illness, awareness of stereotypes alone does not lead to self-stigma.

3. Different conceptualizations of stigma

The conceptualization of mental illness stigma given above combines two leading current concepts, i.e. the one of Corrigan and coworkers Reference Corrigan [28] and the concept of Link and colleagues Reference Link and Phelan [63] .

Corrigan and colleagues focus on the cognitive and behavioral core features of mental illness stigma: Stereotypes (cognitive knowledge structures), prejudice (cognitive and emotional consequence of stereotypes) and discrimination (behavioral consequence of prejudice). Focussing on these core components, their model allows one to examine different elements of stigmatizing attitudes and behaviors and their modifiability by anti-stigma initiatives. It is a merit of this model that it makes it feasible to disentangle different phenomena underlying stigma and to make them accessible to empirical research.

In the definition of Link and Phelan, “stigma exists when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows these processes to unfold” Reference Link and Phelan [63] . In their concept, stereotypes, separation, and status loss/discrimination parallel Corrigan's stereotypes, prejudice and discrimination. Since Link and colleagues deal with various stigmata, although focussing on mental illness stigma, they stress that no definition of stigma can be universally applicable. Therefore, Link and colleagues emphasize that definitions of stigma should always be made transparent by the respective researchers, and dictionary definitions alone such as “a mark of disgrace” are by no means sufficient. Writing from a sociological perspective, in comparison to the model of Corrigan and colleagues, Link and Phelan put more stress on two societal aspects: First, as a precondition of stigma differences between persons have to be noticed, to be regarded as relevant and to be labeled accordingly. This labeling process is at the core of Link's modified labeling theory Reference Link, Cullen, Struening and Shrout [66] . Second, for stigma to unfold its deleterious consequences, the stigmatizing group has to be in a more powerful position than the stigmatized group. Therefore, for instance, jokes about powerful groups such as politicians may be stereotyping but do not normally lead to discrimination and therefore are not ‘stigmatizing’ in a strict sense of the word. This sociological perspective does not contradict the model of Corrigan and colleagues, but helps to connect it with societal aspects. A further focus of the approach of Link and Phelan is the subjective expectation and experience of being labeled and discriminated because of one's mental illness.

Although the two models are well compatible, they still seem to show slightly different consequences in methodology, results and interpretation of studies. Link and colleagues in their research focussed on the expectations and experiences of being labeled and stigmatized, which was usually measured by Link's Perceived Devaluation and Discrimination Scale, and on the consequences of stigma on self-esteem (e.g. [62,64,67] ). Thus the emphasis here is on what we call self-stigma including recent work that operationalises their concept how stigma affects individuals Reference Ritsher and Phelan [86] . In the field of anti-stigma initiatives, the sociological focus on the complexities of discriminating mechanisms in a society seems to lead to a more sceptical approach towards anti-stigma initiatives because effects at an individual level may be outweighed by other paths of discrimination (see our discussion below).

The research of Corrigan and colleagues focussed on the central features of Corrigan's model: Stereotypes, prejudice and (discriminating) behavior of the public towards people with mental illness. Several studies examined these elements and their interrelationship, especially perceptions of dangerousness, fear and social distance Reference Corrigan, Green, Lundin, Kubiak and Penn [18] ; authoritarianism, benevolence and social distance Reference Corrigan, Edwards, Green, Diwan and Penn [17] ; controllability, responsibility and stability Reference Corrigan, River, Lundin, Wasowski, Campion and Mathisen [22] . As an extension of these studies, the effect of anti-stigma initiatives using the strategies of education and contact (see below) was examined in several studies [21,23] . Thus, the research focuses, slightly different from the research of Link and colleagues, on public stigma. Recently though, Corrigan and colleagues have been bridging the gap to the work of Link and coworkers and have extended their research to include conceptual work on self-stigma Reference Corrigan and Watson [25] , to the perception of discrimination by people with mental illness Reference Corrigan, Thompson, Lambert, Sangster, Noel and Campbell [27] and are currently developing a measure of self-stigma in mental illness that operationalises their concept of self-stigma.

4. The consequences of stigma

As far as mental illness is concerned, stigmas seem to be widely supported by the general public. This is true for the United States [61,81] and for other Western nations including Norway Reference Hamre, Dahl and Malt [46] , Greece Reference Madianos, Madianou, Vlachonikolis and Stefanis [71] or Germany [2,52] while levels of stigmatisation may differ between nations. Unfortunately, research suggests that public attitudes toward people with mental illness seem to have become more stigmatizing over the last decades: Survey research suggests that a representative 1996 population sample in the US was 2.5 times more likely to endorse dangerousness stigma than a comparable 1950 group, i.e. perceptions that mentally ill people are violent or frightening substantially increased Reference Phelan, Link, Stueve and Pescosolido [81] . A recent German study also found increasing stigmatizing attitudes towards people with schizophrenia Reference Angermeyer and Matschinger [5] . On the other hand, the use of outpatient psychotherapy in the US increased between 1987 to 1997, at least among people about 60years old, among the unemployed and persons with mood disorders Reference Olfson, Marcus, Druss and Pincus [78] . It has been speculated that the increased use of psychotherapy in these groups may be due to decreased stigmatisation especially of mood disorders. However, the link between stigma and use of psychotherapy was not assessed in this study, psychotherapy was very broadly defined including treatments of only one or two sessions, and the overall use of psychotherapy did not change in this period. In addition, being in psychotherapy may not necessarily mean to consider oneself having a ‘mental illness’ or to be considered ‘mentally ill’ by one's environment, so different stigmata may apply and change independently over time. Another sobering fact is that mental health professionals equally support stigmatizing views [44,58,80,92] .

Two deleterious consequences of stigma can only briefly be mentioned here. First, public stigma results in everyday-life discriminations encountered by persons with mental illness in interpersonal interactions as well as in stereotyping and negative images of mental illness in the media Reference Wahl [103] . Second, structural discrimination includes private and public institutions that intentionally or unintentionally restrict opportunities of persons with mental illness Reference Corrigan, Markowitz and Watson [19] . Examples of structural discrimination are discriminatory legislation or allocation of comparatively fewer financial resources into the mental health system than into the somatic medical system [26,73] . It is important to note that for example a person with schizophrenia may experience structural discrimination whether or not someone treats her or him in a discriminatory way because of some stereotype about schizophrenia Reference Link and Phelan [63] .

In this paper we want to focus on two other negative consequences of stigma that are both related to the way a person with mental illness reacts to the experience of being stigmatized in the society: Self-stigma/empowerment and fear of stigma as a reason to avoid treatment. We focus on these two aspects because both are highly relevant for clinicians working in the mental health field. By this we do not imply that stigma is only an individual problem. In contrast we believe stigma to be primarily a social problem that should be addressed by public approaches Reference Mills [76] . Still, until stigma has been reduced in society, the clinician should be aware of the meaning and consequences of stigma for individuals with mental illness.

4.1. Self-stigma and empowerment

Research has shown that empowerment and self-stigma are opposite poles on a continuum Reference Corrigan [14] . At one end of the continuum are persons who are heavily influenced by the pessimistic expectations about mental illness, leading to their having low self-esteem. These are the self-stigmatized. On the other end are persons with psychiatric disability who, despite this disability, have positive self-esteem and are not significantly encumbered.

Many persons who are discriminated against and suffer from public stigma do not experience self-stigma while others do. Correspondingly, the evidence is equivocal on this point: Some studies suggest that people with mental illness, who are generally well aware of the prejudices against them, show diminished self-esteem [65,66,72,87,102,106] . On the other hand, other surveys did not find that awareness of common stereotypes leads to diminished self-esteem in persons with mental illness Reference Hayward and Bright [47] . Even more amazingly, some stigmatized minority groups show increased self-esteem, including persons of color Reference Hoelter [49] and people with physical disabilities Reference Llewellyn [68] . Being stigmatized may stimulate psychological reactance Reference Brehm [10] so that instead of applying the common prejudices to themselves persons oppose the negative evaluation which results in positive self-perceptions. This fact that some react with righteous anger to stigma, while others are indifferent to stigma and yet another group self-stigmatizes has been called the paradox of self-stigma and mental illness Reference Corrigan and Watson [25] . Why do people react so differently to public stigma? Corrigan and colleagues developed a model of the personal response to mental illness stigma ( Fig. 1 ).

Fig. 1 Model of personal response to mental illness stigma (adapted from Reference Corrigan and Watson [25] ).

Persons with a stigmatizing condition like serious mental illness perceive and interpret their condition and the negative responses of others. The collective representations in the form of common stereotypes influence both the responses of others and the interpretation of the stigmatized. Persons with a stigmatizing condition who do not identify with the stigmatized group are likely to remain indifferent to stigma because they do not feel that prejudices and discrimination actually refer to them ( Fig. 1 ). However, those who identify with the group of the mentally ill apply the stigma to themselves Reference Jetten, Spears and Manstead [51] . Their reaction is moderated by perceived legitimacy. If they consider the stigmatizing attitudes to be legitimate, their self-esteem and self-efficacy are likely to be low [91,93] . If, on the other hand, they regard public stigma to be illegitimate and unfair, they will probably react with righteous anger Reference Frable, Wortman and Joseph [41] ( Fig. 1 ). People who are righteously angry are often active in empowerment efforts, targeting the quality of services.

Related to empowerment and self-stigma is the issue of stigma and disclosure. To disclose one's mental illness may have both significant benefits, e.g. possibly increased self-esteem and decreased distress of keeping one's illness a secret, and costs, e.g. social disapproval. Whether or not individuals decide to disclose will depend on context and their sense of identity Reference Corrigan and Matthews [29] . For instance, if a woman with mental illness does not consider her illness a relevant part of her identity, she will be unlikely to tell her relatives about her mental illness, especially if those have repeatedly made stigmatising remarks about mental illness. If, on the other hand, a man with mental illness who is active in self-help groups and regards his mental illness as an important part of his life has trustworthy colleagues that have not shown discriminating behavior against people with mental illness, he is more likely to disclose his mental illness at work.

While the model of self-stigma, originating in social psychological research on other stigmatized groups (e.g. people of color, people with physical diseases), is useful to understand the different ways people react to stigma, three aspects have to be included to take into account the special case of mental illness. First, self-stigma resulting in decreased self-esteem and self-efficacy must be distinguished from decreased self-esteem during depressive syndromes that are common not only in affective disorders. Second, reaction to stigmatizing conditions depends on the awareness of having a mental illness, which may be impaired during episodes of, for instance, a psychotic condition Reference Rüsch and Corrigan [90] . Third, the reaction to a stigmatizing environment is dependent on one's perception of the subtle stigmatizing messages from other people. This social cognition may be impaired in serious mental illness such as schizophrenia Reference Corrigan and Penn [20] .

4.2. Fear of stigma as a barrier to use health services

Psychiatric symptoms and life disabilities of many persons living with mental illness can be significantly improved by various psychiatric and psychosocial treatments. Unfortunately, many persons who are likely to benefit from that kind of treatment either choose to never start treatment or opt to end it prematurely. This low rate of participation is not only the case in minor mental illness such as adjustment disorders; less than two thirds of persons with schizophrenia take part in treatment Reference Regier, Narrow, Rae and Manderscheid [85] and generally people with serious mental illness do not participate in treatment more often than those with minor disorders Reference Narrow, Regier, Norquist, Rae, Kennedy and Arons [77] . While many persons do not start treatment, even more do not fully adhere to prescribed interventions once they are begun. On average, almost half of persons on anti-psychotic medication fail to comply with the prescribed medication fully Reference Cramer and Rosenheck [31] . This is a major reason for the high rate of relapse that causes almost a billion dollar increase in hospital costs per year world wide Reference Weiden and Olfson [104] .

Health belief models explain why persons choose not to take part in treatments. These models assume that humans act rationally in ways that diminish perceived threats (disease symptoms) and enhance perceived benefits (improved health following treatment) Reference Rosenstock [88] . Key elements in the equation that produce health related behavior are negative effects of treatment, such as side-effects of medication. But of major importance is also the effect on the social environment; i.e. being labeled and stigmatized as a person with a mental illness after treatment.

Persons with mental illness who try to avoid stigma by not pursuing psychiatric services are called “potential consumers”. They consider themselves part of the public, are aware of the common prejudices against persons with mental illness and do not want to be seen as part of the “mentally ill” minority and thus avoid public stigma. They also avoid decreased self-esteem resulting from being mentally ill, i.e. self-stigma. Unlike other stigmatized groups, like those of color, persons with mental illness do not share a readily visible condition. Therefore the greatest single cue that produces public stigma is the label Reference Link [61] ; this label usually stems from participating in psychiatric services. Potential consumers may opt not to access care as a way to avoid this label.

There are some data to support our assertion that stigma limits service use. Persons in a large epidemiologic study were less likely to use services if they expected negative reactions of family members Reference Leaf, Bruce and Tischler [59] . In addition, there are other variables that interact with stigma and service use. Demographics may play a major role; in a study of outpatients with depression, only older persons showed a significant association between perceived stigma and disruption of treatment Reference Sirey, Bruce, Alexopoulos, Perlick, Raue and Friedman [96] . Also social status appears to influence service use because less educated and poorer people express more concern about family reactions Reference Leaf, Bruce, Tischler and Holzer [60] . The vocational background of potential consumers is also relevant. Contrary to what one might expect, those who should know better do avoid treatment due to fear of stigma: Only a third of medical students with clinical levels of distress sought help because they were concerned about stigma [12,39] .

Further research needs to confirm the link between stigma and service use. But the data available so far are sufficient to suggest that the reduction of public and self-stigma will be an important means to increase treatment participation (for an overview see Reference Corrigan and Rüsch [24] ).

5. Ways to reduce the stigma towards mental illness

In Germany, the US and many other countries, consumer groups have actively targeted stigma in an attempt to improve the lives of persons with mental illness. Due to the large number of successful programmes, the following examples are by no means meant to be comprehensive. As a particularly successful example in the US, the National Alliance of the Mentally Ill, a group of family members and persons with mental illness, has been educating the public in order to diminish stigmatizing conditions; e.g. by pressing for better legal protection for persons with mental illness in the areas of housing and work. Called ‘stigmabusters’, the NAMI-programme has been successfully used to protest against media representations of stigma in all 50 states of the US. In Germany, there are various anti-stigma campaigns, two of which should be mentioned here: BASTA – The alliance for mentally ill people (previously called ‘Bavarian Anti-Stigma Action’; ‘basta’ also meaning ‘stop’ in Italian and German), based in Munich, is active in various fields, including protest campaigns using email alerts, extensive education programmes in schools and police academies with active participation of mental health consumers, education of the media, and exhibitions of art by people with mental illness and other cultural activities ( www.openthedoors.de ). Another major German initiative is Irrsinnig Menschlich (engl. ‘Madly Human’), based in Leipzig. Here, too, various educational anti-stigma activities are undertaken, both locally and nationwide: These include the school project “Crazy? So what!” which raises students' awareness of mental health, and the international film workshop “Against the images in our heads”, a practical programme to reduce stigma and improve the lives of persons with mental illness ( www.irrsinnig-menschlich.de ). Other successful examples include the Like Minds, Like Mine Campaign in New Zealand ( www.likeminds.govt.nz ) that involves a vast number of local, regional and national initiatives, including active participation of persons with mental illness at all levels, and Sane Australia ( www.sane.org ), a nationwide anti-stigma campaign active for 20years and particularly successful in educating journalists and fighting stigmatising media messages.

In 1996, the World Psychiatric Association (WPA) started an international programme to fight the stigma and discrimination related to schizophrenia ( www.openthedoors.com ). Schizophrenia was chosen as the focus of this programme because it is a serious condition with symptoms that the public typically associates with mental illness, often of long duration. Rehabilitation of persons with schizophrenia is often hampered by stigma-associated difficulties Reference Sartorius [92] . The WPA-initiative tries to increase the awareness and knowledge of the nature of schizophrenia and treatment options, to improve public attitudes about individuals with schizophrenia and their families and to generate action to eliminate discrimination and prejudice.

Three main strategies have been used to fight stigma: protest, education, and contact Reference Corrigan and Penn [30] .

5.1. Protest

Protest is often applied against stigmatizing public statements, media reports and advertisments. Many of these protest interventions have successfully changed such public statements. A German example is the above mentioned ‘BASTA – the alliance for mentally ill people’ that uses email to quickly alert members about stigmatizing advertisements or media messages. About 80% of the discriminating cases that BASTA took action against were successfully stopped and the respective companies or media institutions apologised. Usually, these campaigns were most effective if several actions coincided: if many people wrote to the public relations department and to the managing director or owner of the respective company or media institution; if BASTA turned to a national surveillance commission, e.g. one that was responsible for supervising advertising messages, and this commission supported BASTA's campaign; and if all these simultaneous activities and the responses of the respective company or media institution were documented on BASTA's website (Kerstin Wundsam, personal communication). There is evidence also from the US that these initiatives are effective in diminishing negative public images of mental illness Reference Wahl [103] . However, little is known about the effect of protest against people's prejudices. Social psychological research has found that protest leads to suppression of stereotypic thoughts and discriminating behavior. Unfortunately, there are two major problems with suppression. First, suppression is an effortful, resource-demanding process that reduces attentional resources, so that people are less likely to learn new information that would disconfirm the old stigmatizing stereotype Reference MacRae, Bodenhausen, Milne and Wheeler [70] . Second, there seems to be a rebound effect to suppressing minority group stereotypes. Subjects, asked to suppress thinking in a stereotypic way, after a while actually had more stigmatizing thoughts than before Reference MacRae, Bodenhausen, Milne and Jetten [69] . Thus, protest seems to be a useful way to reduce stigmatizing public images of mental illness. It may be less apt to change people's prejudices. As a reactive strategy, it may help to reduce stigmatizing public behavior, but it is likely to be less effective in promoting positive, new attitudes. However, effects of repeated protests on behavior should be further investigated. Furthermore, by reducing stigmatising public behaviour protest improves the quality of life for people with mental illness.

