Guest Blog: Stigma Is Public Prejudice Based On Ignorance

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Barriers to Care for Those with Serious Mental Illness

By Timothy Clement

In June, the organization I work for, The Thomas Scattergood Behavioral Health Foundation, hosted a conference in Philadelphia called Opening Closed Doors. Prominent thought leaders in mental health and advocates for family members of those living with mental illness assembled for two days to address the obstacles that interfere with positive outcomes for those with serious mental illness (SMI). Two of the largest barriers identified were well-intentioned privacy laws that sometimes prevent families from participating in the recovery process and involuntary commitment laws that require the presence of imminent danger to self or others.In addition to these challenges, we at the Scattergood Foundation recognize that there are other, societal impediments that hinder wellness for those with SMI: stereotypes, prejudice, and discrimination.

The project on which I work seeks to remedy the stereotypes, prejudice, and discrimination encountered by people with mental illness. Endorsement of stereotypes leads to prejudicial attitudes, which in turn can lead to discriminatory behaviors. This is the process of stigmatization.

The term stigma is sometimes misconstrued as personal shame, guilt, or embarrassment. Those emotional responses certainly can result from stigma, but stigma itself transpires and originates in the public realm. Public stigma is prejudice and discrimination and its genesis can be found within the prevalent stereotypes of those with mental illness, particularly the stereotypes of those with SMI. In addition to the harms inherent in any form of prejudice or discrimination, the prejudice and discrimination directed towards people with mental illness interferes with treatment seeking and treatment adherence. The linkage between stigma and help-seeking behavior has been established by many research studies and is a major reason why 60% to 70% of those with diagnosable conditions do not seek treatment. The desire to avoid the label of “mentally ill” thereby avoiding prejudice and discrimination is the motivation for eschewing treatment.

However, there is another form of stigma that is very personal in its manifestation.

Some individuals with mental illness accept these negative stereotypes and apply them internally. This inwardly directed prejudice is known as self-stigma and it is not uncommon among those with SMI. Research has found that self-stigma results in diminished self-esteem and lowered self-efficacy. Diminished self-esteem is often expressed as the shame, guilt, or embarrassment that many associate or conflate with stigma itself. Lowered self-efficacy results in reduced confidence that one can complete tasks. Research has demonstrated a connection between self-stigma and pursuing life goals such as finding housing, looking for work, and participating in treatment. This is known as the “why try” effect and can be just as damaging to outcomes as illness symptoms.

Occasionally I hear or read statements that minimize stigma’s impact on help-seeking behavior among individuals with SMI. This line of thinking posits that psychosis and delusional thoughts are the culprits that preclude someone with SMI from seeking treatment. And, of course, this is the case sometimes. A person in the depths of a psychotic episode who refuses treatment, much to his or her detriment, often does so because of anosognosia, or the inability to understand that one is ill. However, people in psychotic episodes usually have progressed to this point of extreme illness—not necessarily at a linear pace, but psychosis did not arrive instantaneously. Often the need to seek treatment may have been apparent at an earlier stage, yet treatment either was avoided or it was aborted after initiation. There are a number of reasons why this happens, but stigma—both public stigma and self-stigma—often plays a role. Additionally, many people with SMI are not delusional or in the depths of psychosis but face increased odds of becoming gravely ill if they fail to participate in treatment. So while stigma may not appear to be the problem or even a problem in cases of psychosis, there is a good chance it played a role at some point during the illness progression.

Most people recognize prejudice and discrimination as negative forces that can harm those upon which they are inflicted. However, in the case of mental illness, the damage wrought by prejudice and discrimination can cause those affected to avoid needed treatment for serious illnesses, which can lead to poorer outcomes and reduced life expectancy. Stigma reduction is not just a noble endeavor of social justice; it must occur in order to improve outcomes for those with mental illness.

The first step towards ameliorating stigma is to learn what peer-reviewed research has discovered about stigma and stigma reduction. I encourage readers to click on this hyperlink to the Scattergood Foundation Stigma Guide. It is a brief summary of research findings on the subject. If you are interested in reading the research articles that are cited in the guide, please contact me at the email address listed on the guide and I will gladly supply you with these articles and any additional resources I may have.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.