Disease can make us sad and uncomfortable because, among other things, it reminds us of our own vulnerability. Mental disease even more so, because it affects our thoughts, our desires, our feelings and our actions and so it affects what we consider to be the core of who we are: our mental life and our sense of self.
Yet we don’t speak of it as much as we ought to. We don’t speak of it as much as we do of physical disease, for instance, and one reason for this is the stigma attached to mental illness that casts it as something that discredits or disgraces a person who has it.
Lately, substantial efforts are being made to combat mental health stigma, starting by openly talking about it and about mental illness in general. Notable examples are Michele Obama, who participated in the Change Directions campaign in the US, and the Duke and Duchess of Cambridge and Prince Harry, who contributed to the Heads Together campaign in the UK. These efforts come to add to the work constantly done by various mental health groups like the National Alliance for Mental Illness (NAMI), BASTA and Time to Change that have been fighting stigma for years.
But why is it so important to fight stigma?
Well, one reason is that it rests on largely false beliefs. These vary, depending on the mental illness in question, but they range from the perception that people living with mental illness are dangerous, incompetent, unreliable, irrational and difficult to interact with to the belief that, at least for some disorders, people suffering from mental illness are responsible for their plight and, thus, weak.
But all of us hold false beliefs, and that is not always a bad thing. The problem with the false beliefs that fuel stigmatizing attitudes is that, wherever they come from and whatever the beliefs are, they have the same effects.
First of all, they affect the emotional and social life of people who live with mental disorders and this can make their recovery more difficult.
Either because of beliefs about mental illness or just because of feelings of sadness and awkwardness, others will very often socially distance themselves from people with mental disorders. They will often avoid hiring people who suffer from them, they will not invite them to social events, will not get romantically involved with them or sit next to them on the subway and so on. This type of social isolation, which essentially makes stigmatized people “others,” can only exacerbate the difficulties of living with mental disorders.
In addition to this, people suffering from mental illness will often not come forward, nor seek help for it, because they don’t want the label that comes with it. Even worse, they can internalize the stigmatizing attitudes they try to avoid — this is called self-stigma — and feel less than competent, helpless, and doomed.
In this sense, stigma not only compromises recovery and becomes an obstacle to flourishing, but, also, beyond reflecting disability, it becomes one of its causes. For these reasons, stigma is a question of public health — to which it also incurs substantial costs.
Untreated conditions can lead to lost productivity, lack of access to regular mental health care increases emergency room costs, missed employment opportunities due to stigma can lead to permanent or temporary unemployment (and thus to the costs of unemployment benefits) and costs are also incurred by the underutilization of workplace counseling and employees assistance programs.
But beyond these health-related concerns, a second reason to fight stigma is something equally, if not more, troubling.
It is unfair.
Because of stigma people are labeled in various ways, which then leads to stereotyping and, ultimately, discriminating behavior. There is ample evidence that stigmatized individuals do not enjoy the status of unstigmatized people. For instance, they regularly suffer discrimination in employment and health care, their rights are often violated, they receive less social support and have less access to goods and services than people suffering from unstigmatized illness. In general, people living with mental disorders are often treated as less capable than others and as needing to be taken care of or controlled. This is known as “benevolence stigma” which, despite its name, is still harmful.
Also, stigmatizing attitudes contribute to the lack of parity of esteem between mental and physical health. This means that mental health services and health insurance coverage for mental disorders lag far behind the services and insurance coverage available for physical illness.
And of course, because stigmatizing attitudes are also held by people in office, they affect public policy related to mental health—for example, concerning the allocation of funds and the drafting of laws against mental health discrimination.
So, as psychologist Patrick Corrigan at the Illinois Institute of Technology and retired Professor of Nursing Megan-Jane Johnstone have extensively argued, since stigmatized groups are regularly discriminated against and face restrictions in their civil rights, mental health stigma is also a question of social justice.
These two aspects of mental health stigma — as a public health issue and as a social justice issue — are linked. For mental health stigma has negative implications for public health by increasing morbidity (the occurrence of a disease) and, also increases disparities — including in health, which brings us back to public health.
As a fact that influences the health of individuals but also their general wellbeing, it has lately been argued that mental health stigma should be included in the social determinants of mental health. Social determinants are the social conditions that people live in that affect their health, such as their level of education, social status, access to health care, level of income and so on.
In their recent book The American Health Care Paradox, in which they raise the question why American health care is so poor when so much money is spent on it, Elizabeth Bradley and Lauren Taylor offer substantial evidence that such conditions play a tremendous role in people’s health and that addressing them can help prevent the onset and recurrence of mental illness, decrease health disparities and diminish the cost of public health.
So mental health stigma is not just about health, it is also a question of justice and so it should concern us all. It is also not just about the mind, but of a mind affected by the conditions in which it is situated. As such, if we are serious about effectively addressing people’s mental health and wellbeing, we have to combat stigma and to think of health more broadly than just in clinical terms.