5.2. Education

Education tries to diminish stigma by providing contradictory information. Different forms like books, videos, and structured teaching programmes have been used to convey this kind of information. Brief educational courses on mental illness have proved to reduce stigmatizing attitudes among a wide variety of participants (police officers Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham [84] ; industrial workers and government employees Reference Tanaka, Ogawa, Inadomi, Kikuchi and Ohta [100] ; high school students Reference Esters, Cooker and Ittenbach [38] ). However, research on educational campaigns suggests changes of behavior are often not assessed, effect sizes are limited, and programmes are more effective for participants who have a better knowledge of mental illness before the education or had contact with persons with mental illness beforehand. Thus, educational programmes tend to reach those that already agree with the message Reference Devine and Tesser [35] . Since stigmatising behaviors and attitudes are common among mental health care professionals Reference Gray [44] , effective anti-stigma interventions for this group are important, but are, to our knowledge, rarely available so far and have not yet been evaluated.

It is further important to note that the content of education programmes seems to matter. Nowadays neurobiological models of mental illness are predominant in Western psychiatry. Therefore biological causes of schizophrenia, for example, are a main part of the message in educational programmes. The hope underlying this approach is that to view mental illness as a biochemical, mainly inherited problem will reduce shame and blame associated with it. On the other hand, the focus on neurobiology could, in the eyes of the public, turn people with mental illness into 'almost a different species' Reference Mehta and Farina [74] . The sense of separation between 'us' and 'them' could be increased by pointing out a genetic, unchangeable aetiology and the hope for recovery could be reduced. Mehta and Farina Reference Mehta and Farina [74] found describing mental illness in medical instead of psychosocial terms actually led to harsher behavior towards people with mental illness. A recent international study of public beliefs on causality of mental illness had similar results. Among over 7000 subjects interviewed in Germany, Russia and Mongolia, the view of schizophrenia as being of biological origin led to greater desire for social distance from persons with schizophrenia Reference Dietrich, Beck, Bujantugs, Kenzine, Matschinger and Angermeyer [37] . Given these findings and the complexities of interactions between genes and environment, the message of mental illness as being 'genetic' or 'neurological' may not only be overly simplistic but also of little use to reduce stigma Reference Phelan [82] .

5.3. Contact

Contact with persons with mental illness may help to augment the effects of education on reducing stigma. Research has shown that members of the majority who have met minority group members are less likely to stigmatize against members of this minority [6,43] . Hence, contact may be an important strategy to decrease stereotypes and mental health stigma. Research shows that contact both during undergraduate training Reference Kolodziej and Johnson [55] and in an experimental situation Reference Desforges, Lord, Ramsey and Mason [34] reduced stigma and improved positive attitudes. In a number of interventions with secondary school students education and contact have been combined [8,84,94] . Results suggest that contact may be the more efficacious part of the intervention. Particularly interesting in this respect is an Austrian study that compared education without contact with a combination of both education and contact. A positive change of students’ attitudes was observed only when a consumer was involved in the intervention (contact and education Reference Meise, Sulzenbacher, Kemmler, Schmid, Rössler and Guenther [75] ).

There are a number of factors that create an advantageous environment for interpersonal contact and stigma reduction. This includes equal status among participants, a cooperative interaction as well as institutional support for the contact initiative. For example, a school programme will be more successful if its efforts find support from the principal and if it allows for informal discussions between consumer and students instead of a consumer lecturing in front of a silent audience of students. Cooperation during work also offers a good opportunity to achieve equal status of consumers and members of the majority if both participate in the same task.

Also of importance are minority members who mildly disconfirm the stereotype towards this minority. Contact seems to be effective by changing stigmatizing knowledge structures. After contact, a person's natural stereotype of a minority group may be replaced by another, more positive image of that group Reference Rothbart and John [89] . For instance, after working with a person of equal status and with mental illness at one's new job, one may discard stereotypes about this person being dangerous or incompetent. The strength of the effect of change in stereotypes depends on the level of disconfirmation by the contacted minority group member. Contact experiences with persons who do not at all resemble stereotypes about the minority group are unlikely to have a major effect on those stereotypes Reference Kunda and Oleson [56] . For example, contact during work with a woman with mental illness who is also highly attractive and successful in her professional and personal life may not only fail to diminish stigma but even lead to a boomerang effect Reference Kunda and Oleson [57] . The information about this woman may not be used to disconfirm the stereotype about the minority of people with mental illness, but the woman will likely be subtyped as unusual. She may even be reclassified as belonging to 'us' instead of 'them' Reference Gaertner, Mann, Dovidio and Murrell [42] . This kind of subtyping can in fact corroborate stigma according to the saying that the exception proves the rule.

To sum up our overview of different methods to reduce stigma, contact combined with education seems to be the most promising avenue. To end on a more cautious note, though, one has to bear in mind a limitation of every anti-stigma initiative that focuses on a specific behavior of a certain group, e.g. local employers and their not offering jobs to persons with mental illness. On the one hand, prejudices and behavior of one group are an appealing target, because it reduces the complexity of the stigma-phenomenon and focuses on a target that matters Reference Corrigan [16] . On the other hand, the areas of individual discrimination, structural discrimination and self-stigma lead to innumerable mechanisms of stigmatization. If one discriminating mechanism is blocked, a powerful stigmatizing group can always create new ways to discriminate Reference Link and Phelan [63] . If for example persons with mental illness are protected by new work-legislation, employers can find new, informal ways not to employ or to fire them. Therefore, to substantially reduce discriminating behavior, stigma-related attitudes of power groups have to be fundamentally changed.

6. Conclusions

In this review we gave a conceptual overview of stigma, its main components - stereotypes, prejudice and discrimination - , and its consequences, focussing on self-stigma and empowerment and on fear of stigma as a barrier to use health services. We then discussed different avenues to reduce stigma and gave examples of anti-stigma initiatives. Since stigma is a complex phenomenon, much more research is needed on public stigma, self-stigma, the impact of stigma on families of persons with mental illness and on structural discrimination of persons with mental illness, especially inside the health care system. We also lack information on the different effects stigma has on persons with different mental disorders. It is unlikely that people with various disorders face the same stigmatizing attitudes and react to discrimination in the same way. While current anti-stigma initiatives certainly have a good intention, further empirical work is necessary to find out what strategy and content is best to reduce stigmatizing attitudes and behavior in what target group. We also still need to find out whether, in addition to public approaches, psychotherapeutic approaches might support people with mental illness to better cope with stigma until public stigma has been substantially diminished. In this context we also need more information on the relationship between stigma, emotions such as shame, and self-esteem.

Public stigma has a major impact on many people with mental illness, especially if it leads to self-stigma, and may interfere with various aspects of life, including work, housing, health care, social life and self-esteem. In order to support people with mental illness, successful long-term anti-stigma campaigns are necessary to reduce public stigma in society.

Acknowledgements

The authors are grateful to Christoph Nissen and Roland Zahn for their comments on an earlier draft of this paper.

Fig. 1 Model of personal response to mental illness stigma (adapted from [25]).

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• Volume 20, Issue 8
• Nicolas Rüsch (a1) , Matthias C. Angermeyer (a2) and Patrick W. Corrigan (a3)
• DOI: https://doi.org/10.1016/j.eurpsy.2005.04.004

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A qualitative study: experiences of stigma by people with mental health problems

Affiliations.

• 1 Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK.
• 2 Stockport and District Mind, UK.
• 3 Department of Psychology, Social Work and Counselling, University of Greenwich, London, UK.
• PMID: 29345416
• DOI: 10.1111/papt.12167

Objectives: Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population.

Design: An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

Methods: Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

Results: Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

Conclusions: It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

Practitioner points: People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

Keywords: charity; community; institutional stigma; internalised stigma; labels; mental health; non-statutory; public stigma; qualitative; resilience.

© 2018 The British Psychological Society.

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Annual Review of Sociology

Volume 41, 2015, review article, the stigma complex.

• Bernice A. Pescosolido 1 , and Jack K. Martin
• View Affiliations Hide Affiliations Affiliations: Department of Sociology, Indiana University, Bloomington, Indiana 47405-7103; email: [email protected]
• Vol. 41:87-116 (Volume publication date August 2015) https://doi.org/10.1146/annurev-soc-071312-145702
• First published as a Review in Advance on May 04, 2015
• © Annual Reviews

Since the beginning of the twenty-first century, research on stigma has continued. Building on conceptual and empirical work, the recent period clarifies new types of stigmas, expansion of measures, identification of new directions, and increasingly complex levels. Standard beliefs have been challenged, the relationship between stigma research and public debates reconsidered, and new scientific foundations for policy and programs suggested. We begin with a summary of the most recent Annual Review articles on stigma, which reminded sociologists of conceptual tools, informed them of developments from academic neighbors, and claimed findings from the early period of “resurgence.” Continued (even accelerated) progress has also revealed a central problem. Terms and measures are often used interchangeably, leading to confusion and decreasing accumulated knowledge. Drawing from this work but focusing on the past 14 years of stigma research (including mental illness, sexual orientation, HIV/AIDS, and race/ethnicity), we provide a theoretical architecture of concepts (e.g., prejudice, experienced/received discrimination), drawn together through a stigma process (i.e., stigmatization), based on four theoretical premises. Many characteristics of the mark (e.g., discredited, concealable) and variants (i.e., stigma types and targets) become the focus of increasingly specific and multidimensional definitions. Drawing from complex and systems science, we propose a stigma complex, a system of interrelated, heterogeneous parts bringing together insights across disciplines to provide a more realistic and complicated sense of the challenge facing research and change efforts. The Framework Integrating Normative Influences on Stigma (FINIS) offers a multilevel approach that can be tailored to stigmatized statuses. Finally, we outline challenges for the next phase of stigma research, with the goal of continuing scientific activity that enhances our understanding of stigma and builds the scientific foundation for efforts to reduce intolerance.

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• Stigma, Prejudice and Discrimination Against People with Mental Illness

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More than half of people with mental illness don't receive help for their disorders. Often, people avoid or delay seeking treatment due to concerns about being treated differently or fears of losing their jobs and livelihood. That's because stigma, prejudice and discrimination against people with mental illness are still very much a problem.

Stigma, prejudice and discrimination against people with mental illness can be subtle or obvious—but no matter the magnitude, they can lead to harm. People with mental illness are marginalized and discriminated against in various ways, but understanding what that looks like and how to address and eradicate it can help.

The Facts on Stigma, Prejudice and Discrimination

Stigma often comes from lack of understanding or fear. Inaccurate or misleading media representations of mental illness contribute to both those factors. A review of studies on stigma shows that while the public may accept the medical or genetic nature of a mental health disorder and the need for treatment, many people still have a negative view of those with mental illness.

Researchers identify different types of stigma: (See chart below.)

• Public stigma involves the negative or discriminatory attitudes that others may have about mental illness.
• Self-stigma refers to the negative attitudes, including internalized shame, that people with mental illness may have about their own condition.
• Structural stigma  is more systemic, involving policies of government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services relative to other health care.

Stigma not only directly affects individuals with mental illness but also the loved ones who support them, often including their family members.

Stigma around mental illness especially an issue in some diverse racial and ethnic communities and it can be a major barrier to people from those cultures accessing mental health services. For example, in some Asian cultures, seeking professional help for mental illness may be counter to cultural values of strong family, emotional restraint and avoiding shame. Among some groups, including the African American community's, distrust of the mental healthcare system can also be a barrier to seeking help. (See more on mental health in Diverse Populations .)

Types of Stigma

Source: Adapted from Corrigan, et al., 2014.

Media representations of people with mental illness can influence perceptions and stigma, and they have often been negative, inaccurate or violent representations. A study published by Scarf, et. al. in 2020 looked at a recent example, the popular film Joker (2019), which portrays the lead character as a person with mental illness who becomes extremely violent. The study found that viewing the film "was associated with higher levels of prejudice toward those with mental illness." Additionally, the authors suggest, " Joker may exacerbate self-stigma for those with a mental illness, leading to delays in help seeking."

The stigma of mental illness is universal. A 2016 report on stigma concluded "there is no country, society or culture where people with mental illness have the same societal value as people without mental illness."

Harmful Effects of Stigma and Discrimination

Stigma and discrimination can contribute to worsening symptoms and reduced likelihood of getting treatment. A recent extensive review of research found that self-stigma leads to negative effects on recovery among people diagnosed with severe mental illnesses. Effects can include:

• reduced hope
• lower self-esteem
• increased psychiatric symptoms
• difficulties with social relationships
• reduced likelihood of staying with treatment
• more difficulties at work

A 2017 study by Oexle et al  involving more than 200 individuals with mental illness over a period of two years found that greater self-stigma was associated with poorer recovery from mental illness after one and two years.

An editorial in the Lancet notes that the impacts of stigma are pervasive, affecting political enthusiasm, charitable fundraising and availability, support for local services and underfunding of research for mental health relative to other health conditions.

Some of the other harmful effects of stigma can include:

• Reluctance to seek help or treatment and reduced likelihood of staying with treatment.
• Social isolation.
• Lack of understanding by family, friends, coworkers, or others.
• Fewer opportunities for work, school or social activities or trouble finding housing.
• Bullying, physical violence or harassment.
• Health insurance that doesn't adequately cover your mental illness treatment.
• The belief that you'll never succeed at certain challenges or that you can't improve your situation.

Source: Adapted from Mayo Clinic 2017

Stigma Can Also Impact Family and Friends

Family members and friends, who often provide essential help and support for people with mental illness, can also experience stigma. They may internalize stigma and blame themselves, or they may fear that people will blame them for causing a loved one’s illness or reject the family socially. This stigma can lead to reduced emotional support, social isolation, and reluctance to seek care for their relative. (Yanos, 2023; Mclean, 2023)

Stigma in Diverse Communities

Stigma around mental illness is especially an issue in some diverse racial and ethnic communities, and it can be a major barrier to people from those cultures accessing mental health services. For more information, please see Mental Health Disparities: Diverse Populations.

Stigma in the Workplace

A 2022 national poll from the American Psychiatric Association (APA) found that mental health stigma is still a major challenge in the workplace. About half (48%) of workers say they can discuss mental health openly and honestly with their supervisor, down from 56% in 2021 and 62% in 2020. Half (52%) also say they feel comfortable using mental health services with their current employer, compared to 64% in 2021 and 67% in 2020. In a more positive trend, fewer adults are worried about retaliation if they take time off or seek care for their mental health. About one in three (36%) worried about retaliation if they took time off, compared to 48% in 2021 and 52% in 2020. Less than one-third (31%) were worried about retaliation for seeking care, compared to 43% in 2021 and 2020. (APA, 2022)

Reducing Stigma

Public health approaches.

Many years of research on anti-stigma interventions has found that successful interventions (Yanos, 2023):

• Include contact (in person, but video can also be a feature if done right).
• Focus on a range of disorders, not just depression or mental illness broadly.
• Involve participation of people with “lived experience.”
• Target groups that have the most interaction or where lack of help-seeking is most problematic (e.g., young people, undocumented communities, military communities).
• Are tailored to be credible to specific language and cultural signifiers of the target group.
• Last several years in order to be effective.

Substantial research shows that knowing or having contact with someone with mental illness is one of the best ways to reduce stigma. Individuals speaking out and sharing their stories can have a positive impact. When we know someone with mental illness, it becomes less scary and more real and relatable.

Teens are searching for health information online and mental health issues are among the top searches, according to a national survey from Hope Lab (Hope Lab, 2021). About four in 10 teens said they have looked for people with similar health concerns. Many celebrities, such as Demi Lovato, Dwayne "The Rock" Johnson, Michael Phelps, Taraji P. Henson and Lady Gaga have publicly shared their stories of mental health challenges and brought the discussion much more into the general media and everyday conversation. Young people are looking for information and for these personal stories online.

Recent studies have also shown the effectiveness of brief videos in reducing stigma. One study tracked more than 700 students across two years in a randomized controlled trial and found that watching videos of people sharing their personal experiences and videos with information on mental health improved students' mental health care access (da Conceição, et al 2023). The researchers found that the intervention was particularly effective for those in need, enabling them to recognize their need for care and behave accordingly. Another study found that a video featuring an actor sharing a story was as effective as a person with lived experience. (Amsalem, et al 2023).

Social marketing campaigns can also be effective. For example, a research study looked at the effectiveness of an anti-stigma social marketing campaign in California and found that the campaign increased service use by helping people better understand symptoms of distress and increasing awareness that help is available. (Collins, et al 2019). The researchers suggest that widespread exposure to the mental health campaign could significantly increase access to treatment.

Individual Actions to Reduce Stigma

The National Alliance on Mental Illness (NAMI) offers some suggestions about what we can do as individuals to help reduce the stigma of mental illness:

• Talk openly about mental health, such as sharing on social media.
• Educate yourself and others – respond to misperceptions or negative comments by sharing facts and experiences.
• Be conscious of language – remind people that words matter.
• Encourage equality between physical and mental illness – draw comparisons to how they would treat someone with cancer or diabetes.
• Show compassion for those with mental illness.
• Be honest about treatment – normalize mental health treatment, just like other health care treatment.
• Let the media know when they are using stigmatizing language presenting stories of mental illness in a stigmatizing way.
• Choose empowerment over shame – "I fight stigma by choosing to live an empowered life. To me, that means owning my life and my story and refusing to allow others to dictate how I view myself or how I feel about myself." – Val Fletcher.

Employers who are leading efforts to address stigma offer some suggestions (CWMH):

• Tailor programs/approaches to your company culture and existing strengths.
• Mention your commitment to leading a behaviorally healthy workplace every time you mention the company's commitment to its overall culture of health, attracting and retaining the best talent, and valuing its employees, etc.
• Train leaders to identify emotional distress and make referrals and to responding promptly and constructively to behavioral performance issues.
• Be welcoming of the need for accommodations. Train managers to respond appropriately

Organizations and Campaigns

Across the country numerous organizations and campaigns focus on addressing the issue of mental health stigma and discrimination. A few examples are highlighted below:

How So We Stop Stigma? Conversation

Try these simple tips for talking.

