1. This is the door to an
inpatient psychiatric
unit. It is locked at all
times. Does this look
like a place of
healing? Why or why
not? What does this
environment say
about the patients on
this unit?

2. THE
OF MENTAL
ILLNESS

3. Families will say this, "Only illness in the world
where you never get a covered dish." There is
something about having a mental illness
where everything falls away, and what you
experience is fear and isolation rather than a
sense of people coming towards you.
(Joyce
Burland)

4. What is stigma?
 Original meaning:
Bodily signs that
indicate something
about moral
character of the
person

5. What is stigma?
Coined by Goffman (1963) to
refer to prejudices related to
having a mental illness
In Greek society, stigmatizing
attitudes about the mentally ill
were already apparent

6. What is stigma?
As early as the 16th century,
“madness” was seen as a
“perverted will” and
“symptoms of animal
instincts”…. “a beast”

7. What is stigma?
The Scarlet Letter

8. What is stigma?
 In The Scarlet Letter by Nathanial Hawthorne, Hester
is made to wear an “A”, signifying her identify as an
adulteress. The “A” is meant to be a symbol of
shame, but instead it becomes a powerful symbol of
identity to Hester. The letter’s meaning shifts as time
passes. Originally intended to mark Hester as an
adulterer, the “A” eventually comes to stand for “Able.”
Finally, it becomes indeterminate: the Native Americans
who come to watch the Election Day pageant think it
marks her as a person of importance and status. The
letter helps to point out the ultimate meaninglessness of
the community’s system of judgment and punishment.
More often than not, a symbol becomes a focal point for
critical analysis and debate.

9. What is stigma?
In The Scarlet Letter, Hester is publicly shamed and
forced by the people of Boston to wear a badge of
humiliation, but she was not willing to leave the town.
Hester’s behavior is premised on her desire to determine
her own identity rather than to allow others to determine
it for her. To her, running away or removing the letter
would be an acknowledgment of society’s power over
her: she would be admitting that the letter is a mark of
shame and something from which she desires to escape.
Instead, Hester stays, refiguring the scarlet letter as a
symbol of her own experiences and character. Her past
sin is a part of who she is; to pretend that it never
happened would mean denying a part of herself. Thus,
Hester very determinedly integrates her sin into her life.

10. What is stigma?
 What does the story of The Scarlet Letter
teach us about the stigma of mental illness?

12. What is stigma?
 In place for centuries, the custodial, institution-based model of care
for those with mental illness contributed to their stigmatization by
segregation. The mentally ill were separated from the physically
ill, who were treated in local hospitals in their own communities. The
decision to send persons with mental illness to far-away
institutions, although well intentioned in its origins, dislocated them
from their communities. With time, they lost their connections with
coworkers, friends, and relatives; ultimately, they lost their personal
identity. At a system level, the institutional model also contributed to
the banishment of mental illness, and also of psychiatry, from the
general stream of medicine. The therapeutic nihilism that for
centuries permeated most psychiatric work also contributed to the
asylum mentality. The few-and-far-between therapeutic successes
helped to reinforce the nihilism, in that the remaining conditions
were considered incurable. With time, the stigma associated with
mental conditions and mental health patients also extended to those
in charge of caring for them, psychiatrists included.

13. What is stigma?
 Labeling theory:
 Reactions of others of central significance in
experience of mental illness
 Involves an “exchange of meaning” about what it
means to have a mental illness

14. What is stigma?
Recognition of a differentiating “mark”
+
Devaluation of the bearer of the “mark”
A relational and social construct

15. What is stigma?
 This static concept of stigma has been
enlarged to encompass a social construct
linked to values placed on social identities
through a process consisting of 2 fundamental
components: the recognition of the
differentiating “mark” and the subsequent
devaluation of the bearer. Stigma is therefore a
relational construct based on attributes.
 Consequently, stigmatizing conditions may
change with time and among cultures

16. What is stigma?
The way stigma is perceived by the
Develops in a matrix Perspective
stigmatizer or by the person being
of social stigmatized
relationships and
interactions
Cognitive,
Exists along
affective, and/or
a continuum
behavioral
from the
reactions to Reaction Identity entirely
stigma and its s personal to
consequences
group
belongness

