The stigma of mental illness has proven to be persistent and stubbornly immune to a wide range of stigma-reducing campaigns, programs, and interventions. The intensity of stigma varies by diagnosis, with depression and anxiety being less stigmatizing than, for example, schizophrenia and bipolar disorder. However, all deviations from what medicine defines as mental health or normal mental status bestow a negative label upon those diagnosed. Labeling a person as mentally ill has serious adverse health and psychosocial consequences, such as, exposing them to being discredited, ridiculed, blamed for their symptoms, hospitalized against their will, and excluded from opportunities in education, employment, or housing. As a society, we tend to attribute, if not justify, this differential treatment of those diagnosed to their potential dangerousness, unpredictability, and irresponsibility. We portray them as less reliable in their everyday interactions, their social roles, and as a financial and social burden, if not downright violent and dangerous. We have created and reproduced a cultural script, a collective story, that ascribes these characteristics potentially to all persons with a mental illness.
This process of labeling as different, assigning negative connotations to the label (i.e., stereotyping), separating “them” from “us” (i.e., otherizing), and, finally, depriving of opportunities and resources persons with mental illness is the definition of stigmatization (Link and Phelan, 2001). Persons exposed to this process often internalize the negative stereotypes about their condition and apply them to themselves, and/or anticipate being treated as “less than” in their interactions with others. The recognition that a mental illness confers a discrediting status can lead to internalizing and anticipating stigmatization regardless of one’s interpersonal and social experiences.
Numerous deleterious health, psychological, and behavioral outcomes are associated with internalizing, anticipating, and/or experiencing stigma, including increased stress, social isolation and loneliness, a decrease in self-worth, concealment of one’s symptoms or diagnosis, and importantly, resigning to one’s symptoms and avoiding accessing and using mental health services because of shame and hopelessness (Corrigan, 2012). In essence, stigmatizing persons with mental illness amplifies their suffering and marginalization and further undermines their health, quality of life, and chances of recovery.
It is encouraging that, in the US, we have recognized the multifaceted harms inflicted by stigma. In the past three decades, there has been a significant increase in efforts to understand, measure, and intervene to reduce the stigma of mental illness (National Academies of Sciences, 2016). A review of the literature found that from 2004 to 2014, “on average, 36 measures of stigma have been developed per year since 2004” (Fox et al., 2018). Multiple stigma-reducing initiatives have also been launched by different organizations and systems, including the stigma free campaign of the National Alliance on Mental Illness. The social isolation and stress imposed by the COVID-19 pandemic also presented stigma-reducing opportunities by raising awareness of widespread pandemic-related depression and anxiety; thus, normalizing these conditions. The stubborn persistence of stigma of mental illness is therefore puzzling. We suggest that there are two fundamental and interrelated aspects of the stigma of mental illness that we have overlooked and that contribute to its enduring nature and limited effectiveness of stigma-reducing efforts.
First, the stigma of mental illness is intersectional, that is, other statuses a person has alongside their diagnosis of mental illness, such as race, ethnicity, gender, social class, age, or housing status interface with their mental illness status and generate different stigma experiences. For example, although they might share the same diagnosis (e.g., bipolar disorder) a young Black American (henceforth Black) man who is poor and lives on the street is exposed to more extensive stigmatization than a young White non-Latinx (henceforth White) middle-class woman who is stably housed. The stereotypical notions of dangerousness, unpredictability, and irresponsibility that are often associated with mental illness are more likely to be ascribed to the young Black man because of the intersection of his race, gender, age, social class, and housing status, compared to the young White woman. Racist and classist attitudes, explicit or implicit, among the public, and the persons and institutions that interact with the young Black man will likely be activated and result in stigmatizing interpersonal and institutional experiences for him. Hence, he will be exposed to three intersecting systems of stigmatization, exclusion, and oppression, namely, racism, classism, and the stigma of mental illness. The young White woman’s intersecting statuses of race, gender, class, and housing stability, however, afford her privileges that protect her from and thus reduce the stigma of mental illness.
Exposure to stigmatizing reactions of different intensity also influence processes of internalizing and anticipating stigma. For example, the young Black man may be more likely than the young White woman to internalize and anticipate stigma and, in turn, engage in behaviors that undermine his well-being (e.g., self-isolating or avoiding services) to protect himself from further stigmatizing reactions. Yet, since he navigates the world by inhabiting all his potentially stigmatizing intersecting statuses, we must recognize that he might be attributing his stigma experiences to one or more of his statuses and not assume that he considers his diagnosis the primary source of stigma. Therefore, when we administer a “stigma of mental illness measure,” it is unclear whether we are measuring stigmatizing experiences, perceptions, attitudes towards mental illness or other intersecting statuses that we associate with mental illness.