• "Thanks for opening up to me."
• "Is there anything I can do to help?"
• "I'm sorry to hear that. It must be tough."
• "I'm here for you when you need me."
• "I can't imagine what you're going through."
• "People do get better."
• "Oh man, that sucks."
• "Can I drive you to an appointment?"
• "How are you feeling today?"
• "I love you."

Don't Say

• "It could be worse."
• "Just deal with it."
• "Snap out of it."
• "Everyone feels that way sometimes."
• "You may have brought this on yourself."
• "We've all been there."
• "You've got to pull yourself together."
• "Maybe try thinking happier thoughts."

Source: MakeItOK.org

  References

• Amsalem, D. et al. 2023. Stigma Reduction Via Brief Video Interventions: Comparing Presentations by an Actor Versus a Person With Lived Experience. Psychiatric Services. https://doi.org/10.1176/appi.ps.20230215
• APA News Release: Employees Say Workplaces Are Offering Fewer Mental Health Services in 2022, According to APA Poll. May 22, 2022.
• Barnett, D. 2023. ‘Tis the Season: Opportune Time to Help Reduce Stigma of Substance Use Disorders Psychiatric News. Nov. 27, 2023. https://doi.org/10.1176/appi.pn.2023.12.12.35
• Center for Workplace Mental Health. Working Well Toolkit . 2016.
• Collins, R.L., et al. Social Marketing of Mental Health Treatment: California's Mental Illness Stigma Reduction Campaign . Am J Public Health . 2019 June; 109(Suppl 3): S228–S235.
• Corrigan, Pw, Druss, BG, Perlick, DA. The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care . Psychological Science in The Public Interest . 2014, 15(2);37-70.
• da Conceição, V., Mesquita, E., & Gusmão, R. (2023). Effects of a stigma reduction intervention on help-seeking behaviors in university students: A 2019-2021 randomized controlled trial . Psychiatry research, 331, 115673. Advance online publication. https://doi.org/10.1016/j.psychres.2023.115673
• Forde, K. 2020. By Sharing Their Own Struggles, Celebs Help Teens Tear Down Mental Health Stigma .
• Greenstein, L. 9 Ways To Fight Mental Health Stigma . NAMI blog, Oct. 11, 2017.
• Hope Lab, Common Sense, and California HealthCare Foundation. 2021. Coping With Covid-19: How Young People Use Digital Media To Manage Their Mental Health.
• Mayo Clinic. Mental health: Overcoming the stigma of mental illness . 2017.
• McLean/Mass General Brigham, 2023. Let’s Face It, No One Wants To Talk About Mental Health
• Oexle N, Müller M, Kawohl W, et al. Self-stigma as a barrier to recovery: a longitudinal study . European Archives of Psychiatry and Clinical Neuroscience . October 2017. doi: 10.1007/s00406-017-0773-2.
• Pescosolido, BA. The public stigma of mental illness: what do we think; what do we know; what can we prove? J Health Soc Behav . 2013 Mar;54(1):1-21. doi: 10.1177/0022146512471197.
• Scarf, D., et al. Association of Viewing the Films Joker or Terminator: Dark Fate With Prejudice Toward Individuals With Mental Illness . JAMA Network Open . April 24, 2020.
• Yanos, P., Amsalem, D., Dixon, L. 2023. Brief video interventions to reduce self-, public, and affiliate stigma among/toward young individuals with psychosis. Presentation at APA 2023 Mental Health Services Conference

Physician Review

Nikhita Singhal, M.D. University of Toronto, Psychiatry Resident

Medical leadership for mind, brain and body.

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• Research article
• Open access
• Published: 05 October 2018

A qualitative study on the stigma experienced by people with mental health problems and epilepsy in the Philippines

• Chika Tanaka   ORCID: orcid.org/0000-0002-6288-5532 1 ,
• Maria Teresa Reyes Tuliao 2 ,
• Eizaburo Tanaka 3 ,
• Tadashi Yamashita 4 &
• Hiroya Matsuo 1  

BMC Psychiatry volume  18 , Article number:  325 ( 2018 ) Cite this article

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Stigma towards people with mental health problems (PMHP) is known to have substantial negative impacts on their lives. More in-depth exploration of the stigma and discrimination experienced by PMHP in low- and middle-income countries is needed. Previous research suggests that negative attitudes towards PMHP are widespread among the Filipino general public. However, no study has investigated PMHP’s own experiences of being stigmatised in the Philippines.

A qualitative study was conducted on the stigma experienced by PMHP (including people with epilepsy) and its related factors in the Philippines, employing the constructivist grounded theory approach. We analysed data on 39 PMHP collected through interviews with PMHP, their carers, and community health volunteers who know them well.

The findings highlight the culturally and socio-economically specific contexts, consequences, and impact modifiers of experiences of stigma. Participants emphasised that PMHP face stigma because of the cultural traits such as the perception of mental health problem as a disease of the family and the tendency to be overly optimistic about the severity of the mental health problem and its impact on their life. Further, stigma was experienced under conditions where mental health care was not readily available and people in the local community could not resolve the PMHP’s mental health crisis. Stigma experiences reduced social networks and opportunities for PMHP, threatened the economic survival of their entire family, and exacerbated their mental health problems. An individual’s reaction to negative experiences can be fatalistic in nature (e.g. believing in it is God’s will). This fatalism can help PMHP to remain hopeful. In addition, traditional communal unity alleviated some of the social exclusion associated with stigma.

Conclusions

The study indicates that existing stigma-reduction strategies might have limitations in their effectiveness across cultural settings. Therefore, we propose context-specific practical implications (e.g. emphasis on environmental factors as a cause of mental health problems, messages to increase understanding not only of the possibility of recovery but also of challenges PMHP face) for the Philippines.

Peer Review reports

Stigma and discrimination against people with mental health problems (PMHP) are a global public health issue [ 1 , 2 , 3 ] and can have substantial negative impacts on all aspects of a person’s life, from employment and housing to social and family life [ 4 , 5 , 6 , 7 ]. Public stigma, the general public’s reaction towards a stigmatised group, can be conceptualised as having three distinct elements [ 8 ]. First, a negative belief about a stigmatised group is seen as stereotype. Second, an emotional reaction to the stereotype is seen as prejudice. Third, a behavioural manifestation of the prejudice is discrimination. Historically, research on stigma related to mental health has been conducted mainly on stereotypes, prejudices, and intentions to discriminate that are held by the general public with regard to PMHP. Such research revealed that the general public frequently label PMHP as dangerous, blameworthy, incompetent and weak, which is often accompanied with emotions of fear and anger and can lead to behavioural intention of avoidance, punishment, and coercion [ 9 , 10 , 11 , 12 ]. Further, the literature shows that internalisation of public stigma or self-stigma is also frequent among PMHP, which reduces self-esteem, causes social isolation, and inhibits help-seeking behaviour [ 6 , 13 , 14 , 15 ].

Recent research has more often investigated levels of discrimination using direct reports from PMHP. The results of such research suggest that discrimination against PMHP is a universal phenomenon around the world [ 2 , 3 , 16 ]; however, PMHP’s experiences of discrimination and its related factors might differ in high-income countries (HICs) versus low- and middle- income countries (LMICs). Some studies suggest that PMHP experience a lower level of stigma in LMICs [ 17 ], such as India [ 18 ], China [ 19 ], and Nigeria [ 20 ], compared with HICs. The reasons for the more positive acceptance of PMHP in those settings have been considered to be a more supportive environment with social cohesion as well as more social role options that PMHP are able to fulfil [ 21 , 22 ]. At the same time, there is also accumulating evidence revealing that in LMICs, experiences of stigma, discrimination and human rights abuses related to mental health problems are common and severe [ 23 , 24 , 25 , 26 , 27 ]. The stigmatisation in LMICs has been attributed to the combined effects of socioeconomic and ethno-cultural characteristics of the setting [ 28 ]. For example, the economic situation of widespread poverty may contribute to further marginalisation of PMHP who are not able to financially contribute to society [ 29 ]. Moreover, the cultural value of collectivism may results in discrimination towards PMHP especially with regarding to marriage and childrearing, since a person’s mental health problem is often seen as the family’s mental health problem [ 30 ]. Overall, practices and outcomes of stigma differ across cultures and socioeconomic backgrounds [ 29 , 31 , 32 ], and meaningful comparison across cultural settings may not be achievable with cross-cultural measures [ 33 ]. In consideration of this, researchers have called for an in-depth qualitative exploration of the experiences of stigma among PMHP in LMICs settings, where about 85% of the world’s population live [ 21 ].

PMHP in the Philippines, a lower-middle income country in Asia, might experience a significant level of stigma and discrimination. Filipino immigrants believed that personal characteristics (i.e. self-centeredness and “soul weakness”) resulted in mental health problems [ 34 , 35 ], which have been shown to be related to blaming PMHP and discriminatory behaviour in other settings [ 36 ]. Also, a multi-country survey revealed that, among 16 countries surveyed, the Philippines had the second highest proportion of citizens who agreed that PMHP should not be hired for a job even if they are qualified [ 37 ]. Further, some studies that involved interviews with Filipino immigrants living in Australia and the United States and that sampled from the general population revealed that a fear of being labelled as ‘crazy’ and spoiling their family’s reputation made Filipinos hesitate to seek help from mental health professionals [ 35 , 38 , 39 ]. Although these previous studies provide some knowledge regarding public stigma in the Filipino context, all of them looked at stereotypes, prejudices and intentions to discriminate held by the general public towards PMHP. To our knowledge, there is no study investigating PMHP’s own experiences of being stigmatised and discriminated against and the related factors in the Philippines.

To fill the gaps in the literature, we conducted a qualitative study on the factors related to experiences of stigma as well as the experiences itself of PMHP in the Philippines, using interviews with PMHP and people who know them well. Revealing the existence, types, and sources of stigma experienced by PMHP in the Philippines can contribute to the stigma research in Asian LMIC settings. Further, exploring the experiences of stigma and its related factors can provide fundamental knowledge for the design of an effective stigma reduction program in the Filipino setting.

The current research utilised the principles of constructivist grounded theory, which is deemed suitable for revealing the social phenomenon of PMHP’s experiences of stigma [ 40 ] in the Filipino context. The constructivist grounded theory assumes a relativist ontology (accepting that multiple realities exist) and a subjectivist epistemology (involving a co-construction of meaning through interaction between the researcher and participant) [ 41 ]. It provides a means of studying power, inequality, and marginality [ 42 ].

Our study was conducted in Muntinlupa, the southernmost city in the Philippines’ National Capital Region. The city has a population of 481,461 as of 2016. The majority comprises Tagalog ethnic groups and professes Christian, primarily Roman Catholic, faith. Households below the food threshold, the minimum income required to meet basic food needs, account for 21.5% of the total in the city [ 43 ]. The majority of citizens cannot afford private medical services, which cost five times more than the public medical services [ 44 ]. With respect to public psychiatric service, the city has one outpatient and no in-patient facility. The nearest public in-patient psychiatric facility is located about 23 km away.

Main data collection

Participants.

We collected data on PMHP from three different sources of information: PMHP themselves, their carers, and community health volunteers who knew them well. The eligibility criteria for PMHP were 1) having a mental health problem, listed in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), or epilepsy, and 2) currently not using residential care. Epilepsy was included for several reasons. First, people with epilepsy are known to suffer stigma and discrimination [ 45 , 46 ]. Second, the condition has a long history of being classified as a psychiatric problem [ 47 ]. Third, even with the present-day efforts promoting mental health in LMICs, epilepsy is often treated together with mental health issues [ 48 ]. Last, pilot interviews revealed that local lay people do not clearly differentiate epilepsy from mental health problems.

For the recruitment, we approached 42 PMHP in person; one of them declined to participate owing to time constraints. Thus, we obtained informed consent from 41 PMHP. Among them, two PMHP were excluded because they were confirmed to have only physical health problems and no mental health problems as listed in DSM-5. Consequently, we used data of 39 PMHP for our analysis. The profiles of the final sample are shown in Table  1 . In 20 of the PMHP, we interviewed the PMHP and their main carer, usually a parent or sibling. In the remaining 19 PMHP, only a main carer was interviewed, as the 19 PMHP had communication difficulties that hindered them from answering interview questions. Additionally, in 11 PMHP, we conducted interviews with a community health volunteer who was in charge of the district in which the PMHP lived.

Recruitment

We aimed to include a wide variation in the characteristics of the PMHP, namely, gender, age, marital status, educational attainment, employment status, religion, type of mental health problem, and history of using health and welfare services. To achieve this, the participants were recruited by purposive sampling in cooperation with two different collaborating stakeholders. First, as stigma was considered to inhibit Filipino people from seeking professional help for their mental condition [ 35 , 49 ], we recruited the majority of PMHP ( n  = 36) in cooperation with community health volunteers, which enabled us to recruit PMHP regardless of their history of receiving health care. The community health volunteers had good knowledge of the profiles of the residents of the district under their charge and covered all the areas of the city. Second, we recruited a small number of PMHP ( n  = 3) with common mental health problems (e.g. anxiety and depressive problems) from the outpatient clinical practice of a psychiatrist, as the community health volunteers did not identify any people with these types of problems.

To check the eligibility of those who had never been diagnosed by a specialist as having a mental health problem, a research member, ET, carefully reviewed the data of the individual participants, including interview recordings, transcriptions, and field notes, and then provided informed presumption if the participants had a mental health problem or not. ET also assessed which chapter, the broadest classification in DSM-5, the participant most fitted. ET has clinical experience as a psychiatrist in Japan for over 15 years.

Interview procedures

Data on the PMHP were collected through semi-structured in-depth interviews. Prior to the beginning of data collection, an interview guide was developed, referring to previous research [ 18 , 50 ], and then modified based on six pilot interviews in the setting. The interview guide had a series of open questions on three major topics: onset of mental health problems and coping behaviours, experiences of being treated negatively owing to the problem and its consequences, and activities PMHP gave up because of how others might respond to their health problem. The interview guides for interviews with PMHP and for interviews with carers and community health volunteers can be accessed in Additional files  1 and 2 , respectively. Consistent with the grounded theory methods, we used the interview guide as a flexible tool that could be revised as the analysis progressed. The carers and community health volunteers were not asked about their own experiences of stigma as a carer or person working in mental health. Instead, we asked them about the PMHP’s experiences regarding the same topics, based on their observations. Demographic data of the PMHP were also obtained at the beginning of the interview.

The first author, CT (female, a Japanese public health nurse), conducted all of the data collection between January and March 2017. During the interview, Tagalog or English was used as preferred by the participants. When Tagalog was chosen, the interviews were interpreted by one of two health workers who had lived in the city for more than 30 years and were fluent in both Tagalog and English. After explaining the study and gaining informed consent, the interviews were conducted in their home, a health centre, or the city hospital, depending on the participants’ preference. Wherever possible, we conducted interviews in a space where there was no one but the interviewee, interviewer, and interpreter around. However, five PMHP were not willing to be interviewed alone. In which case, a family member was in the same place and assisted the interview. All the interviews were digitally recorded with interviewees’ permission and lasted between 19 and 53 min; the median length was 29 min. The participants received 100 Philippine pesos (1.9 US dollars) as acknowledgement for their participation.

Supplementary data collection

We included data of interviews with seven health workers into our analysis to gain a wider perspective on the stigma experienced by PMHP. CT conducted the interviews during her one-month participant observation at health services provided by the city government. During the observation, CT discussed the role of stigma and its impact on PMHP with more than 85 health and welfare workers. We analysed seven interviews with those who shared episodes on PMHP with whom they were in direct contact as a part of their duty at work. The interviewees were three community health volunteers, two nurses, one doctor, and one rehabilitation program officer. Notes were taken during the interviews and six out of seven interviews were audiotaped with their permission.

All of the recordings were transcribed verbatim by two trained transcribers. Tagalog recordings were simultaneously translated into English by the transcribers fluent in English and Tagalog. An independent research assistant randomly selected 10% of the English transcripts and checked their accuracy by matching them with the Tagalog and English recordings. During this checking process, no significant errors were found thus the transcripts were quality assured.

Data analysis started as soon as the initial data were collected. We set aside theoretical ideas from the existing literature; instead, we remained open to exploring the theoretical possibilities we could discern from the data. After reading each of the transcripts at least twice, CT and ET independently conducted the initial coding. Simple codes were created to describe the phenomenon in each segment of data, using the qualitative data analysis software, Nvivo Version 11.4.1 (QSR International, 2016). The initial codes with identical meanings were merged through discussion, whereas those with different meanings were left unchanged to increase the variety in the interpretation of the data. We used data from interviews with cares, health volunteers, health and welfare workers to increase variety of data on stigma experienced by PMHP and gain comprehensive understanding of its context. Thus, when accounts showed some discrepancy between a person with mental health problem and his/her carer or a person who knew him/her well, we used the data from both accounts for our analysis.

The authors gradually moved on to the focus coding, in which the initial codes were concentrated on or collapsed into categories that make analytical sense, and then tested these against extensive data. The interpersonal interaction between people with and without mental health problems was treated as the central phenomenon of our interest. To explore comprehensively PMHP’s experiences of stigma, we decided to treat any “uncomfortable treatments from others” reported as stigma experience, regardless of the actors’ motivation. We constantly compared data on similarities and differences within a participant as well as across participants to examine the categories and develop links among them. CT led the preliminary focus coding. Subsequently, discussions were held between CT, ET, and HM, in which we reviewed the developed categories and links to determine if they were grounded in data and sufficiently explained the phenomenon.

After analysing the data of the 35 PMHP, a tentative model that explains the relations between categories was developed. We then collected and analysed data on four additional PMHP. Through discussion, the full research team determined that the categories and themes were sufficiently relevant and that the model held true for these additional PMHP. We then concluded that the model was theoretically saturated.

Analyses revealed four interrelated themes surrounding stigma experienced by PMHP: (1) the context affecting stigma experience, (2) stigma experience, (3) impact modifier of the stigma experience, and (4) consequence of the stigma experience. Figure  1 shows the relationship among the themes.

Stigma experienced by people with mental health problems and its related factors in the Philippines

Context affecting stigma experience

We identified two contextual categories that changed how others treated PMHP in a negative way.