17. What is stigma?
 Visibility: how obvious the mark is
 Controllability: whether the mark is under
the bearer’s control
 Impact: if it instills fear by conveying an
element of danger

18. What is stigma?
 Mental health patients who
 show visible signs of their conditions because of their
symptoms, or because medication side effects may
make appear “different”,
 are socially construed as being weak in character or
lazy,
 who display threatening behaviours
usually score high on the dimensions of
visability, controllability and impact. By a process of
association and class identity, all persons with mental
illness are equally stigmatized: regardless of impairment
or disability level, the individual patient is lumped into a
class, and belonging to that class reinforces the stigma
against the individual.

19. Stigma—a definition
 “Beliefs, attitudes and behaviours that result in
social rejection or isolation of an individual
based on any set of characteristics that are
perceived by a group to be undesirable or
threatening, regardless of whether exposure to
the person with these characteristics would
actually cause adverse consequences to
others” (Van Dorn, 2005)

20. Types of stigma
 Public
 Self

21. Public stigma….
 Impacts on achieving essential life
goals, particularly obtaining competitive
employment and living safely and independently
 Fosters criminalization
 People with mental illness are dealt with by the
police, courts and jails, instead of mental health
system
 Related to inadequate funding for the mental health system
and “get tough”, policies
 People with S&S of mental illness are more likely than others
to be arrested (Teplin, 1984)
 People with mental illness tend to spend more time
incarcerated than people without mental illness
(Steadman, McCarty and Morrissey, 1989)
 Impacts utilization of health care system

22. Those affected by self-stigma
experience…
 Social isolation:
 people restrict their social networks in anticipation
of rejection
 Loss of self-esteem:
 people believe that they are less valuable as
people
 Limited prospects for recovery

23. Other consequences of stigma
include…
 Impaired social adaptation
 Socialisolation, exclusion from friendships
 Access to employment blocked
 Non-adherence to medication treatment

24. Models of stigma
 Cognitive models: stigma related processes
formed and maintained at the psychological
level.
 Stereotype:
 Knowledge structures learned by most members of a social
group; represent collectively agreed on ideas about groups
people
 Of mental illness: dangerousness, incompetence, character
weakness
 Prejudice
 Endorsement of negative stereotype, experience negative
emotional reactions
 Discrimination
 Behavioural reaction, often angry, leading to hostile
discrimination such as withholding care, or fearful, leading to
discriminatory avoidance

25. Models of stigma
 Motivational models: explain WHY people
stigmatize, or the function it serves, although it
is an incomplete picture
 Ego-justification
 Stigma avoids potential threat to one’s physical or
psychological self, by avoiding a socially perceived
threat
 Stigma rationalizes negative group based attitudes
and discrimination
 Group or system-justification: not satisfactory
explanations

26. Models of stigma
 Institutional models:
 Definition: rules, policies, and procedures of
private and public institutions in positions of
power that intentionally restrict the rights and
opportunities of the group affected
 Examples:
 Legislation
restricting rights and opportunities of
people with mental illness

27. Models of Stigma
 Structural models:
 Relates to the effect rather than the intent of an
action, rule or law
 Group goals are not accomplished because they
seem to clash with dominant ideologies that
maintain the status quo
 E.g.cost-effectiveness:
funding for mental health
programs, insurance parity

28. Stigma and violence

29. Stigma
 Those diagnosed with schizophrenia are
particularly subject to negative attitudes and
distancing behaviour
 Schizophreniais seen to be associated with
dangerousness, violence and unpredictability
 Majority express preference for social
distancing-rates have increased over past 40
years
 Fewer negative attitudes about depression

30. Van Dorn, Swanson,
Elbogen, and Swartz (2005)
 Research question
 What are the differences in how mental health
stakeholders (patients, families, clinicians) view
people with schizophrenia as compared with
general public?
 What are the differences in desire for social
distance?