With a few recent exceptions (Holley et al., 2019; Morrow et al., 2020), mental illness stigma research, interventions, and programs have not adopted a truly intersectional perspective that recognizes the different types of -isms (e.g., racism, sexism, classism, and heterosexism), that is, the systematic processes of exclusion or privilege that interact and generate vastly different stigma experiences among persons with mental illness. We suggest a change in terminology that will sensitize us to this feature of stigma, that is, to always refer to the intersectional stigma of mental illness instead of the stigma of mental illness.
Second, the intersectional stigma of mental illness operates at the institutional level as well as the intrapersonal, interpersonal, and structural levels. Most of the stigma-reducing efforts have focused solely on the intrapersonal and interpersonal levels. For instance, we have interventions for strategic disclosure of one’s diagnosis and psychoeducational and contact interventions to increase public and provider understanding of and familiarity with persons with mental illness. To a lesser extent, we have also designed laws and policies to protect persons with mental illness from systematic exclusion from educational, employment, and housing opportunities to address stigma on the structural level. Yet, we have overlooked the stigma than operates on the institutional level, that is, in mental health organizations, specialized residential facilities, clinics, emergency departments, and hospitals. Whether these institutions stigmatize persons they serve can be directly gleaned from their operating policies and written regulations. For example, asking patients’ preferred pronouns in a mental health clinic is an institutional policy that reduces the intersectional effects of genderism and mental health stigma.
We also advocate for the importance of examining unwritten policies and routine ways, in which care is provided that become part of “how things are done” in different institutions. These regularities in staff and provider behaviors can result in stigmatizing practices in ways that are unintentional and go unrecognized by practitioners. For instance, the language providers typically use to describe patients’ behaviors (for example, labeling patients as noncompliant or “frequent flyers” when they have numerous readmissions) has the potential to stigmatize patients. The decision to flag patients’ electronic health records for agitation can bias providers, stigmatize patients, and increase the use of physical or pharmacological restraints. Moreover, it is safe to assume that these stigmatizing labels and practices weaved into the routine workings of institutions are more likely to impact patients facing multiple intersecting forms of “-isms,” such as, Black, Indigenous, and People of Color, poor patients, those who are homeless, or who identify as LBGTQ+. To fully understand the stigma experiences of persons navigating mental health institutions and design effective interventions, we must collect extensive data on how institutions might contribute to and reproduce intersectional stigma, regardless of staff or provider consciously held attitudes and intentions. Recognizing the intersectional and institutional manifestations of the stigma of mental illness can bring about a paradigm shift and contribute to meaningful reduction in stigma.
Helen-Maria Lekas is a Research Scientist in the Social Solutions and Services Research division at the Nathan S. Kline Institute and is a Research Associate Professor at NYU in the Department of Psychiatry Crystal Fuller Lewis is the director of the Social Solutions and Services Research division at the Nathan S. Kline Institute and a Research Scientist and is a Research Associate Professor at NYU in the Department of Psychiatry. Kerstin Pahl is a Research Scientist in the Social Solutions and Services Research division at the Nathan S. Kline Institute and is a Research Associate Professor at NYU in the Department of Psychiatry. Daniele Martino is a Research Coordinator in the Social Solutions and Services Research division at the Nathan S. Kline Institute. Suzanne Feeney, MBA is Director, Institute of Program and Policy Innovation at the NYS Office of Mental Health (OMH), and Dhanushki Samaranayake, PhD is Director, Thought Leadership, Institute of Program and Policy Innovation at OMH.
References
Corrigan, P. W., & Rao, D. (2012). On the self-stigma of mental illness: Stages, disclosure, and strategies for change. The Canadian Journal of Psychiatry, 57(8), 464-469.
Fox, A. B., Earnshaw, V. A., Taverna, E. C., & Vogt, D. (2018). Conceptualizing and measuring mental illness stigma: The mental illness stigma framework and critical review of measures. Stigma and Health, 3(4), 348.
Holley, L. C., Oh, H., & Thomas, D. S. (2019). Mental illness discrimination and support experienced by people who are of color and/or LGB: Considering intersecting identities. American Journal of Orthopsychiatry, 89(1), 16.
Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 363-385.
Morrow, M., Bryson, S., Lal, R., Hoong, P., Jiang, C., Jordan, S., … & Guruge, S. (2020). Intersectionality as an analytic framework for understanding the experiences of mental health stigma among racialized men. International Journal of Mental Health and Addiction, 18(5), 1304-1317.
National Academies of Sciences, Engineering, and Medicine. (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. https://doi.org/10.17226/23442.