Public belief about mental health problems

Public beliefs surrounding mental health issues are a contextual category of stigma experienced by PMHP in the Philippines. It consists of three themes: familial problems, unrealistic pessimism and optimism about severity, and oversimplified chronic course.

Familial problems

Community health volunteers and health workers observed that families of PMHP and people in the local community do not provide appropriate support for PMHP because they perceive mental affliction as a family problem and indicative of so-called “bad blood”. The belief that mental health problems can be transmitted among relatives pushed families of PMHP to deny the existence of mental health issues and people in the community to distance themselves from PMHP. A nurse shared an episode of a male patient with depression:

His family could not accept the idea that one of their relatives is actually depressed. (…) It’s because in our culture, when it comes to mental illness, it tends to be a family affair. People think if one of you has a history of mental illness, there is a chance that almost all of you already have that as well. We care about how others think about our family more than anything else. And other people feel that it is not their place to intervene in some family matters. (Interview 48, Nurse, Female)

In particular, marrying age PMHP faced stigma because of the belief in heredity. People in the community often believe that PMHP have mental health problems in their family’s blood and are afraid of developing those problems in their kinship via marriage.

I had one neighbour that I reported to the barangay [district government] because she mocked me. She was saying that I had mental illness in our blood and no one dare marry me and get in trouble. (Interview 51, PMHP, Male)

Unrealistic pessimism and optimism about severity

PMHP experienced stigma when others were overly pessimistic about the severity of a mental health problem. Participants often criticised those who believe that mental health problems generally cause severe functional impairments. This belief has resulted in unfair treatment towards PMHP in the Philippines.

[Researcher: What is the biggest challenge for the [social inclusion] program?] Finding a job. It’s very difficult. The community people don’t believe they [PMHP] are functional and don’t hire them. (…) So now some barangays [district governments] have started to hire them. We hope people see them working hard and start to trust them. (Interview 27, Rehabilitation program officer, Male)

Meanwhile, unrealistic optimism about its severity also caused stigma. The commonly held belief is that individuals are able to overcome any psychological suffering by themselves, and as a result, it will not become a serious problem. It was common for PMHP to be doubted or withheld empathy in such a culture that emphasises resilience and humour under stressful situations.

Filipinos are proud of being resilient. We find something funny in any difficult situation. But when you have this illness, that kind of thinking gives you a huge pressure. (…) One day, I opened up about my mental illness to my friends, but they all had the same reaction. They laughed at me and didn’t take it seriously. (Interview 71, PMHP, Female)

Oversimplified chronic course

The oversimplified chronic course of mental health problems emerged as one of the causes of stigma. People without any experience of a mental health problem often misunderstand the repetitive relapse and remission in the course of a mental health problem. They tend to apply an acute illness model and expect a complete cure in the short term. However, as the symptoms are prolonged, they begin to mistrust the PMHP’s account.

After one month of no work, I was able to work and sleep. But in February, it came back. I couldn’t sleep for several days. (...) My supervisors were thinking that I should be working a night shift duty, but I told them that I would have to take sick leave. But because it was the same reason for my previous absent, they are already thinking that I am making up stories. (Interview 30, PMHP, Male)

Interpersonal condition

Interpersonal condition was identified as a direct trigger of stigma experience. It consists of two themes: unresolved threat and unmet expectation.

Unresolved threat

Unresolved threat is a condition where PMHP are at risk of hurting themselves or others owing to their mental health problems, with the people in contact with the PMHP failing to manage such risks. Under such conditions, PMHP often experience physical violence, being avoided, and being restricted by others. Although the PMHP, their families, and community health volunteers attributed the threats to PMHP’s personal factors, such as personality and outwardly noticeable symptoms, they also emphasised the culpability of people in the local community for their lack of understanding and skills in interacting with PMHP. When others became familiar with PMHP, they successfully managed those threats and prevented PMHP from experiencing stigma. The mother of a boy with a neurodevelopmental problem told us:

My son easily becomes violent. For example, when someone takes and plays with his toy. The neighbours don’t understand why he is angry and they bully him. But there are also some playmates who fully understand him. When they know that my son is about to be angry, they immediately keep distance from him. And after a while, my son calms down and they start playing around together. (Interview 4, Mother of a boy with a mental health problem)

Unmet expectation

Unmet expectation was another context of stigma. In this context, there is a gap between PMHP’s abilities and other people’s expectations of them. Some PMHP reported suffering from stigma when others’ expectations were too high for their situation. People in this cultural setting tend to value strong bonds and reciprocity among families and neighbours. PMHP sometimes were unable to perform in accordance with this value owing to their mental health conditions. Violation of this value was judged as morally wrong.

They [the neighbours] say I should help my mum by doing washing, cleaning, and taking care of my brother, even when I say I feel weak or don’t know how to. (Interview 5, PMHP, Female) She is big but still doesn’t help her mother. That’s why the neighbours don’t like her. They say she is not a good daughter. (Interview 18, Community health volunteer, Female)

Meanwhile, some other PMHP experienced stigma when others underestimated PMHP’s abilities. Families often criticised other people that looked only at PMHP’s disabilities but not at their abilities.

When someone in our neighbourhood was trying to talk to my sister and she did not respond back, they started bullying her and calling her crazy. [Researcher: How do you think we can change such situation?] I think proper communication towards her would be the best since she’s really a good listener. The problem is that other people don’t know she actually understands things really well. (Interview 8, Sister of a woman with a mental health problem)

Stigma experience

Although we frequently found that PMHP were positively treated by others because of their mental health problems, we also discovered that almost all the PMHP participants were faced with negative treatment from others. PMHP experienced psychological abuse (e.g. being verbally insulted, laughed at, stared at, gossiped about, doubted), physical violence (e.g. being hit, stones being thrown at them), being restricted (e.g. being told not to go outside alone, tied with a rope to a pillar), not being supported (e.g. lack of understanding and sympathy), being taken advantage of (e.g. being cheated out of money and belongings), being neglected (e.g. privacy not being protected, medical care not being provided), and being rejected (e.g. not being associated with, not being hired). Families were an important source of stigma in terms of prominence as stigma from families was often repetitive (e.g. frequently being slapped) and prolonged (e.g. being locked up in a room for several months). PMHP also experienced stigma frequently from their neighbours, and sometimes from school friends, co-workers and employers. People who were involved with PMHP as a part of their duty at work (i.e. health workers and public safety officers) were a source of stigma as well. For complete information on the stigma experience by source, please see Table  2 .

Impact modifier of stigma experience

Even if the nature of stigma experiences were similar, the extent and degree of its influence on PMHP’s life varied depending on impact modifier of stigma experience . PMHP had three impact modifiers consisting of internal (i.e. fatalistic appraisal) and external (i.e. peer bonds, community unity) factors.

Fatalistic appraisal of stigma experience

Fatalistic appraisal of stigma experience offered PMHP and their families a strategy to cope with the emotional pain caused by stigma experience. People in the setting generally believed that God predetermined life events in the past, present and future. Some PMHP and their family accepted unfair treatments from others as “fate.” They were able to remain hopeful because they believed that God would help them if they had faith in God.

Sometimes people say he is crazy. [Researcher: What do you do in response to that?] Nothing. People say what they want to say. We just say “God is good.” As long as we believe in Him, it will be alright. (Interview 23, Sister of a man with a mental health problem)

Peer bonds , the emotional bonds with other people with similar mental health problems, empowered PMHP to change their stigmatised situation in a positive way. Stigma experience could marginalise them in the community, but when they were together with peers who understood not only their health condition but also their lowered social status, they were empowered and motivated to change the situation for themselves and their peers.

[Researcher: What are the barriers to your recovery?] The different perceptions of people towards us [she and other people with mental health problems]. It is so discouraging for us. And we are the only ones who can understand each other very well. We are like brothers and sisters already. Nevertheless, we make sure that the reason we join the [rehabilitation] program is not only for ourselves but to show them that we can change ourselves for the better. If we will be given a chance to work again, we will make 100 percent effort to get things done accordingly. (Interview 34, PMHP, Female)

Support based on Bayanihan spirit

Support based on Bayanihan spirit , a traditional concept of community unity, relieved the negative impacts of stigma on PMHP. It was not rare that community people gave food or rented a house free to PMHP and their family who had little income. Helping one another in a time of need was inherent in their lives, called Bayanihan in Tagalog. For example, a homeless woman with schizophrenia told us that she had felt hopeless because she had been bullied at school and was in a materially deprived circumstance. However, she was now enjoying her life and managing to make a living because some of her neighbours treated her as a valued community member (e.g. regularly invited her to a local dancing event) and occasionally gave her food. A community health volunteer explained why she had good relationships with the community as follows:

That is natural here. When your family member is sick, neighbours and friends are there to pay for medicines, bring food, help with housework, and take care of small kids. We call it Bayanihan. (Interview 3, Community health volunteer, Female)

Consequence of stigma experience

Stigma experience was found to bring about a substantial negative impact on PMHP’s social networks, roles, opportunities, and mental health.

Reduction of social networks

Stigma experience reduced PMHP’s social networks, which led to them spending their days isolated at home without any interaction with people outside of their immediate family. This was due not only to the direct influence of experiences of stigma (i.e. being physically restrained , being avoided by others ) but also the indirect influence of changes in three aspects: PMHP’s behaviour, restriction by families, and relationships with others. First, after being negatively treated, PMHP tended to “close off to everybody” and distanced themselves from others.

Going out is sometimes like an obstacle. (…) After that [hearing my friends gossiping about me], I have been afraid of people’s judgments. (Interview 62, PMHP, Female)

Second, families started to restrict PMHP’s behaviour to protect them from further stigma experiences.

We do not allow him to go out. We are afraid that something like that [neighbours calling him crazy] might happen to him again or someone might abduct him. (Interview 9, Sister of a man with a mental health problem)

Third, stigma experiences provoked conflicts, from a quarrel to a physical fight, and worsened the relationship between PMHP and others. The conflicting relationships produced a further stigmatising attitude towards PMHP.

He got into a fight with his playmates because they said bad words to him. (…) Many of our neighbours told me that he should be in a cell. They told me that they knew a policeman who could put him in jail. (Interview 1, Mother of a man with metal health problem)

Lost social roles and opportunities

As a result of stigma experience, PMHP lost social roles and opportunities , such as being employed, going to school, having a romantic partner, getting married, parenting, helping with household chores and the family business, taking care of younger siblings and joining religious activities.

She was a member of the choir in church. She likes singing and has a good voice. And plenty of friends visited her in the past and they went to church together. But no more. Nobody visits her, and she quit attending it. (Interview 10, Mother of a woman with a mental health problem)

Increased financial strain

Lost social roles and opportunities increased financial strain, which negatively affected the families as well as PMHP themselves. In this setting, PMHP and their families lived in communities where many people find it difficult to make a living. The cost of transportation to medical facilities and treatment fees put them in a further difficult situation economically. In such conditions, entire families often suffered from the financial strain that was due to stigma to the degree that they could not afford basic items including food and clothing.

If only I could find a good job like when I was well. Even though we do not have enough money to buy things, my family really makes an effort to find ways that we can buy those medicines. (Interview 20, PMHP, Male)

Aggravated mental health

The participants reported that the stigma experiences aggravated mental health in PMHP. The memory of negative treatment from others often stuck in their mind and its influence lasted for a long time. A 32-year-old woman with anxiety problem explained how the experience of being bullied when she was a teenager influenced her current condition:

It triggers my anxiety. When I remember their facial expressions, even now, I feel overwhelmed and breathless (Interview 39, PMHP, Female).

The experience of stigma also affected the mental health condition of PMHP by preventing them from seeking help. Some PMHP and their families choose to keep their mental health status a secret. However, families have limited capacities to take care of a person with a mental health problem, especially in the case of someone with severe symptoms. In the worst case in terms of the influence of stigma on PMHP’s mental health, a community health volunteer reported that the parents of a daughter with a mental health problem locked her up in her room and took care of her without seeking professional help. However, her condition kept deteriorating and eventually she committed suicide inside her room.

To our knowledge, this is the first study to document the stigma experienced by PMHP in the Philippines. This study adds to the understanding of discrimination in LMIC settings and its related contextual factors in the Philippines.

First, our results showed that PMHP in the Philippines experienced stigma, which brought about negative impacts on PMHP’s social networks, roles and opportunities, financial burden, and mental health. Although stigma types, sources, and areas of impact were generally consistent with the existing literature in this field [ 4 , 6 , 51 ], we found that experiences of stigma threatened the economic survival of the entire family of PMHP and increased the mental health crisis in the LMIC context, given the minimal welfare and mental health care provisions. Several studies with participants recruited from clinical settings have shown that PMHP in LMICs suffered less from stigma [ 2 , 18 , 19 , 20 ]. In this study, we involved PMHP without psychiatric service use, which prevented us from overlooking the stigma experienced by the poorest and most marginalised PMHP. Our findings might better reflect the reality in LMIC settings, where it is estimated that more than 70% of PMHP receive no treatment for their mental health conditions [ 52 ].

Second, we found that pessimistic and over-optimistic reactions to a mental health problem are among the important contexts of experiences of stigma in the Philippines. Historically, stigma research has mainly focused on the pessimistic view on the prognosis and its negative effects [ 10 , 53 , 54 , 55 , 56 ]. Meanwhile, when the over-optimistic view on the outcome of mental health problems has been documented among Filipino immigrants, it was only recognised as a barrier to help-seeking [ 35 , 39 ]. Our qualitative exploration’s original finding is that the over-optimistic belief among the community regarding the severity of mental health problems results in PMHP’s receiving inappropriate or negative treatment. This is an important finding for the Philippines, because resilience and optimism under difficult situations are among the well-known cultural traits of Filipinos [ 57 , 58 ]. Stigma resulting from optimism might be prevalent in the Philippines; a prior study showed that among the 16 countries, the Philippines posted the highest proportion of respondents who agreed that mental illness would improve on its own [ 59 ].

Third, the results indicated that mental health problems were perceived as problems of the family and discouraged people from accepting mental health problems. The finding is consistent with psychiatrists’ clinical experiences with Filipino patients [ 60 , 61 ]. We also found that a belief in transmissibility among relatives led to PMHP experiencing reduced marriage opportunities. Previous studies conducted on Chinese descent groups [ 62 , 63 , 64 ] showed that the threat of genetic contamination was related to endorsement of reproductive restriction. We propose that it might hold true in the Filipino context, meaning that the threat to family lineage through genetic contamination via marriage accounts for some of the discrimination experienced by PMHP.

Fourth, we revealed a context-specific impact modifier of stigma experiences, namely, fatalistic appraisal of stigma experience . Existing studies have discussed that Filipinos typically attribute illness to “the will of God” [ 39 , 49 , 65 ]. A new finding of this study is that negative treatments from others were also attributed to fate. Globally, it is known that fatalistic appraisal of negative events inhibits active coping and worsens health [ 66 , 67 ]. However, we found that fatalism offered a spiritual coping strategy and shielded PMHP from the adverse effects of stigma in the Catholic dominant setting of the Philippines. These findings are consistent with the literature that have showed that fatalism facilitates adjustment to negative life events [ 49 , 68 , 69 ]. Moreover, support based on Bayanihan spirit was another culturally relevant impact modifier. The origin of the Bayanihan spirit is traced back to the country’s tradition wherein towns’ people cooperate to carry a family’s entire house on their shoulders to a new location. It is considered a core essence of the Filipino culture. Our finding supports the arguments by Lasalvia [ 21 ] and Mascayano et al. [ 29 ] that communal network, which tends to be better maintained in LMICs, is among the existing strengths to reduce the negative effects of stigma.

Lastly, the research method of obtaining perspectives from multiple participants who witnessed and experienced stigma allowed us to reveal that the interpersonal conditions (i.e. unresolved threat and unmet expectations ) preceded stigma experiences. Consistent with previous research from India [ 24 ] and Indonesia [ 70 ], in the setting where mental health care is not readily available at a local level, people in the community needed to cope with the possible danger of PMHP to self or others and can violate PMHP’s human rights. Similar to the results of prior qualitative analyses of interviews with PMHP and their families [ 18 , 71 ], the expectations of others in contrast to PMHP’s actual capabilities caused negative reactions from others. Those interpersonal conditions might be a more important determinant of stigma experiences than PMHP’s personal factors, considering the previous studies showing individual variables (e.g. employment status, symptom, and treatment experiences) accounted for only less than 30% of total variance of experienced stigma [ 2 , 3 ].

Practical implications

Our results suggest that mental health care must have the objective of the reduction of stigma towards PMHP. The Department of Health and Local Government Units are required by the Mental Health Act [ 72 ], established in 2018 as the first law of its kind in the Philippines, to initiate and sustain nationwide campaigns to raise the level of awareness on the protection and promotion of mental health and rights. In conducting stigma reduction campaigns, they should: 1) target families of PMHP, community people, health workers, and public safety officers; 2) avoid genetic explanations for mental health problems and emphasise the role of environmental and social factors as its cause; 3) increase public understanding of not only the possibility of recovery but also the challenges that PMHP face; and 4) improve families’ and community members’ skills in assessing and coping with possible danger posed by PMHP to self or others [ 73 , 74 , 75 , 76 ]. These interventions might be more effective when they utilise the existing communal network and increase social contact between PMHP and others [ 77 , 78 ] We also propose that mental health and welfare services for PMHP should: 1) be community-based and support PMHP in meeting expectations that are meaningful for themselves and others; 2) provide opportunities for PMHP to share their experiences with peers to empower them [ 79 , 80 , 81 ]; and 3) prevent PMHP from internalising experiences of stigma with acknowledgement of fatalistic appraisal of them as a coping strategy. Lastly, to mitigate the adverse influences of stigma, it is necessary to change the structure of health care and welfare service provision for PMHP (e.g. inclusive education, welfare benefits, and job schemes). It is also essential to provide effective and accessible mental health care.

