What is Stigma?
The most cited definition of stigma is that of Goffman1: an “attribute that is deeply discrediting” and that reduces the bearer “from a whole and usual person to a tainted, discounted one”(p. 3)1.
Goffman1 also observed that stigma can be seen as a relationship between an “attribute and a stereotype” to produce a definition of stigma as a “mark” (attribute) that links a person to undesirable characteristics (stereotypes) (p.4). In this case, having a mental illness is the attribute and the stereotypes are discussed below.
Stigma is manifested through bias, distrust, fear, embarrassment and stereotyping that leads people who are symptomatic to avoid diagnosis and treatment, in order to avoid the stigma. Stigma leads people to avoid living, socializing or working with someone or to avoid employing or renting to the stigmatized person. The social, economic, emotional and psychological impacts exacerbates symptoms and negatively impacts the lives of both people with brain disorders and the people who care about them.
The stigma placed on someone with a brain disorder also interacts with other stigmatized identities such as people who are poor or who are a member of marginalized communities that already experience oppression. Adding one more 'label' increases their social exclusion and so stigma tends to be even more significant in these communities.
Stereotypes and Archetypes
In talks I have given to graduate students in leading schools of social work and psychology, I asked them to write down two words they associated with mental illness. These included: homeless, different, misunderstood, sadness, isolation, flaky, unreliable, hurtful, psycho, functioning, therapy, crazy, dangerous, unpredictable, scared, dysfunctional. Asked to write down two stereotypes of people with mental illness, some of the words they wrote were: homeless, delusional, violent, unstable, dangerous, weak, difficult, stigmatized, different. With the most common words in both categories being unstable, violent/dangerous and homeless. These are the stereotypes that people see when they know that someone has a brain disorder because for most people it is a 'hidden condition'. These are people who are being trained to work with the mentally ill and though this was not a question about their own values, their responses were evidence of how pervasive these ideas are about people with brain disorders.
Stereotypes of being 'scary' or 'unpredictable' or 'weak' feed the stigmatization of people with brain disorders who fear 'coming out' to friends or family because of judgment, shame or perceived failure to cope. Most of all, people fear that they will not be seen as 'equal' to others and that their life chances will be limited. The latter is a fear that is also part of having a chronic condition and so also exists outside of the stigmatized position.
The stereotypes and archetypes of people with brain disorders (aka the mentally ill) are created and supported by movies such as One Flew Over the Cuckoo's Nest, Black Swan, or The Shining, books such as The Catcher in the Rye or TV shows such as Law & Order or ER, where the person with bipolar disorder never takes their medication and then gets into all sorts of trouble, often including murder or self-destructive behaviors. I am not saying that this stereotype does not exist but reality is much more varied than the media portrays. The recently released film, Silver Linings Playbook is one rare example that showed someone taking medications, going to therapy, getting social support and exercising in order to control their symptoms. (Ignore the corny love story:-)
These stereotypes are also built upon those relatively rare occasions when people who are in a psychotic state or otherwise impaired by a brain disorder do something that ignites a media fire and everyone with that mental condition then becomes afraid of being viewed as someone who could commit such unimaginable acts. The truth is that most people with a mental illness are more a danger to themselves than others, and are mostly not a danger at all. Most of us are not ill all the time and have lives that get interrupted by bouts of illness, of various frequency and intensity, like so many other chronic conditions. We manage symptoms in all sorts of ways in order to lead productive lives.
How Stigma Works
I am inspired to write this piece about stigma by a young woman at my university who was referred to me by her professor so that I could be a resource to her during a difficult time. He knew of my public identity as someone with manic depression (aka bipolar disorder) and thought I could help her during an episode of bipolar disorder. She was scared to tell her friends because she was afraid of being judged (or of being a burden). The isolation she felt was not helpful to her condition because having social support is such a powerful source of healing power. Among other things, I suggested she tell one or two trusted friends for support and also seek out the counseling center on campus.