31. Results
 Little difference between stakeholder groups in desire
for social distance
 Family members and clinicians are less likely to see
person as violent
 Service users most strongly believed the person likely or
very likely to be violent
 All groups likely to endorse a biomedical model of
causality
 Family members and service users more likely than
clinicians to endorse stressful circumstances as a cause
 Significant association between belief that the person
was likely to be violent and desire for social distance

32. Conclusions
 Negative attitudes evident even in groups with
close association to persons with
schizophrenia
 People’s beliefs about cause and treatment
effectiveness seem to affect perceptions of
potential for violence, thus reducing desire for
social distance

33. Changing public stigma
 Protest strategies
 Anecdotal evidence suggests that protest can be
effective as a punishing consequence to decrease the
likelihood that people will repeat the behaviour
 Asking people to suppress their prejudice about a
group can promote a backlash and worsen attitudes
as a result (Corrigan, etal 2001)
 Educational approaches
 Produces short term improvements in attitudes
(Corrigan etal), those with greater prejudice are less
likely to benefit from education

34. Changing public stigma
 Interpersonal contact
 Most promising results
 Contact with promoted greater improvement in
attitudes than protest, education and controls
 Improvements seem to be most pronounced
when contact is with a person who moderately
disconfirms stereotype (Reinke, etal 2004)

35. Targeted stigma change
 Anti-stigma programs are more successful
when they target specific groups of people
rather than the general public
 Specific prejudicial attitudes and discriminatory
behaviours need to be targeted
 Behaviours are more likely to change when
strategies target attitudes that correspond to the
behaviour
 Power groups must be challenged in the
setting in which they might discriminate

36. Targeted stigma change
 Targets
 Landlords who fail to lease or make reasonable
accommodation
 Employers who fail to hire or make reasonable
accommodation
 Health care providers who withhold some services or are
unnecessarily coercive
 Criminal justice personnel who are unnecessarily coercive
and who fail to use mental health services
 Policy makers who allocate insufficient resources, interpret
regulations in an “unfriendly” manner
 The media who perpetually disseminate stigmatizing
images

37. Erasing public stigma—structural
change
 Affirmative actions: government approved
activities focused on redressing historical
disparities
 Prohibitionof discrimination
 Requiring “reasonable accommodation”
 Making changes to the work environment to assist the
person to work
 Fair housing

38. Food for thought
 What is the relationship between how North
Americans understand the etiology of
psychosis and the experience of stigma?
 Ifpsychosis was viewed as being caused by
social factors, would there be any difference in
the experience of stigma?

39. More food for thought
 Are psychiatric diagnoses a part of the
problem or part of the solution?
 Dosome aspects of anti-stigma campaigns have
a potentially negative impact on service users
because they frame most psychosocial problems
as a psychiatric diagnosis?

40. There’s a sea of
dandelions, beautiful
dandelions. What a
beauty! Somewhere we
were taught that
dandelions are
ugly, they’re weeds.
Where did we get this
stigma about the
dandelions? And it just
struck me how a lot of
life can have stigma
attached to it, just
like mental illness.
(Ruth Detweiler)

42. Additional References
Arboleda-Florez, J. (2003). Considerations on the stigma of mental illness
(Editorial). Canadian Journal of Psychiatry, 48 (10), 645-650.
Corrigan, P., Green, A., Lundin, R., Kubiak, M., & Penn, D. (2001). Familiarity
with and social distance from people who have serious mental
illness. Psychiatric Services, 52 (7), 953-958.
Corrigan, P., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness:
explanatory models and methods for change. Applied and
Preventative Psychology, 11, 179-190.
Jarvis, G. (2007). The social causes of psychosis in North American
Psychiatry: a review of a disappearing literature. The Canadian Journal
of Psychiatry, 52 (5), 287-294.

43. Additional References 2
Pilgrim, D. & Rogers, A. (2005). Psychiatrists as social engineers:
a study of an anti-stigma campaign. Social Science and
Medicine, 61, 2546-2556.
Rusch, N., Angermeyer, M., & Corrigan, P. (2005). Mental illness
stigma: concepts, consequences, and initiatives to reduce
stigma. European Psychiatry, (20), 529-539.
Van Dorn, R., Swanson, J., Elbogen, E., & Swartz, M. (2005). A
comparison of stigmatizing attitudes toward persons with
schizophrenia in four stakeholder groups: perceived likelihood
go violence and desire for social distance. Psychiatry, 68 (2),
152-163.