Study limitations

We were unable to recruit people with common mental health problems who were not using psychiatric services. In fact, community health volunteers do not recognise any people having common mental health problems. This may reflect stigma-related situations where local people do not recognise the manifestation of symptoms of those problems as a health issue, or where people with those problems hide their conditions. Additionally, cultural and language barriers may have played a part in data collection and interpretation. However, we also encountered a number of situations where the interviewee provided the data collector, who was from another cultural background, with further explanations, especially on their culture. Further, some interviews were too short to be considered an in-depth interview. Also, we needed to rely in part on data from narratives of people who know PMHP well, instead of from PMHP themselves. These were because the interviewer had difficulty encouraging some participants, especially PMHP, to talk about sensitive topics. Thus, there might be experiences and related themes that we could not explore. Lastly, we conducted the study in one city; thus, the results may not be generalisable to another part of the Philippines (e.g. rural and Muslim-dominant areas).

Our findings highlight that PMHP in the Philippines experience substantial discrimination and its adverse effects are severe to the degree that it threatens the financial survival of the entire family. Culture-bound beliefs and social structure (e.g. perceiving mental health problems as a familial problems, traditional communal unity) played important roles in shaping and modifying stigma experiences. More research is needed to develop stigma reduction interventions utilising these findings and to evaluate their effectiveness.

Abbreviations

The Diagnostic and Statistical Manual of Mental Disorders

High-income countries

Low- and middle-income countries

People with mental health problems

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Acknowledgments

We are grateful to the interviewees for their participation. We would like to thank Dr. Magdalena C. Meana, Dr. Ma. Luisa Babaran-Echavez, and barangay health workers for their assistance with data collection.

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CT had a major role in the conception of the study, undertook the data collection, carried out the data analysis, and had a major role in writing the manuscript. MT contributed to the design of the study, assisted the data collection and interpretation, and supervised writing the manuscript. ET assisted data collection, conducted data analysis, and revised the manuscript. YT assisted data collection and revised the manuscript. HM supervised the design of the study, had a role in data analysis, and revised the manuscript. All authors read and approved the final manuscript.

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Ethical approval was obtained from the ethical committee of the Graduate School of Health Sciences, Kobe University, Japan (reference number 561). The study was conducted in accordance with the ethical guidelines set forth by the Declaration of Helsinki and the Ethical Guidelines for Medical and Health Research Involving Human Subjects provided by the Ministry of Health, Labour, and Welfare of Japan. The City Health Office of the local government approved a head of time our study protocol, especially ethical aspects for potentially participating citizens. Potential participants received written and oral information about the study. It was emphasized that participation was voluntary. During the data collection, we obtained written consent from all the interviewees and verbal assent from PMHP whose carers participated in the interviews. In the case where the interviewee was under 18 years old, we gained verbal assent from them and written consent from their parents.

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Interview guide for interviews with people with mental health problems. A set of questions we referred while interviewing PMHP. (DOCX 88 kb)

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Interview guide for interviews with carers and community health volunteers. A set of questions we referred while interviewing carers and community health volunteers. (DOCX 90 kb)

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Tanaka, C., Tuliao, M.T.R., Tanaka, E. et al. A qualitative study on the stigma experienced by people with mental health problems and epilepsy in the Philippines. BMC Psychiatry 18 , 325 (2018). https://doi.org/10.1186/s12888-018-1902-9

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Mental health: overcoming the stigma of mental illness.

False beliefs about mental illness can cause significant problems. Learn what you can do about stigma.

Stigma is when someone views you in a negative way because you have a distinguishing characteristic or personal trait that's thought to be, or actually is, a disadvantage (a negative stereotype). Unfortunately, negative attitudes and beliefs toward people who have a mental health condition are common.

Stigma can lead to discrimination. Discrimination may be obvious and direct, such as someone making a negative remark about your mental illness or your treatment. Or it may be unintentional or subtle, such as someone avoiding you because the person assumes you could be unstable, violent or dangerous due to your mental illness. You may even judge yourself.

Some of the harmful effects of stigma can include:

• Reluctance to seek help or treatment
• Lack of understanding by family, friends, co-workers or others
• Fewer opportunities for work, school or social activities or trouble finding housing
• Bullying, physical violence or harassment
• Health insurance that doesn't adequately cover your mental illness treatment
• The belief that you'll never succeed at certain challenges or that you can't improve your situation

Steps to cope with stigma

Here are some ways you can deal with stigma:

• Get treatment. You may be reluctant to admit you need treatment. Don't let the fear of being labeled with a mental illness prevent you from seeking help. Treatment can provide relief by identifying what's wrong and reducing symptoms that interfere with your work and personal life.
• Don't let stigma create self-doubt and shame. Stigma doesn't just come from others. You may mistakenly believe that your condition is a sign of personal weakness or that you should be able to control it without help. Seeking counseling, educating yourself about your condition and connecting with others who have mental illness can help you gain self-esteem and overcome destructive self-judgment.
• Don't isolate yourself. If you have a mental illness, you may be reluctant to tell anyone about it. Your family, friends, clergy or members of your community can offer you support if they know about your mental illness. Reach out to people you trust for the compassion, support and understanding you need.
• Don't equate yourself with your illness. You are not an illness. So instead of saying "I'm bipolar," say "I have bipolar disorder." Instead of calling yourself "a schizophrenic," say "I have schizophrenia."
• Join a support group. Some local and national groups, such as the National Alliance on Mental Illness (NAMI), offer local programs and internet resources that help reduce stigma by educating people who have mental illness, their families and the general public. Some state and federal agencies and programs, such as those that focus on vocational rehabilitation and the Department of Veterans Affairs (VA), offer support for people with mental illness.
• Get help at school. If you or your child has a mental illness that affects learning, find out what plans and programs might help. Discrimination against students because of a mental illness is against the law, and educators at primary, secondary and college levels are required to accommodate students as best they can. Talk to teachers, professors or administrators about the best approach and resources. If a teacher doesn't know about a student's disability, it can lead to discrimination, barriers to learning and poor grades.
• Speak out against stigma. Consider expressing your opinions at events, in letters to the editor or on the internet. It can help instill courage in others facing similar challenges and educate the public about mental illness.

Others' judgments almost always stem from a lack of understanding rather than information based on facts. Learning to accept your condition and recognize what you need to do to treat it, seeking support, and helping educate others can make a big difference.

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• StigmaFree me. National Alliance on Mental Illness. https://www.nami.org/Get-Involved/Take-the-stigmafree-Pledge/StigmaFree-Me. Accessed April 25, 2017.
• What is stigma? Why is it a problem? National Alliance on Mental Illness. https://www.nami.org/stigmafree. Accessed April 25, 2017.
• Stigma and mental illness. Centers for Disease Control and Prevention. https://www.cdc.gov/mentalhealth/basics/stigma-illness.htm. Accessed April 25, 2017.
• Sickel AE, et al. Mental health stigma: Impact on mental health treatment attitudes and physical health. Journal of Health Psychology. http://journals.sagepub.com/doi/pdf/10.1177/1359105316681430. Accessed April 25, 2017.
• Americans with Disabilities Act and mental illness. Womenshealth.gov. https://www.womenshealth.gov/mental-health/your-rights/americans-disability-act.html. Accessed April 25, 2017.
• Picco L, et al. Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and self-esteem. Psychiatric Research. 2016;246:500.
• The civil rights of students with hidden disabilities under Section 504 of the Rehabilitation Act of 1973. U.S. Department of Education. https://www2.ed.gov/about/offices/list/ocr/docs/hq5269.html. Accessed May 2, 2017.
• Wong EC, et al. Effects of stigma and discrimination reduction trainings conducted under the California Mental Health Services Authority. Rand Health Quarterly. 2016;5:9.

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State of Mental Health in America 2024

This report ranks all 50 states and the District of Columbia based on fifteen mental health prevalence and access measures for youth and adults. These measures are collected from federal data sources, including data from SAMHSA, the CDC, and the Department of Education. The data for the 2024 State of Mental Health in America report were gathered through 2022.

These rankings provide a baseline for answering some questions about how many people in America need and have access to mental health services.

This report also includes two policy spotlights – one on creating supportive communities through prevention and another on keeping people in communities with a focus on housing.

• Introduction
• Conclusions
• Article Information

Changes shown on attributions (A), preferences for social distance (B), and perceptions of dangerousness (C), by condition. Significant changes ( P  < .05) from one wave to the next (eg, 1996 to 2006) are indicated with heavy lines. Changes that were significant across the full time period (ie, 1996-2018), but not across successive waves, are indicated with a dashed line. All estimates are weighted. Data collected from the US National Stigma Studies. 12

The solid line provides the estimated trend across age groups (A), over time (B), and across cohorts (C). The shaded areas around the lines represent CIs, from light (95%) to dark (75%). Estimated cohort trends, which represent cohort-specific deviations from age and period trends, were obtained by averaging over all of the age-by-period combinations for a given cohort. For convenience, cohorts are indexed according to the first birth year in the birth cohort. The 1907 and 1917 cohorts were pooled to increase cell sizes. In all cases, higher values indicate a preference for greater social distance; lower values indicate the reverse. All estimates are weighted and adjust for respondents’ educational level, sex, and race and ethnicity, as well as the education, sex, and race and ethnicity of the person described in the vignette. Data collected from the US National Stigma Studies.

eMethods. Materials and Methods

eTable 1. Unadjusted Survey Year Differences

eTable 2. Adjusted Survey Year Differences

eTable 3. Model Fit of Candidate Models in APC Analyses

eTable 4. Deviation Magnitude Tests

eTable 5. Average Cohort Deviation Across Periods

eTable 6. Age and Period Main Effects

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Pescosolido BA , Halpern-Manners A , Luo L , Perry B. Trends in Public Stigma of Mental Illness in the US, 1996-2018. JAMA Netw Open. 2021;4(12):e2140202. doi:10.1001/jamanetworkopen.2021.40202

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Trends in Public Stigma of Mental Illness in the US, 1996-2018

• 1 Department of Sociology, Indiana University, Bloomington
• 2 Department of Sociology, Pennsylvania State University, University Park

Question   What changes in the prejudice and discrimination attached to mental illness have occurred in the past 2 decades?

Findings   In this survey study of 4129 adults in the US, survey data from 1996 to 2006 showed improvements in public beliefs about the causes of schizophrenia and alcohol dependence, and data from a 2018 survey noted decreased rejection for depression. Changes in mental illness stigma appeared to be largely associated with age and generational shifts.

Meaning   Results of this study suggest a decrease in the stigma regarding depression; however, increases and stabilized attributions regarding the other disorders may need to be addressed.

Importance   Stigma, the prejudice and discrimination attached to mental illness, has been persistent, interfering with help-seeking, recovery, treatment resources, workforce development, and societal productivity in individuals with mental illness. However, studies assessing changes in public perceptions of mental illness have been limited.

Objective   To evaluate the nature, direction, and magnitude of population-based changes in US mental illness stigma over 22 years.

Design, Setting, and Participants   This survey study used data collected from the US National Stigma Studies, face-to-face interviews conducted as 1996, 2006, and 2018 General Social Survey modules of community-dwelling adults, based on nationally representative, multistage sampling techniques. Individuals aged 18 years or older, including Spanish-speaking respondents, living in noninstitutionalized settings were interviewed in 1996 (n = 1438), 2006 (n = 1520), and 2018 (n = 1171). The present study was conducted from July 2019 to January 2021.

Main Outcomes and Measures   Respondents reacted to 1 of 3 vignettes (schizophrenia, depression, alcohol dependence) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , criteria or a control case (daily troubles). Measures included beliefs about underlying causes (attributions), perceptions of likely violence (danger to others), and rejection (desire for social distance).

Results   Of the 4129 individuals interviewed in the surveys, 2255 were women (54.6%); mean (SD) age was 44.6 (16.9) years. In the earlier period (1996-2006), respondents endorsing scientific attributions (eg, genetics) for schizophrenia (11.8%), depression (13.0%), and alcohol dependence (10.9%) increased. In the later period (2006-2018), the desire for social distance decreased for depression in work (18.1%), socializing (16.7%), friendship (9.7%), family marriage (14.3%), and group home (10.4%). Inconsistent, sometimes regressive change was observed, particularly regarding dangerousness for schizophrenia (1996-2018: 15.7% increase, P  = .001) and bad character for alcohol dependence (1996-2018: 18.2% increase, P  = .001). Subgroup differences, defined by race and ethnicity, sex, and educational level, were few and inconsistent. Change appeared to be consistent with age and generational shifts among 2 birth cohorts (1937-1946 and 1987-2000).

Conclusions and Relevance   To date, this survey study found the first evidence of significant decreases in public stigma toward depression. The findings of this study suggest that individuals’ age was a conservatizing factor whereas being in the pre–World War II or millennial birth cohorts was a progressive factor. However, stagnant stigma levels for other disorders and increasing public perceptions of likely violence among persons with schizophrenia call for rethinking stigma and retooling reduction strategies to increase service use, improve treatment resources, and advance population health.

Stigma, the prejudice and discrimination attached to devalued conditions, has been consistently cited as a major obstacle to recovery and quality of life among people with psychiatric disorders. 1 - 3 Stigma has been implicated in worsening outcomes for people with serious mental illness, 4 , 5 with nearly 40% of this population reporting unmet treatment needs despite available effective treatments. 6 , 7 Although some psychiatrists claim that stigma has decreased 8 or is irrelevant, 9 stigma remains concerning to health care professionals, patients, advocacy groups, and policy makers. Research has not supported claims of a decrease in stigma. 3 Moreover, national levels of public stigma have been associated with treatment-seeking intentions and experiences of discrimination reported by people with mental illness. 10 , 11 Findings on antistigma interventions also reflect the persistence of stigma 3 , 12 , 13 ; the unclear, limited, or short-term effectiveness of both large-scale messaging and small-scale interventions 12 - 16 ; and the lack of scalability of many such programs. Herein, we examine US public stigma over a 22-year period to provide a detailed assessment of changes in the nature and magnitude of public stigma over 2 decades for major mental health disorders.

The US National Stigma Studies (US-NSSs) use the General Social Survey (GSS), a biannual, household-based, multistage, cluster-sampled interview project providing nationwide, representative data on adults (age ≥18 years) living in noninstitutionalized settings in the continental US. 12 Face-to-face interviews for the US-NSSs were conducted by trained interviewers using the pencil/paper mode in 1996 (n = 1444; response rate, 76.1%) and computer-assisted personal interview format in 2006 (n = 1522; response rate, 71.2%) and 2018 (n = 1173; response rate, 59.5%). The GSS follows the American Association for Public Opinion Research ( AAPOR ) reporting guideline, which the present study followed. Mode effects, tested between 1996 and 2006, were minimal 17 and analyses to identify potential biases resulting from changing response rates did not identify problems. 18 Weights are provided and used where appropriate. Respondents receive an information page in English/Spanish and are asked for their consent to begin the interview. Institutional review board approval for the GSS and this study is held at NORC and at Indiana University. The present study was conducted from July 2019 to January 2021.

The US-NSSs used a survey experimental design using vignettes describing a fictitious person with behaviors meeting Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition 19 criteria for schizophrenia, major depression, alcohol dependence, and a daily troubles control (eMethods in the Supplement ). 20 , 21 This vignette strategy avoids identifying the nature of the problem, allowing for data collection on knowledge, recognition, and labeling by respondents. 20 , 21 The vignette character’s psychiatric condition as well as their self-reported sex (man or woman), race (African American, Hispanic, or White), and educational level (eighth grade, high school, or college) were randomly varied and assigned as experimental characteristics in the stimulus. These data were not reported or collected in the interview. One vignette per respondent was read aloud by the interviewer and printed on a card given to the respondent who was then asked a series of questions.

Three sets of dependent variables operationalized stigma. First, attributions targeted respondents’ evaluation of likely scientific causes (chemical imbalance and genetics) as well as their recognition of the situation as a mental illness. Other potential moral/social explanations (bad character, God’s will, ups and downs of life, and way raised [all coded 1 if very/somewhat likely; 0 otherwise]) were also included. Second, dangerousness asked about the likelihood that the vignette person would do something violent toward others (coded 1 if very/somewhat likely; 0 otherwise). Third, social distance, the most common measure of stigma, measured respondents’ unwillingness to work closely with the vignette person on a job, live next door to them, spend an evening socializing with them, marry into their family, make friends with them, or live near a group home (categories collapsed into not willing/do not know [1] or willing [0]); details are reported in eTable 1 in the Supplement . Additional analyses used an overall social distance, factor-analytic scale for depression (1-factor solution, factor loadings ranging between 0.47 and 0.80, Cronbach α = .85).

Statistical analyses evaluated changes across years. Because data were weighted, a design-based F statistic that used the second-order Rao and Scott 22 correction was used to test the equality of raw percentages. To adjust for possible sociodemographic shifts between survey years and examine disparities, logistic regression models were fit. Differences in the estimated probabilities for outcomes were calculated, holding control variables at sample-specific means. The delta method was used to determined 95% CIs. To explore subgroup differences in trends, we fit a series of regression models that included interactions between time periods and respondents’ sociodemographic characteristics. Model estimates were used to calculate estimated probabilities of preferring social distance at each time point (1996, 2006, and 2018) and for each group (eg, men vs women), as well as group-specific changes over time and group differences in trends. Owing to the population representation of racial and ethnic groups in the US population, African American and Hispanic groups were collapsed into a non-White category in the subgroup analysis to avoid estimation problems within the vignette-specific analyses. Variance estimates were again obtained via the delta method. In addition, an exploratory age, period, and cohort analysis applied the age-period cohort (APC)–I method of Luo and Hodges 23 to assess the unique contribution of birth cohorts to overall trends in the preferences of US residents for social distance. Aligned with Ryder’s view that a cohort’s meaning is “implanted in the age-time specification,” 24 [p861] this approach quantifies cohort associations as the differential outcomes of time periods depending on age groups (eMethods in the Supplement ). Different from conventional APC models that assume cohort associations occur independently of period and age, the APC-I approach acknowledges the association of age, period, and cohort, as originally proposed by Ryder, which makes the approach useful for identifying factors that might be attributed to cohort membership. The total sample size of the individual-level APC analysis is 4134, with the number of participants per age-period combination ranging between 126 and 345. Hypothesis tests were all 2 sided. The APC analysis was carried out using R, version 3.6.2 (R Foundation for Statistical Analysis). The rest of the analysis—including data cleaning and variable transformations—was performed using Stata, version 16 (StataCorp LLC). Findings at P  < .05 were considered significant.