Two weeks prior a graduate student from my university, who had found an advocacy piece I wrote on Huffington Post emailed me and asked to meet to talk about his own issues with stigma and coping in a world which did not understand his illness. He was scared to be stigmatized by his fellow students and professors and was scared that perhaps he would not make it in the profession of his choice - one that is both stressful and prestigious and based heavily on a trust relationship.
I also write this piece for all the other students, friends, friends of friends, and strangers who have contacted me with similar requests over the years since I first told my story in a public domain: first in a book chapter in a book edited by Stephen Hinshaw, PhD called Breaking the Silence (Oxford Press). Each time I wrote about my own mental illness: in an op/ed piece I wrote for the Seattle Times, in my book, Bipolar 101 and in a Huffington Post piece, more people contacted me for advice on 'coming out' as crazy and how to overcome the fear associated with that process.
Coming Out of the Crazy Closet
Coming out of the crazy closet was not my choice. I had a particularly bad episode which caused me to be hospitalized and so my workplace became aware of my condition. After my worse fears had come to be (being hospitalized), and after having to advocate on my own behalf using the Americans with Disabilities Act, I became convinced that more 'succesful' people had to admit to having a brain disorder in order for it to be normalized. My only model was Kay Redfield Jamieson who wrote the classic Unquiet Mind.
My advocacy slowly grew because the people whom I would speak with asked me to continue to speak out because it had made a difference to their own lives. I really did not want to be known as 'the crazy professor' but I also knew I felt that way because I did not want to be stigmatized. Yet in some ways I had bought into the stigma by not wanting to be known for being 'crazy'. I joined a group of professionals in Seattle who are finding support among each other and trying to figure out how to use their voice and power as successful professionals living with brain disorders. How to deal with mental illness at work takes up a lot of discussion among this group of people.
Even people in mental health professions carry stigmatized notions of who we are because they only see us when we are ill. They do not see us as we work at the top of the corporate lader or leading countries. However in 1998, the Prime Minister of Norway, Kjell Magne Bondevik took the unprecedented and brave step of taking several weeks off to deal with his depression - an illness that arguably costs ~$50billion in the year 20002 in workplace costs. Of this ~$50 billion, only 31% were direct medical costs and 62% were workplace costs. But the impact of stigma is real even if it may be cheaper to treat than to have workplace costs. A UK study done by the organization MIND and reported by The Guardian (July 1, 2011), found that 1 in 5 people in the UK who reported a mental illness at work were either fired or pushed out of their post. In the same Guardian article, it was reported that when asked confidentially, one in five British politicians admitted to having, and concealing, a mental health condition.
When a condition is stigmatized it creates stress for the stigmatized individual and disinclines them to seek help for their condition, which robs them of them of the help they need to get better. Getting better helps people get control of their lives and see themselves differently. Getting social support is vital to getting better.
I did not step out of the 'crazy closet' willingly but once out, there was nowhere to go. I decided to become an advocate because of how many people were shocked that "someone like you" had a mental illness. I wish I had known other people to talk to about this when I was in the throes of despair. I also came to agree with my hospital psychiatrist that my unique position as a social worker, associate professor in social work and someone who is living with manic depression, gave me a voice that could facilitate change. I became an activist to help myself fight the stigma I faced within and without and to inspire others to become more at peace with their illness and to be able to find the support they needed to get, and stay, well.
I entreat others to come out of the 'crazy closet' and join me in putting different faces on the ideas that compose the stereotypes of who are the people with mental illness. The energy it takes to live in the dark is energy that could be spent on being healthy.
Note: I use the words mad and crazy here in an effort to destigmatize them. I also prefer the term brain disorders to mental illness. For no other reason that to use a term that has yet to be so stigmatized.
1Goffman E. 1963. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice Hall
2Greenber, PE, Kessler, RC, Birnbaum, HG et al (2003). The economic burden of depression in the United States: how did it change betwee 1990 and 2000. Journal of Clinical Psychiatry, 64(12), 1465-1475.