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Beating stigma seems obvious—Stop it!—but to what end? Here, I describe three agendas that outline the goals of anti-stigma tasks.
(1) The SERVICES Agenda, decrease label avoidance so people engage in evidence-based services. Although there are several effective treatments for people with mental illness, many opt not to seek these services in time of need or drop out of them prematurely. This occurs because people want to avoid providers and places where users are associated with stigmatizing labels. The Services Agenda seeks to replace label avoidance with a certain sense of optimism so that people are more willing to engage in care.
(2) The RIGHTS Agenda, decrease public stigma so people enjoy rightful life opportunities. Public stigma robs people of rights to a complete education, good job, nice place to live, satisfactory health care, and intimate relationship. A Rights Agenda mirrors civil rights movements of the past fifty years seeking to advance opportunities and quality of life for people of color, women, and the LGBTQ community. The Rights Agenda embodies social injustice concerns of mental illness stigma. It mobilizes the rectitude of intent that represents civil rights movements around the world by appealing to the progressives’ sense of right and wrong. The clarion call to righteousness empowers messaging, giving the agenda an assertive quality not seen in the “sales” approach of Services Agendas.
(3) The SELF-WORTH Agenda, decrease self-stigma to replace shame with dignity. The Self-Worth Agenda addresses harmful effects of self-stigma which lead to beliefs that people with mental illness should be ashamed of themselves. The Self-Worth Agenda strives to replace shame with feelings of pride. People with lived experiences themselves first recognized and challenged these beliefs. Thousands of mutual help and peer services have developed across the country. Mutual help and peer support programs are developed and operated by people with mental illness, for people with mental illness. They are often augmented by disclosure programs, those that help people decide about strategically disclosing their mental health experiences to promote empowerment.
Agendas Compete
In the zeal to repudiate stigma, many believe all good intentioned efforts are effective. However, agendas for stigma change work differently depending on the setting, with some strategies actually making things worse. The Services Agenda, for example, seeks to destigmatize mental illnesses by framing them as treatable disorders, which can lead to unintended consequences for the Rights Agenda. Framing a person in terms of treatable disease is meant to assuage concern about the efficacy of interventions. “Depression is an illness like high blood pressure; both are easily treatable.” But stressing treatable disease accentuates the idea of difference; that the person with depression is somehow not like the “normal” majority. And people who are different are somehow broken. The difference in mental health, unlike in blood pressure, leads to disdain.
A focus on treatable disease may also turn narratives about mental illness and stigma to pity. Although pity and sympathy are driven by benevolent wishes of the “normal” majority, research by our group mostly shows untoward effects of pity. Those with mental illness who pity peers are likely to view those peers with more stigma and as dangerous, leading to greater social avoidance. Pity also turns inward to troubling effects. People with lived experience who view their mental health experiences with pity show diminished self-esteem and powerlessness which can ironically lead to greater depression! A pity message echoes old notions of charity where people of advantage bestow opportunities on the needy. This dated idea has been replaced by a mandate for empowerment. Everyone has a right to opportunity; those with an advantage should make sure all have the power to obtain these opportunities. I do not mean to say that “treatable disease” as an effort to decrease label avoidance and get people into care fails to have benefits, only that proponents of a Services View need to be mindful of its unintended effects on Rights Agendas.