Table 1 provides the sociodemographic profile of US NSS respondents across the 3 survey periods: 1996 (n = 1438), 2006 (n = 1520), and 2018 (n = 1171). Representation of age, sex, race and ethnicity, and educational level were roughly in line with US Census Bureau data (1996: men, 642 [44.6%]; women, 796 [55.4%]; mean [SD] age, 44.7 [17.0] years; 2006: men, 666 [43.8%]; women, 854 [56.2%]; mean [SD] age, 46.7 [17.0] years; men, 566 [48.3%]; women, 605 [51.7%]; mean [SD] age, 49.0 [17.4] years). The slight overrepresentation of women across time has been commonly seen in interview studies. The GSS did not collect specific ethnicity data until 2000; from then, race and ethnicity categories comprised non-White (2006: 425 [28.0%]; 2018: 322 [27.5%]) and White (2006: 1095 [72.0%]; 2018: 849 [72.5%]) individuals. Overall mean (SD) age was 44.6 (16.9) years.

Figure 1 depicts unadjusted changes across survey waves. Adjusted changes reveal few differences compared with unadjusted results and are reported here (eTable 2 in the Supplement ). Scientific attributions (chemical imbalance, genetics) were high and selected by increasing percentages of US residents, with the major increase occurring in the first period (1996-2006). Overall, in the earlier period (1996-2006), scientific attributions (eg, genetics) for schizophrenia (11.8%), depression (13.0%), and alcohol dependence (10.9%) increased. The only case in which public endorsement was lower than 50%, but still substantial, was for the control situation: daily troubles ( Figure 1 A; eTable 1 in the Supplement ). These results may suggest a medicalization of life problems. However, this early significant increase in the category of chemical imbalance was followed by a decrease later.

Although problem recognition increased only for schizophrenia in the first period and for alcohol dependence only in the second period, the levels were high for all mental illnesses. No change was documented for depression, with recognition already high, or for the control, in which depression was considered not warranted, signaling a distinct difference in the public response to nonclinical problems ( Figure 1 A).

Social and moral attributions were endorsed by relatively few respondents with little change over time ( Figure 1 A). Significantly fewer respondents cited ups and downs as a cause of depression or selected God’s will. The latter choice decreased significantly in the first period for daily troubles, even as the way an individual was raised increased significantly later. Alcohol dependence, however, was increasingly stigmatized, marked by significant change in respondents simultaneously citing bad character (18.2%) and ups and downs of life (11.3%) (eTable 2 in the Supplement ). Overall, trends suggest increasing mental health literacy, including distinguishing between daily problems and mental illness.

Social distance showed little change over time, except for depression ( Figure 1 B). In the later period (2006-2018), the desire for social distance decreased for depression in work (18.1%), socializing (16.7%), friendship (9.7%), family marriage (14.3%), and group home (10.4%) (eTable 2 in the Supplement ). For depression, the decreases were statistically significant and substantial. Reductions occurred in the later period, spanning all domains except neighbor, which was already low. Other minor changes in a direction indicating a higher stigma were in evidence early. This change included an increase in social distance for schizophrenia as neighbor and having the vignette person marry into the family ( Figure 1 B; eTable 2B in the Supplement ).

Inconsistent, sometimes regressive change, was observed, particularly regarding dangerousness for schizophrenia ( Figure 1 C) (1996-2018: 15.7% increase, P  ≤ .001) and bad character for alcohol dependence (1996-2018: 18.2% increase, P  ≤ .001).

The similarity between unadjusted and adjusted results suggests that sociodemographic characteristics offer little power in explaining stigma. Table 2 reports the results of analyses of subgroup factors for race and ethnicity, sex, age, and educational attainment (vignette person characteristics controlled). There were no significant differences in the overall time trends for sociodemographic groups, but a few associations were observed within periods. More men endorsed stigma (ie, in the most recent period for socializing, in the middle period for neighbor, and in the earliest period for friendship and group home support) compared with women. More respondents who self-reported race as non-White desired social distance from individuals with depression as neighbors in the most recent period.

The most consistent sociodemographic association was noted with age. Older individuals in each period were significantly more unwilling to have the vignette person marry into the family. This response did not change over time. In addition, more individuals with lower levels of education endorsed stigma in the most recent period (neighbor) and the middle period (marriage into the family).

In Figure 2 , a composite social distance scale depicts possible explanations of the stigma decrease for depression (eTables 3-6 in the Supplement ). Age and social distance appeared to be conservatizing factors ( Figure 2 A). Distinct period responses were noted, especially from 2006 to 2018, when stigma toward depression decreased significantly (Figure 2B). Two cohorts were more likely than expected to report lower stigma—the Silent Generation (part of the 1937-1946 birth cohort, after the Greatest Generation but before the Baby Boomers) and Millennials (1987-2000 birth cohort) ( Figure 2 C). The average deviation for the 1937-1946 birth cohort was −0.12 (SE, 0.05) ( P  = .02), and the average deviation for the 1987-2000 birth cohort was−0.21 (SE, 0.08) ( P  = .01) (eTable 5 in the Supplement ).

Our analyses identified both stability and change in stigma over the 22-year period from 1996 to 2018. Five robust and clear patterns emerged. First, the period around the turn of the century (1996-2006) saw a substantial increase in the public acceptance of biomedical causes of mental illness. Survey participants were more likely to recognize problems as mental illness and draw a line between daily troubles and diagnosable conditions. These changes mark greater scientific beliefs and a decrease in stigmatizing attributions, but no reduction in social rejection. Overall, trends suggest increasing mental health literacy, including distinguishing between daily living problems and mental illness, aligning with earlier research. 25 , 26 Second, the more recent period (2006-2018) documented, to our knowledge, the first significant, substantial decrease in stigma, albeit for one mental illness diagnosis: major depression. Fewer survey respondents expressed a desire for social distance from people with depression across nearly all domains, including work and family. Considered in the context of previous research, these decreases are statistically significant, substantively large, and persist in the presence of controls. Other disorders did not see reductions in social distance, and public perceptions of dangerousness for schizophrenia and moral attributions for alcohol dependence increased.

Third, respondents’ sociodemographic characteristics offered little insight into stigma, generally, or into observed decreases for depression. What is unusual about these findings is the absence of subgroup differences, suggesting a broad shift in the respondents’ thinking about depression. This absence of sociodemographic differences may be unexpected, but it supports findings from earlier NSSs. 10 , 27

Fourth, change over time may be associated with age as a conservatizing factor, 28 , 29 a cohort process in which older, more conservative individuals are replaced by younger, more liberal US residents, 29 , 30 and/or a period outcome stemming from broad shifts that are uniformly seen regarding social distance discriminatory predispositions across age and cohort. Although prior research tended to assume the observed trends primarily reflect a period-based process, we used the APC-I method to explore unique cohort patterns in public stigma of mental illness. Disaggregating the effects of age, period, and cohort revealed age as a conservatizing factor also seen in a parallel German study, 12 and a liberalizing tendency among both pre-WWII birth cohorts (referred to by demographers as the Silent Generation) and the most recent birth cohorts (Millennials), and a recent period outcome.

Fifth, although findings for depression are notable, other results may raise concerns. For schizophrenia, there has been a slow shift toward greater belief of dangerousness. Although not statistically significant in either of the time periods, the increase was substantial and relatively large over the entire period (approximately 13%), a finding analyzed in detail elsewhere. 31 The results for alcohol dependence are similarly mixed. Although there was an increase in the selection of alcohol dependence as a mental illness with chemical and genetic roots, the problem was also trivialized as ups and downs. Moreover, we observed a return to a moral attribution of bad character in the first period that remain stable into the second period.

This study has limitations. Responses to survey vignettes reflect attitudes, beliefs, and predispositions—not behavior. The lack of importance of sociodemographic characteristics may signal insensitivity in a vignette approach or in stigma measurement. 32 - 34 Although subgroup differences are widely believed to exist, such research is rare and often not generalizable. Yet, although our estimates of sociodemographic outcomes are somewhat inefficient owing to sample size constraints, power analyses indicate that they are adequately powered to detect very small effects overall (Cohen h = 0.12), and small to moderate associations within vignette condition (Cohen h = 0.25) (eMethods in the Supplement ). In addition, our vignettes are designed to capture public perceptions of behavior changes that typically occur with the onset of mental illness. Public response might differ if the vignettes included information about help-seeking and eventual recovery. Research that specifically targeted this limitation revealed a small but statistically significant lowering of public stigma when vignette persons were described as being in treatment or recovery. 35

Other limitations must also be considered. Decreasing response rates present a challenge to researchers who seek to model trends over time in attitudes or behaviors. As noted, GSS response rates decreased approximately 16% over the 22-year period in question. If GSS respondents were somehow increasingly selected on tolerance for individuals with mental illness, finding stigma change would be likely even in the absence of actual change. This explanation seems unlikely given our results. We found respondents’ attitudes toward mental illness were more accepting in some cases (eg, depression), but less accepting in others (eg, schizophrenia). Even for depression, in which change was found across social venues, the degree to which that happens varied greatly. If findings were an artifact of a simple sample selection process, we would not expect to observe this level of complexity. Trends over time would be more consistent across conditions, and differences between social domains would be less pronounced.

Equally important, although it may be tempting to associate the changes in mental health literacy in the earlier period with the stigma reduction for depression in the latter period, doing so would be premature. These data cannot support claims about lag effects owing to the GSS’s cross-sectional design. In addition, previous work, which examined this issue in detail in the earlier period alone, could document neither individual nor aggregate associations between accepting scientific attributions for mental illness and stigma levels. 10

Despite limitations, these findings have important implications for research and treatment as well as antistigma program and policy efforts. First and foremost, the results of this study suggest that public stigma can change. To our knowledge, this study is one of the first indications that revise the larger cultural climate of prejudice and discrimination without the coordinated, translational, and research-monitored program of stigma reduction used in other Western nations. 3 , 12 , 13 Research and antistigma efforts require content retooling to make use of what is known and address the most problematic and unique aspects of stigma. In the US, controversial and structural aspects of mental illness stigma have rarely been addressed. Not only are perceptions of violence increasing for schizophrenia, individuals with schizophrenia likely face the greatest resistance in dismantling public, legal, policy, treatment, and resource barriers. Furthermore, calls for tailoring efforts to diverse or specialized populations may be limited by a thin, unrepresentative, and contradictory scientific base. 36 , 37 Data gaps in our analysis signal the need for novel stigma targets in research, whether new measures or populations widely believed to hold distinct ideas about mental illness and stigma. Our results also raise questions on how the progress reported herein can be accelerated and regressive shifts reversed. These results suggest that we must be realistic because societies change slowly and change efforts must be persistent and sustainable. Randomized clinical trial–based antistigma research often reports positive findings in typical inoculation-style programs but confronts effects that are extinguished over time. 3 , 38

The NSSs have served as the de facto primary data source about public stigma in the US for the past 2 decades. In this analysis of 22 years of survey data, we found a significant decrease in public stigma toward major depression and increased scientific attribution for schizophrenia, major depression, and alcohol dependence. Our findings are consistent with the claims of Braslow et al 5 that what the public believes and knows often aligns with science (ie, increasing agreement with scientific attributions) but may fail to influence their attitudes and behavior (ie, desire for social distance from individuals with mental illness, except depression). The societal and individual effects of stigma are broad and pervasive. Stigma translates into individual reluctance to seek care, mental health professional shortages, and societal unwillingness to invest resources into the mental health sector. Yet, the research, teaching, and programming resources targeted to redress prejudice and discrimination remain a low priority, small in scale, and individually focused. 39 With indications that the level of stigma may be reducing, strategies to identify factors associated with the decrease in stigma for depression, to address stagnation or regression in other disorders, and to reach beyond current scientific limits are essential to confront mental illness’s contribution to the global burden of disease and improve population health.

Accepted for Publication: October 27, 2021.

Published: December 21, 2021. doi:10.1001/jamanetworkopen.2021.40202

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Pescosolido BA et al. JAMA Network Open .

Corresponding Author: Bernice A. Pescosolido, PhD, Department of Sociology, Indiana University, 1022 E Third St, Bloomington, IN 47401 ( [email protected] ).

Author Contributions: Drs Pescosolido and Halpern-Manners had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Pescosolido, Halpern-Manners, Luo.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Pescosolido, Halpern-Manners.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Halpern-Manners, Luo.

Obtained funding: Pescosolido, Perry.

Administrative, technical, or material support: Pescosolido, Perry.

Supervision: Pescosolido.

Conflict of Interest Disclosures: Dr Luo reported receiving grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: Support for the study was provided by the Brain & Behavior Research Foundation (formerly National Alliance for Research on Schizophrenia & Depression) Distinguished Investigator Award and from Indiana University Network Science Institute (Dr Pescosolido), and base support and supplement from the National Science Foundation to the National Opinion Research Center (NORC) for the General Social Survey (GSS) and the National Stigma Studies.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: All GSS data are available from NORC ( https://gss.norc.org ) and the GSS data explorer ( https://gssdataexlporer.norc.org ).

Additional Contributions: We thank Alejandra Laszlo Capshew, MS (Indiana Consortium for Mental Health Services Research), who assisted with project management; the College of Arts and Sciences and the Sociomedical Sciences Research Institute at Indiana University provided infrastructural support; and Tom W. Smith, PhD, and Jaesok Son, PhD (NORC at the University of Chicago), provided project assistance as key members of the NORC GSS Team. No financial compensation was provided.

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The Difference Between Stigma vs. Stereotype

• Stigma vs. Stereotype

Examples of Stigma

• Cultural Perpetuation
• Consequences

Frequently Asked Questions

The terms " stigma " and "stereotype" are often used to describe negative behaviors in society that are directed towards specific groups of people. When a certain thing is attached to a stigma, it is associated with feelings of shame.

Stigmas are often driven by negative stereotypes, which are oversimplified and popular beliefs or ideas about a particular group of people or persons that are often untrue or only partially true.

In society, stigmas and stereotypes are often involved in shaming or discriminating against people who have a mental illness , certain disabilities, or are a part of a certain sexuality, race, or religion.

Both stereotypes and stigmas can have powerful holds on society as a whole and can leave a mark on certain people or groups that leave them feeling ashamed or in danger for simply being.

Read on to find out more about stigmas and stereotypes and how they differ from one another.

Stigma vs. Stereotype Definitions 

The Oxford dictionary defines stigma as, “a mark of disgrace associated with a particular circumstance, quality, or person.”

The Oxford Dictionary defines a stereotype as, “a widely held but fixed and oversimplified image or idea of a particular type of person or thing.”

While the two definitions seem similar, and they are, there are some marked differences between the two.

A stigma is always negative and develops because of a stereotype. Stereotypes, although often wrong or partially wrong, aren’t always negative. Although stereotypes can be positive, they are still problematic because they "other" people, don't allow people to be seen as individuals, and box people into certain expectations.

Examples of stigma include:

• Using labels to exclude certain persons or groups of people
• Assuming that persons with mental health conditions are dangerous
• Thinking that people with physical health conditions are unable to contribute to society
• Making negative assumptions about a person's intelligence or behavior based on a physical or mental health condition or race, ethnicity, religion, etc.

Examples of stereotypes (which may not always be negative) include:

• Presuming that people who wear glasses are smart
• Thinking that women are naturally nurturing
• Believing that Asian-Americans are smart
• Assuming that teachers and nurses are women and that doctors and engineers are men

The Development of Stigmas and Stereotypes

Stigmas are underlined by stereotypes, so they typically develop after a stereotype has been widely accepted.

Discrimination 

According to the American Psychiatric Association, stigmas that develop because of perpetuated stereotypes can lead to discrimination.

Discrimination is the unfair treatment of groups of people because of held beliefs surrounding their health status, sex, age, or race.

Discrimination can be both direct and indirect and can come in the form of:

• Excluding certain groups of people from things such as rental housing, employment, or other services.
• Imposing extra measures on certain groups of people that do not apply to the rest of the general population.

Direct discrimination occurs when done directly from one person to a specific group of people; indirect discrimination takes place when a person is discriminatory on behalf of someone else.

For example, a person who owns a rental property excludes a person with a disability from living at the property. That is a form of direct discrimination. A manager of a rental property that has been told to screen people with disabilities is an example of indirect discrimination.

Another example of discrimination is when an older adult applies for a job that they are qualified for. Since they are older than other candidates, the employer decides to hire someone with fewer qualifications because they are younger. That is a form of age discrimination.

Cultural Perpetuation 

Cultural perpetuation is a way in which certain stigmas and stereotypes continue to pass from one generation to the next. This type of perpetuation of certain long-held beliefs or notions surrounding stigmas and stereotypes is what gives them their longevity.  

How Does Cultural Perpetuation Advance Stereotypes?

The longer a culture supports a specific stereotype or stigma, the more staying power it has.

Studies suggest that stereotypes are perpetuated because of the cultural schema theory, which is a theory based on the idea that people use certain classifications to help them understand cultures other than their own.

When they do this with misinformation that they have been taught about specific groups of people, they keep the cycle of stereotypical discrimination going.

The idea of cultural schema can also be used to help people justify certain negative experiences they’ve had because they connect them to long-held negative stereotypical beliefs.    

What Are the Consequences of Stigma and Stereotypes?

The vast collection of stigmas and stereotypes still prevalent in society leads to negative consequences for the people and groups involved. These consequences range depending on the group being stigmatized and the result of the discrimination.

On Marginalized Groups 

Marginalized populations are groups of people who are continuously subjected to discrimination and exclusion because of who they are. Some examples of marginalized groups include:

• People who belong to the lesbian, gay, bisexual, transgender, questioning, queer, intersex, pansexual, two-spirit (2S), androgynous and asexual (LGBTQQIP2SAA) community
• Black, Indigenous, and people of color
• Older adults
• People with disabilities or chronic health conditions
• Those who have immigrated to the United States
• People who do not speak English or have learned English as a second language
• People who fall into a low-income category

These groups are marginalized because there is an uneven distribution of power between social groups and that is largely due to stereotypical beliefs and stigmas. The consequences of this power imbalance lead to many challenges and discrepancies, such as:

• Less emotional support
• An increase in negative interactions within society
• Higher rates of substance abuse
• An increased risk of both psychological and physiological disease or illness
• Higher rates of suicide

Around Mental Health 

The stigma surrounding mental health has been slowly decreasing in recent years, however, it is still strong and those with mental health issues are still subject to discrimination. Because of this, people with mental health issues can experience:

• A reduced sense of hope
• Lower self-esteem
• An increase in their symptoms
• Difficulties maintaining social relationships accompanied by social isolation
• A lessened chance that they will stick to their treatment plan or seek help for their disorder
• Difficulties in the workplace or issues finding opportunities to participate in gainful employment, studies, or school activities
• Physical violence or harassment
• An inability to access health insurance that covers the cost of their treatment

Self-Stigma and Mental Illness

Because of the societal stigma attached to mental health disorders, many people with psychiatric disorders often self-stigmatize. This means that they have a negative attitude towards themselves. Having self-stigmatizing attitudes have been shown to decrease a person's likelihood of recovering from their mental illness.  

Around Substance Abuse 

Many people with addiction or substance abuse disorder often find themselves heavily stigmatized. People look down on those who use substances, and because of this, certain consequences plague people with addiction. They can include:

• Having a more difficult time reaching out for help out of fear of being judged or getting into trouble
• Hiding their use of drugs or using alone which can be dangerous
• A lowered quality of life because it can be more challenging to find housing or a job
• Having a difficult time getting proper health care

When people suffer from addiction, they can experience three types of stigma: self, social, and structural.

Self-stigma is when they begin to have negative attitudes towards themselves which can increase drug use, cause low-self-esteem, and avoid reaching out for help. Social stigma comes from outside sources and often leads to self-stigma.

Structural is imposed on people with addiction by healthcare providers, people who offer social services, workplaces, and government organizations. All three types cause the aforementioned consequences.

Advocating Against Negative Stigma 

Many things can be done to help reduce stigma across different groups. Becoming an ally with groups that experience stereotypical discrimination is the first step in understanding how they are affected and what needs to be done to change how society views certain communities.

What the Law Says 

There are various laws in place that are designed to keep discrimination from occurring, but that doesn’t mean that it doesn’t still happen.

For example, the Americans with Disabilities Act was developed to help protect people with disabilities from discrimination. That being said, not all laws that are in place to end stigma and discrimination based on stigma are adhered to all of the time.

What You Can Do to Stop Stigma and Discrimination 

Several things can be done to help reduce stigma:

• Educational programs: Anti-stigma education interventions can present factual information to a wide audience to help reduce the stigma that surrounds a certain group of people.
• Mental Health Literacy Campaigns: Similar to the educational program strategy, mental health literacy campaigns aim to implement the sharing of mental health information to help positively change society’s knowledge and attitude towards those with mental illnesses.
• Contact: People with stereotypical views rarely come into contact with the people who are a part of the group being stigmatized in their minds. To reduce stigma, people have to overcome the divide and spend more time with those in stigmatized groups.
• Protest and Advocacy: Protests have been highly effective strategies for civil rights changes. Participating in peaceful protests with those who have experienced discrimination and their allies can help you impose change at the grassroots level. 

Stigmas and stereotypes are still rampant in the United States. Although the two are not the same thing, they both develop into discriminatory behaviors towards people who do not deserve it.

While there is change to be made, some groups that have been stigmatized for much of modern history are beginning to see the tides change. The way to ensure that progress continues to be made is by becoming an ally and lawful advocate.

There are three main types of stigma: self, social, and structural. Self-stigma occurs when a person is convinced that the negative beliefs of others are valid and begins to see themselves in the way that those who stigmatize them do. Social is when society stigmatizes an individual or group of people as a whole, causing feelings of shame. Finally, structural stigmas are perpetuated by workplaces, social services, and healthcare providers. These can be the most damaging because they often lead people to refrain from seeking help.

While a stigma is always negative, stereotypes are not. They can be both positive and negative. That being said, both negative and positive stereotypes can have negative consequences because they are often untrue.

Stereotypes influence the development of stigmas and stigmas influence discrimination. While the three are different in definition, they are all closely tied together. You cannot have a stigma without a perpetuated stereotype. 

People most often hear about mental disorders being highly stigmatized, but they are not the only health condition that is attached to negative beliefs and attitudes. Other disorders that are or have been heavily stigmatized include HIV/AIDS, tuberculosis, epilepsy, substance use disorders, and venereal diseases.

Campellone TR, Caponigro JM, Kring AM. The power to resist: the relationship between power, stigma, and negative symptoms in schizophrenia. Psychiatry Res. 2014;215(2):280-285. doi:10.1016/j.psychres.2013.11.020

Turan JM, Elafros MA, Logie CH, et al. Challenges and opportunities in examining and addressing intersectional stigma and health .  BMC Med . 2019;17(1):7. doi:10.1186/s12916-018-1246-9

Better Health Channel. Stigma, discrimination and mental illness .

Planned Parenthood. What are gender roles and stereotypes?

American Psychiatric Association. Stigma, prejudice, and discrimination against people with mental illness.

Ontario Human Rights Commission. 10. Forms of Discrimination.

Hunzaker MBF. Making sense of misfortune: cultural schemas, victim redefinition, and the perpetuation of stereotypes.   Social Psychology Quarterly . 2014;77(2):166-184. doi:10.1177/0190272514521219

Sevelius JM, Gutierrez-Mock L, Zamudio-Haas S, et al. Research with marginalized communities: challenges to continuity during the COVID-19 pandemic. AIDS Behav. 2020;24(7):2009-2012. doi:10.1007/s10461-020-02920-3

Baah FO, Teitelman AM, Riegel B. Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health—An integrative review .  Nursing Inquiry . 2019;26(1):e12268. doi:10.1111/nin.12268

Hochhauser S, Rao S, England-Kennedy E, Roy S. Why social justice matters: a context for suicide prevention efforts. Int J Equity Health. 2020;19(1):76. doi:10.1186/s12939-020-01173-9

Oexle N, Müller M, Kawohl W, et al. Self-stigma as a barrier to recovery: a longitudinal study. Eur Arch Psychiatry Clin Neurosci. 2018;268(2):209-212. doi:10.1007/s00406-017-0773-2

Government of Canada. Stigma around drug use.

Kane JC, Elafros MA, Murray SM, et al. A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries . BMC Med. 2019;17(1):17. doi:10.1186/s12916-019-1250-8

By Angelica Bottaro Bottaro has a Bachelor of Science in Psychology and an Advanced Diploma in Journalism. She is based in Canada.

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COVID-19 and Mental Health

What is covid-19.

COVID-19 is a disease caused by a virus named SARS-CoV-2. COVID-19 most often affects the lungs and respiratory system, but it can also affect other parts of the body. Some people develop post-COVID conditions, also called  Long COVID  . These symptoms can include neurological symptoms such as difficulty thinking or concentrating, sleep problems, and depression or anxiety.

Why is NIMH studying COVID-19 and mental health?

Both SARS-CoV-2 and the COVID-19 pandemic have significantly affected the mental health of adults and children. Many people experienced symptoms of  anxiety ,  depression , and substance use disorder during the pandemic. Data also suggest that people are more likely to develop mental illnesses or disorders in the months following COVID-19 infection. People with Long COVID may experience many symptoms related to brain function and mental health  .

While the COVID-19 pandemic has had widespread mental health impacts, some people are more likely to be affected than others. This includes people from racial and ethnic minority groups, mothers and pregnant people, people with financial and housing insecurity, children, people with disabilities, people with preexisting mental illnesses or substance use problems, and health care workers. 

How is NIMH research addressing this critical topic?

NIMH is supporting research to understand and address the impacts of the pandemic on mental health. This includes research to understand how COVID-19 affects people with existing mental illnesses across their entire lifespan. NIMH also supports research to help meet people’s mental health needs during the pandemic and beyond. This includes research focused on making mental health services more accessible through telehealth, digital tools, and community-based interventions.

NIMH is also working to understand the unique impacts of the pandemic on specific groups of people, including people in underserved communities and children. For example, NIMH supports research investigating how pandemic-related factors, such as school disruptions, may influence children’s brain, cognitive, social, and emotional development.

Where can I learn more about COVID-19 and mental health?

• NIMH video: Mental Illnesses and COVID-19 Risks
• NIMH Director’s Messages about COVID-19
• NIMH events about COVID-19
• NIMH news about COVID-19

Where can I learn more about Long COVID and COVID-19?

• NIH page on Long COVID 
• NIH RECOVER Initiative  
• CDC COVID-19 resources 

How can I find help for mental health concerns?

If you have concerns about your mental health, talk to a primary care provider. They can refer you to a qualified mental health professional, such as a psychologist, psychiatrist, or clinical social worker, who can help you figure out the next steps. Find tips for talking with a health care provider about your mental health.

You can learn more about getting help on the NIMH website. You can also learn about finding support  and locating mental health services  in your area on the Substance Abuse and Mental Health Services Administration (SAMHSA) website.

Last Reviewed:  May 2024

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Study finds large gaps in mental health care for people with chronic pain

Millions of people with chronic pain fall into gaps in the mental health care system when it comes to treating symptoms of anxiety and depression, according to new research from the Comprehensive Center for Pain & Addiction.

A new University of Arizona Health Sciences study found that adults with chronic pain are more likely to experience symptoms of anxiety and depression than people without chronic pain, yet they access mental health care at lower rates and are less likely to have their mental health needs met in treatment. 

In 2021, approximately 51.6 million U.S. adults experienced chronic pain, according to the Centers for Disease Control and Prevention. The study showed that while people living with chronic pain represent 20.4% of the U.S. adult population, they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms. 

“People living with chronic pain may form a distinct population with special mental health care needs,” said lead author Jennifer S. De La Rosa, PhD , strategy director for the U of A Health Sciences Comprehensive Center for Pain & Addiction , which funded the study. “Improving outcomes for people with chronic pain will include connecting more people to mental health care, as well as increasing the availability of mental health care that is responsive to their needs.” 

Jennifer De La Rosa, PhD, is the strategy director for the University of Arizona Health Sciences Comprehensive Center for Pain & Addiction and an assistant research professor at the College of Medicine – Tucson’s Department of Family and Community Medicine.

Photo by Noelle Haro-Gomez, U of A Health Sciences Office of Communications

The paper, “The unmet mental health needs of U.S. adults living with chronic pain,” was recently published in the journal PAIN .

This study builds on previous Comprehensive Center for Pain & Addiction research that found 1 in 20 U.S. adults have a combination of chronic pain and symptoms of anxiety or depression, and adults living with chronic pain are approximately five times more likely to have untreated symptoms of anxiety or depression compared to those not living with chronic pain.

The new study examined the degree to which people with chronic pain and mental health symptoms accessed and benefitted from mental health treatment. The research team analyzed data from 31,997 people who participated in the National Health Interview Survey, which has been identified as the best single source for the surveillance of chronic pain.

Researchers identified chronic pain-associated disparities in three areas: the need for mental health treatment; the use of mental health treatment; and the success of treating anxiety and depression symptoms when mental health treatment was used.

They found that 43.2% of U.S. adults living with chronic pain – approximately 21.5 million people – had a mental health need. By comparison, mental health care needs were identified in only 17.4% of U.S. adults who do not have chronic pain.

Among all U.S. adults with mental health treatment needs, chronic pain was associated with a 40.3% reduction in the odds of using mental health treatment.

“For those with chronic pain, the narrative about what needs to be done to address mental health is qualitatively different than for those who don’t have chronic pain,” said De La Rosa, who is an assistant research professor in the  U of A College of Medicine – Tucson’s Department of Family and Community Medicine . “Improving health care for people with chronic pain includes not only connecting people to care, but also addressing a disproportionate failure to achieve relief, even in the context of caregiving."

Researchers found that when mental health treatment is used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms.  

The study team found that only 44.4% of people with chronic pain, an estimated 9.5 million people, used mental health services and had their anxiety and depression symptoms adequately treated compared with 71.5% of those without chronic pain. When mental health treatment was used, U.S. adults with chronic pain are more than twice as likely as others to experience continuing anxiety or depression symptoms. 

People living with chronic pain represent 20.4% of the U.S. adult population, yet they make up an estimated 55.5% of U.S. adults with clinically significant anxiety and depression symptoms.

“There are many possible reasons an individual with chronic pain might have suboptimal mental health experiences, including the accessibility of care and the feasibility of attending appointments,” De La Rosa said. “Additionally, few mental health providers are trained in chronic pain, so only a small percentage of people living with chronic pain are likely receiving mental health treatment that is designed to address their needs. By further examining the role chronic pain plays in our national mental health crisis, we have a potentially transformative scientific and policy opportunity to build the United States health care system’s capacity to address co-occurring chronic pain and mental health challenges.”

“This study identified a significant gap in meeting the mental health needs of people who live with chronic pain,” said senior author  Todd Vanderah, PhD , director of the Comprehensive Center for Pain & Addiction, Regents Professor and head of the  Department of Pharmacology  in the U of A College of Medicine – Tucson and a BIO5 Institute member. “Our goal at the Comprehensive Center for Pain & Addiction is to use this information to reimagine and transform health care for chronic pain. By recognizing and treating the co-occurrence of anxiety and depression symptoms and chronic pain, we can empower millions of people affected by pain to thrive.”

Other co-authors from the Comprehensive Center for Pain & Addiction include Medical Director Mohab Ibrahim, MD, PhD , professor of  anesthesiology  at the College of Medicine – Tucson and director of the  Chronic Pain Management Clinic ; Policy Director Beth E. Meyerson, PhD, MDIV , professor of family and community medicine at the College of Medicine – Tucson; and members Alicia M. Allen, PhD , associate professor of family and community medicine at the College of Medicine – Tucson; Kyle Suhr, PhD , associate professor of psychiatry at the College of Medicine – Tucson; and  Benjamin R. Brady, DrPH . Other co-authors are doctoral student  Katherine E. Herder and  Jessica S. Wallace , a program evaluator in the College of Medicine – Tucson’s Department of Family and Community Medicine.

Jennifer S. De La Rosa, PhD     Assistant Research Professor, Department of Family and Community Medicine, College of Medicine – Tucson Strategy Director, Comprehensive Center for Pain & Addiction

Todd Vanderah, PhD Director, U of A Health Sciences Comprehensive Center for Pain & Addiction Regents Professor and Head, Department of Pharmacology, College of Medicine – Tucson Professor, Department of Anesthesiology, College of Medicine – Tucson Professor, Department of Neurology, College of Medicine – Tucson Member, BIO5 Institute

Related Stories

Study shows millions of people live with co-occuring chronic pain and mental health symptoms

Phil Villarreal Uof A Health Sciences Office of Communications 520-403-1986, [email protected]

Protecting athletes’ mental health from social media risks

A q&a with marcia faustin, sports medicine physician for the u.s. gymnastics team.

Recently, U.S. Surgeon General Vivek Murthy wrote an op-ed in the New York Times to raise the alarm about the impact social media is having on the mental health of our youth.

Athletes of all ages and levels are at risk of mental illness. To better understand the impact of social media on athletes’ mental wellbeing, we interviewed UC Davis family and sports medicine physician Marcia “Marcy” Faustin .

Faustin is the co-head physician for UC Davis Division 1 athletics and the U.S. Gymnastics Team. She has cared for star athletes like Simone Biles and Sunisa Lee and is headed to the Summer Olympics in Paris this month. Faustin also practices at the UC Davis Health Sports Medicine Clinic in Sacramento.

What do you advise athletes to do in terms of social media use around competitions?

I take care of athletes at all levels, from recreational sports to the young 4-5-year-old kiddos, all the way up to the collegiate level, and then at the Olympic level. Across the board, my message is to be mindful of how much time you spend on social media. For example, before you have a competition, it may not be the best idea to hear so many people's opinions about what can go wrong.

We advise them to really focus on their community and the people they trust. They can talk to them about their fears and concerns, their anxieties about the competition that appropriately are there. One strategy we try to implement is encouraging the athletes, even at the Olympic level, to take time to process their experience before getting on social media.

Who do athletes go to when they are facing online backlash or are being targeted?

They mainly go to their trusted sources. These may be their parents, teammates who understand what they're going through and coaches with whom they spend most of their time. They will also come to the medical staff, their athletic trainer or whoever that trusted person may be. Sometimes, if there is a need to escalate and for somebody to know to stop online bullying, then we can raise those concerns.

How can sports medicine physicians help athletes cope with the pressure from traditional media and social media?

First and foremost, it is important for sports medicine physicians to understand the significant impact that both traditional and social media can have on athletes. These athletes have significant pressure on them, especially those with more visibility. Unfortunately, people aren't always very kind.

We need to be aware and mindful of those negative impacts so we can help guide our patients through them.

Do you find any social media bias among athletes in terms of gender and race?

There are a lot of biases, whether that's racial and ethnic, sexual orientation or gender biases, to name a few. For example, individuals of minority backgrounds experience bias both in their everyday lives and on social media.

We know for women, there is the pushing of this ideal of what their bodies should look like, which can be more pronounced in certain sports. But we can't forget that men also face similar pressures to look a certain way.

How can athletes protect themselves from the pressure and negativity of social media and traditional media?

Athletes should be mindful of how much social media they absorb and how it can impact their emotions. It is important to set boundaries on how much time they spend on social media and at what time of day. They need to make sure not to allow social media use to take away from their everyday activities and self-care.

There are times when athletes are obligated to be present at press conferences. The managers, coaches and medical team play a role in reminding the athletes that they can decline questions or, if possible, choose to decline interviews.

We’ve seen athletes in different sports come out to talk about their mental health. Does it encourage people, especially athletes, to seek help when someone famous says they’re struggling or pulling out from a competition?

Vulnerability is powerful. It requires bravery, self-awareness and willingness to reveal yourself to help others around you feel less isolated. We've seen it across the NBA, NFL, Olympic sports and professional tennis, to name a few. When an athlete of that magnitude says, “It’s ok to not be ok,” it opens the door for others to do the same, which is beautiful. These stories lead to breaking down the stigma of mental illness. Progress is being made to destigmatize mental illness.

Is there something from a health care perspective that you would like reporters to know or wish they would be mindful of when interviewing these athletes?

Reporters play an important role in sharing an athlete’s story and influencing the audience perspective of that athlete. Encouraging training in aspects such as diversity, equity and inclusion or trauma may create a psychologically safer environment for athletes. In collaboration with sports medicine physicians, we proposed a few considerations for improving the interaction between the media and athletes.

You’re already in the Olympics with the team. How are you feeling about that?

I recently returned from an exciting and exhilarating USA Gymnastics Women’s and Men’s Olympic trials. We are now in Paris prepping for the Olympics.

It's exciting to return for a second Olympics and to help support these incredible athletes! They inspire the world with their talent in and out of the gym. It’s an honor and blessing to be a part of Team USA. Less than 2% of physicians are black females, so if I can inspire even one person to pursue a career in medicine, I’d call that a success.

Related Readings

• Faustin’s article: Media's Effect on Athletes' Mental Health
• Effect of media on the mental health of elite athletes
• Mental health resources for athletes
• Watch Faustin talk about her work with Team USA Women’s Gymnastics (video)

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• v.1(1); 2002 Feb

Understanding the impact of stigma on people with mental illness

Patrick w corrigan.

1 University of Chicago Center for Psychiatric Rehabilitation and Chicago Consortium for Stigma Research, 7230 Arbor Drive, Tinley Park, IL 60477, USA

AMY C WATSON

Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. As a result of both, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people. Although research has gone far to understand the impact of the disease, it has only recently begun to explain stigma in mental illness. Much work yet needs to be done to fully understand the breadth and scope of prejudice against people with mental illness. Fortunately, social psychologists and sociologists have been studying phenomena related to stigma in other minority groups for several decades. In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area.

The impact of stigma is twofold, as outlined in Table ​ Table1. 1 . Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination. Social psychologists view stereotypes as especially efficient, social knowledge structures that are learned by most members of a social group ( 1 - 3 ). Stereotypes are considered "social" because they represent collectively agreed upon notions of groups of persons. They are "efficient" because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group ( 4 ).

Comparing and contrasting the definitions of public stigma and self-stigma

The fact that most people have knowledge of a set of stereotypes does not imply that they agree with them ( 5 ). For example, many persons can recall stereotypes about different racial groups but do not agree that the stereotypes are valid. People who are prejudiced, on the other hand, endorse these negative stereotypes ("That's right; all persons with mental illness are violent!") and generate negative emotional reactions as a result ("They all scare me!") ( 1 , 3 , 6 ). In contrast to stereotypes, which are beliefs, prejudicial attitudes involve an evaluative (generally negative) component ( 7 , 8 ). Prejudice also yields emotional responses (e.g., anger or fear) to stigmatized groups.

Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioral reaction ( 9 ). Prejudice that yields anger can lead to hostile behavior (e.g., physically harming a minority group) ( 10 ). In terms of mental illness, angry prejudice may lead to withholding help or replacing health care with services provided by the criminal justice system ( 11 ). Fear leads to avoidance; e.g., employers do not want persons with mental illness nearby so they do not hire them ( 12 ). Alternatively, prejudice turned inward leads to self-discrimination. Research suggests self-stigma and fear of rejection by others lead many persons to not pursuing life opportunities for themselves ( 13 , 14 ). The remainder of this paper further develops examples of public and self-stigma. In the process, we summarize research on ways of changing the impact of public and self-stigma.

PUBLIC STIGMA

Stigmas about mental illness seem to be widely endorsed by the general public in the Western world. Studies suggest that the majority of citizens in the United States ( 13 , 15 - 17 ) and many Western European nations ( 18 - 21 ) have stigmatizing attitudes about mental illness. Furthermore, stigmatizing views about mental illness are not limited to uninformed members of the general public; even well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness ( 22 - 25 ).

Stigma seems to be less evident in Asian and African countries ( 26 ), though it is unclear whether this finding represents a cultural sphere that does not promote stigma or a dearth of research in these societies. The available research indicates that, while attitudes toward mental illness vary among non-Western cultures ( 26 , 27 ), the stigma of mental illness may be less severe than in Western cultures. Fabrega ( 26 ) suggests that the lack of differentiation between psychiatric and non-psychiatric illness in the three great non-Western medical traditions is an important factor. While the potential for stigmatization of psychiatric illness certainly exists in non-Western cultures, it seems to primarily attach to the more chronic forms of illness that fail to respond to traditional treatments. Notably, stigma seems almost nonexistent in Islamic societies ( 26 - 28 ). Cross-cultural examinations of the concepts, experiences, and responses to mental illness are clearly needed.

Several themes describe misconceptions about mental illness and corresponding stigmatizing attitudes. Media analyses of film and print have identified three: people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should be marveled; or they are responsible for their illness because they have weak character ( 29 - 32 ). Results of two independent factor analyses of the survey responses of more than 2000 English and American citizens parallel these findings ( 19 , 33 ):

• fear and exclusion: persons with severe mental illness should be feared and, therefore, be kept out of most communities;
• authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others;
• benevolence: persons with severe mental illness are childlike and need to be cared for.

Although stigmatizing attitudes are not limited to mental illness, the public seems to disapprove persons with psychiatric disabilities significantly more than persons with related conditions such as physical illness ( 34 - 36 ). Severe mental illness has been likened to drug addiction, prostitution, and criminality ( 37 , 38 ). Unlike physical disabilities, persons with mental illness are perceived by the public to be in control of their disabilities and responsible for causing them ( 34 , 36 ). Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric disability with anger and believing that help is not deserved ( 35 , 36 , 39 ).

The behavioral impact (or discrimination) that results from public stigma may take four forms: withholding help, avoidance, coercive treatment, and segregated institutions. Previous studies have shown that the public will withhold help to some minority groups because of corresponding stigma ( 36 , 40 ). A more extreme form of this behavior is social avoidance, where the public strives to not interact with people with mental illness altogether. The 1996 General Social Survey (GSS), in which the Mac Arthur Mental Health Module was administered to a probability sample of 1444 adults in the United States, found that more than a half of respondents are unwilling to: spend an evening socializing, work next to, or have a family member marry a person with mental illness ( 41 ). Social avoidance is not just self-report; it is also a reality. Research has shown that stigma has a deleterious impact on obtaining good jobs ( 13 , 42 - 44 ) and leasing safe housing ( 45 - 47 ).

Discrimination can also appear in public opinion about how to treat people with mental illness. For example, though recent studies have been unable to demonstrate the effectiveness of mandatory treatment ( 48 , 49 ), more than 40% of the 1996 GSS sample agreed that people with schizophrenia should be forced into treatment ( 50 ). Additionally, the public endorses segregation in institutions as the best service for people with serious psychiatric disorders ( 19 , 51 ).

STRATEGIES FOR CHANGING PUBLIC STIGMA

Change strategies for public stigma have been grouped into three approaches: protest, education, and contact ( 12 ). Groups protest inaccurate and hostile representations of mental illness as a way to challenge the stigmas they represent. These efforts send two messages. To the media: STOP reporting inaccurate representations of mental illness. To the public: STOP believing negative views about mental illness. Wahl ( 32 ) believes citizens are encountering far fewer sanctioned examples of stigma and stereotypes because of protest efforts. Anecdotal evidence suggests that protest campaigns have been effective in getting stigmatizing images of mental illness withdrawn. There is, however, little empirical research on the psychological impact of protest campaigns on stigma and discrimination, suggesting an important direction for future research.

Protest is a reactive strategy; it attempts to diminish negative attitudes about mental illness, but fails to promote more positive attitudes that are supported by facts. Education provides information so that the public can make more informed decisions about mental illness. This approach to changing stigma has been most thoroughly examined by investigators. Research, for example, has suggested that persons who evince a better understanding of mental illness are less likely to endorse stigma and discrimination ( 17 , 19 , 52 ). Hence, the strategic provision of information about mental illness seems to lessen negative stereotypes. Several studies have shown that participation in education programs on mental illness led to improved attitudes about persons with these problems ( 22 , 53 - 56 ). Education programs are effective for a wide variety of participants, including college undergraduates, graduate students, adolescents, community residents, and persons with mental illness.

Stigma is further diminished when members of the general public meet persons with mental illness who are able to hold down jobs or live as good neighbors in the community. Research has shown an inverse relationship between having contact with a person with mental illness and endorsing psychiatric stigma ( 54 , 57 ). Hence, opportunities for the public to meet persons with severe mental illness may discount stigma. Interpersonal contact is further enhanced when the general public is able to regularly interact with people with mental illness as peers.

SELF-STIGMA

One might think that people with psychiatric disability, living in a society that widely endorses stigmatizing ideas, will internalize these ideas and believe that they are less valued because of their psychiatric disorder. Self-esteem suffers, as does confidence in one's future ( 7 , 58 , 59 ). Given this research, models of self-stigma need to account for the deleterious effects of prejudice on an individual's conception of him or herself. However, research also suggests that, instead of being diminished by the stigma, many persons become righteously angry because of the prejudice that they have experienced ( 60 - 62 ). This kind of reaction empowers people to change their roles in the mental health system, becoming more active participants in their treatment plan and often pushing for improvements in the quality of services ( 63 ).

Low self-esteem versus righteous anger describes a fundamental paradox in self-stigma ( 64 ). Models that explain the experience of self-stigma need to account for some persons whose sense of self is harmed by social stigma versus others who are energized by, and forcefully react to, the injustice. And there is yet a third group that needs to be considered in describing the impact of stigma on the self. The sense of self for many persons with mental illness is neither hurt, nor energized, by social stigma, instead showing a seeming indifference to it altogether.

We propose a situational model that explains this paradox, arguing that an individual with mental illness may experience diminished self-esteem/self-efficacy, righteous anger, or relative indifference depending on the parameters of the situation ( 64 ). Important factors that affect a situational response to stigma include collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. This model has eventual implications for ways in which persons with mental illness might cope with self-stigma as well as identification of policies that promote environments in which stigma festers.

CONCLUSIONS

Researchers are beginning to apply what social psychologists have learned about prejudice and stereotypes in general to the stigma related to mental illness. We have made progress in understanding the dimensions of mental illness stigma, and the processes by which public stereotypes are translated into discriminatory behavior. At the same time, we are beginning to develop models of self-stigma, which is a more complex phenomenon than originally assumed. The models developed thus far need to be tested on various sub-populations, including different ethnic groups and power-holders (legislators, judges, police officers, health care providers, employers, landlords). We are also learning about stigma change strategies. Contact in particular seems to be effective for changing individual attitudes. Researchers need to examine whether changes resulting from anti-stigma interventions are maintained over time.

All of the research discussed in this paper examines stigma at the individual psychological level. For the most part, these studies have ignored the fact that stigma is inherent in the social structures that make up society. Stigma is evident in the way laws, social services, and the justice system are structured as well as ways in which resources are allocated. Research that focuses on the social structures that maintain stigma and strategies for changing them is sorely needed.

More From Forbes

Healthcare leaders must lead mental health discussions in the workplace—here’s why (and how).

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Jacob Kupietzky is President of HealthCare Transformation , a company dedicated to providing hospitals with experienced interim executives.

From the White House to sectors throughout our society, mental health—prioritizing it, talking about it and understanding it—has become a growing pillar of well-rounded workplace environments. Yet, the reality is we have a long way to go.

A Deloitte report found that " two-thirds of women don’t feel comfortable discussing mental health at work or disclosing mental health as the reason for taking time off." Almost three-quarters of U.S. employees feel mental health conversations are appropriate, but only 58% feel comfortable actually having them. The same study reveals that a surprising number of senior-level employees (7 out of 10) "have not received workplace training about how to talk to their team about mental health." According to a 2023 survey that underscores the importance of mental health, " 90% of Americans feel we are in a mental health crisis ." In an industry like healthcare, where burnout is more the rule than the exception, cultivating a culture that promotes positive mental health practices is of utmost importance.

The Value Of Prioritizing Mental Health

By removing the stigma associated with mental health, healthcare leaders are also creating value in a multitude of ways:

Aiding In Employee Recruitment And Retention

When your top executives are setting a positive mental health example, your healthcare system builds a reputation as a desirable place to work. The result is attracting top talent and developing a tenured workforce.

Best High-Yield Savings Accounts Of 2024

Best 5% interest savings accounts of 2024, fostering innovation and quality patient care.

By leading with a person-first mentality, employees don’t see your establishment as just a place to work. They are more likely to become invested in their contributions as part of the whole and to go above and beyond. They feel empowered to speak up about what they need and where there are opportunities for improvement. This can foster innovation in medical practices and methodologies and a commitment to high-quality care.

Strengthening The Resilience Of The Organization

A mentally healthy workforce is adaptable to the ever-changing nature of healthcare and the inevitable turbulence of the industry. This equates to an overall resilience and ability to thrive in complex environments.

Create A Culture Of Supporting Mental Health

In my experience, culture shifts start at the top. When leaders set the standard for behaviors like maintaining work-life balance, vocalizing their own battles with stress and overwhelm, and encouraging employees to put their well-being first, they create a ripple effect that carries throughout the organization. In working with numerous hospitals and healthcare systems, here are a few of my recommendations for amplifying the importance of mental health:

Develop Comprehensive Training Programs

It’s one thing to talk about mental health. It’s another to keep it at the forefront of your organization’s day-to-day. Thoughtful training programs should help leaders understand the importance of mental health, how to talk about it with their teams and how to identify mental health struggles. Comprehensive training equips all leaders—especially middle-level leaders who have a significant impact on culture—to prioritize mental health with the employees they lead.

Incorporate Mental Health Into Benefits Packages

From establishing employee assistance programs and offering mental health days as part of your leave policy to making mental health professionals available to your people, look for opportunities to enhance the benefits your organization provides. Further, ensure they are easy to access. Set up human resources/operations support to help employees with questions.

Establish A Culture Of Openness And Respect

The more mental health becomes part of meeting discussions, organization-wide announcements and team-building initiatives, the more your workforce will grow comfortable with the topic. What you focus on expands. The front-loaded effort will pay off in the long run. Along the way, ask for feedback through surveys, direct conversations or other data collection methods. If your efforts aren’t helpful, or employees don’t resonate with them, it’s time to pivot.

The Importance Of Mental Health In The Workplace

In the aftermath of the most significant health crisis in generations, Covid-19, we have a cohort of healthcare professionals who have experienced tremendous stress and trauma. It is not enough to applaud our healthcare workers; as leaders, we must go deeper. By implementing workplace policies that address mental health, demonstrating healthy behaviors and keeping mental health at the forefront of leadership strategy, executives can create environments where employees thrive both personally and professionally.

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Amplifying the voices of Kentuckians with highly stigmatized mental health conditions, like schizophrenia, personality disorders, bipolar disorders, psychotic disorders, OCD, dissociative disorders, people who have experienced involuntary commitment, and more.

Stigma Silenced [Stories Spoken]: A Mental Health Podcast UKY Human Development Institute

• Health & Fitness
• MAY 23, 2024

Finding Wellness through Peer Support with Taylor Price

***Content warning: discussions of hospitalization and suicide.***  In this episode of Stigma Silenced [Stories Spoken], host Bailey Patterson (she/her) engages in an insightful interview with Taylor Price (she/her), who shares her journey with her bipolar 2 diagnosis.  Taylor discusses her wellness journey from her initial diagnosis, her experiences with suicide attempts and hospitalization, and her current state of wellness. She highlights the transformative power of peer support, recounting how joining support groups changed her life and inspired her to start a support group in Lexington, Kentucky. This candid conversation sheds light on the complexities of living with bipolar disorder and the crucial role of peer support.  - View a transcript here: Word Document // PDF -  Stigma Silenced [Stories Spoken] is dedicated to amplifying the stories of Kentuckians with highly stigmatized mental health conditions. We want to expand the scope of the mental health awareness conversation. It seeks to highlight and center conversations about these highly stigmatized disabilities by bringing people with lived experiences to the forefront. Our goal is to create a space where people with highly stigmatized diagnoses can speak honestly and openly about themselves, their experiences with their condition be it positive and/or negative, the treatment, stigmatization, systemic barriers and violence, and marginalization they face due to their disability and how this affects them overall as human beings.  - The views and opinions expressed in this podcast are those of the guest speakers and do not necessarily reflect the views, positions, or opinions of the University of Kentucky, the Human Development Institute, Sphere, or any related entities.

• MAR 25, 2024

Reclaiming Madness with Mack Thompson

In this first episode of Stigma Silenced [Stories Spoken], host Bailey Patterson (she/her) engages in insightful conversation with Mack Thompson (he/they), a self-advocate and anthropology student at the University of Kentucky. Mack shares their journey navigating mental health, neurodiversity, and the intersections of identity. From reclaiming the term "mad" to advocating for autonomy and sympathy, Mack challenges the stigmatization surrounding mental health. This episode sheds light on the power of community, the importance of listening to people with lived experiences, and the celebration of Mad Pride. Join us as we delve into a conversation that aims to uplift and empower individuals to embrace their unique experiences. - View the transcript of this episode: Word Document / PDF - Stigma Silenced [Stories Spoken] is dedicated to amplifying the stories of college students with highly stigmatized mental health conditions. We want to expand the scope of the mental health awareness conversation. It seeks to highlight and center conversations about these highly stigmatized disabilities by bringing people with lived experiences to the forefront. Our goal is to create a space where people with highly stigmatized diagnoses can speak honestly and openly about themselves, their experiences with their condition be it positive and/or negative, the treatment, stigmatization, systemic barriers and violence, and marginalization they face due to their disability and how this affects them overall as human beings.  - The views and opinions expressed in this podcast are those of the guest speakers and do not necessarily reflect the views, positions, or opinions of the University of Kentucky, the Human Development Institute, Sphere, or any related entities.

• © UKY Human Development Institute

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