Stigma and Mental Stigma and Mental IllnessIllness

– A Barrier to Health – A Barrier to Health SeekingSeeking

ANTHONY STERN, M.D.ANTHONY STERN, M.D.ALBERT EINSTEIN COLLEGE OF MEDICINEALBERT EINSTEIN COLLEGE OF MEDICINE

ANNUAL WORLD MENTAL HEALTH DAYANNUAL WORLD MENTAL HEALTH DAYOCTOBER 10OCTOBER 10THTH, 2010, 2010

MALAGA, SPAINMALAGA, SPAIN

OVERVIEWOVERVIEW

I Stigma, Psychiatric Disorders, and Health I Stigma, Psychiatric Disorders, and Health SeekingSeeking

II Stigma and Mental Ilness: A Brief History II Stigma and Mental Ilness: A Brief History of the Conceptof the Concept

III Stigma and Clinical Reality: Three III Stigma and Clinical Reality: Three Intertwined ThreadsIntertwined Threads

IV Conclusion: Fighting the Good Fight IV Conclusion: Fighting the Good Fight against Stigmaagainst Stigma

General Health Care:General Health Care:The Role of StigmaThe Role of Stigma

• Health Care FactsHealth Care Facts• The Links between Stigma and Health The Links between Stigma and Health

CareCare

Extrapolations:Extrapolations:

from a fuller understanding of stigma and from a fuller understanding of stigma and mental illnessmental illness

from studies of difficulties seeking mental from studies of difficulties seeking mental health carehealth care

One U.K. Example of “Label One U.K. Example of “Label Avoidance”:Avoidance”:

2004 GMS (General Medical Services) 2004 GMS (General Medical Services) ContractContract

Patients often would not grant permission to be enlisted into GP Patients often would not grant permission to be enlisted into GP practice SMI registerspractice SMI registers

This has hampered the effort to target primary health care for SMI This has hampered the effort to target primary health care for SMI patientspatients

Andre Tyler, Institute of Psychiatry: “Many of those affected with Andre Tyler, Institute of Psychiatry: “Many of those affected with SMI feel there is SMI feel there is

stigma attached to practice registers and by signing one they will stigma attached to practice registers and by signing one they will live with this live with this

permanent record or label.”permanent record or label.”

David Yeomans, University of Leeds: “People with SMI are often David Yeomans, University of Leeds: “People with SMI are often treated differently treated differently

they are given a mental health label, which is part of the problem they are given a mental health label, which is part of the problem in trying to persuade in trying to persuade

patients to register.”patients to register.”

““Running on Empty: Building Momentum to Improve Well-Being in Running on Empty: Building Momentum to Improve Well-Being in Severe Severe

Mental Illness”, John Abbott et. al., pp. 14-15Mental Illness”, John Abbott et. al., pp. 14-15

STIGMA:STIGMA:The Origins of the ConceptThe Origins of the Concept

Emile DurkheimEmile Durkheim

1858-19171858-1917

18951895 1893 1893 1912 1912

18971897

Erving Erving GoffmanGoffman

1922-1922-19821982

19631963

1961 1961 1959 1959

Goffman’s Concept of Goffman’s Concept of Stigma:Stigma:

Undesirable DifferentnessUndesirable Differentness• ““Stigma is the process by which the Stigma is the process by which the

reaction of others reaction of others

spoils normal identity”spoils normal identity”• The stigmatized person presents evidence The stigmatized person presents evidence

of being of being

different in an undesirable way: “he is thus different in an undesirable way: “he is thus reduced in our reduced in our

minds from a whole and usual person to a minds from a whole and usual person to a tainted, tainted,

discounted one”discounted one”

Link-Phelan Model of Link-Phelan Model of StigmatizationStigmatization

Bruce Link Jo Bruce Link Jo PhelanPhelan

• LABELLING: The identification of differencesLABELLING: The identification of differences• STEREOTYPING: These differences are viewed as negative STEREOTYPING: These differences are viewed as negative

because of because of prevailing beliefsprevailing beliefs• SEPARATING: “Us” and “Them” are disconnectedSEPARATING: “Us” and “Them” are disconnected• DISCRIMINATION: “They” (those labelled) experience DISCRIMINATION: “They” (those labelled) experience

status loss leading to status loss leading to unequal circumstancesunequal circumstances

Link-Phelan Model:Link-Phelan Model:The Role of PowerThe Role of Power

““Access to social, economic and political Access to social, economic and political power” power”

allows the stigmatization process to occurallows the stigmatization process to occur

Bruce G. Link and Jo C. Phelan , Bruce G. Link and Jo C. Phelan ,

"Conceptualizing Stigma", Annual Review "Conceptualizing Stigma", Annual Review of Sociologyof Sociology

Volume 27 (2001), pp. 363-385Volume 27 (2001), pp. 363-385

Types of StigmaTypes of Stigma

• ““received” stigma: prejudice and received” stigma: prejudice and discriminationdiscrimination

• ““self-stigma”: internalized feelings of self-stigma”: internalized feelings of devaluationdevaluation

• ““structural” or “institutional” stigma: structural” or “institutional” stigma: low service use, low service use,

inadequate funding for treatment and inadequate funding for treatment and researchresearch

• ““courtesy” stigma: families, providers, courtesy” stigma: families, providers, and mental and mental

health systems for treatment and researchhealth systems for treatment and research• ““public” stigma: diffuse public attitudespublic” stigma: diffuse public attitudes• ““social ” stigma: public, structural and social ” stigma: public, structural and

courtesycourtesy

Levels of the Stigmatizing Levels of the Stigmatizing ProcessProcess

(Thornicroft, Hinshaw)(Thornicroft, Hinshaw)

• COGNITION - IGNORANCE COGNITION - IGNORANCE AND AND

STEREOTYPINGSTEREOTYPING

• AFFECT - PREJUDICEAFFECT - PREJUDICE• BEHAVIOR - BEHAVIOR -

DISCRIMINATIONDISCRIMINATION

Patrick Corrigan: Patrick Corrigan: www.stigmaandempowerment.orgwww.stigmaandempowerment.org

click on “Publications” and click on “Publications” and “Resources”“Resources”

20

October 2004, American October 2004, American Psychologist: Psychologist:

“How Stigma Interferes with “How Stigma Interferes with Mental Health Care”Mental Health Care”

What causes the failureWhat causes the failure to seek or use care? to seek or use care?

Corrigan:Corrigan:

STIGMA (“SELF-STIGMA” AND STIGMA (“SELF-STIGMA” AND ““LABEL AVOIDANCE”)LABEL AVOIDANCE”)

HEALTH ILLITERACY (LACK OF HEALTH ILLITERACY (LACK OF KNOWLEDGE) KNOWLEDGE)

ABOUT ILLNESS AND ABOUT SERVICESABOUT ILLNESS AND ABOUT SERVICES

AVAILABILITY AND ACCESSIBILITYAVAILABILITY AND ACCESSIBILITY

Two Factors That May Influence Whether a Person Who Might Benefit From Mental Health Treatment Actually Seeks It

Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59(7), 614-625. doi:10.1037/0003-066X.59.7.614

© 2004 American Psychological Association

U. of Michigan Medical U. of Michigan Medical StudentsStudents

Depression, Stigma, and Suicidal Depression, Stigma, and Suicidal Ideation in Ideation in

Medical StudentsMedical Students

Thomas L. Schwenk, MD; Lindsay Davis, Thomas L. Schwenk, MD; Lindsay Davis, BS; Leslie A.BS; Leslie A.

Wimsatt, PhDWimsatt, PhD

JAMA JAMA 2010; 304(11):1181-1190.2010; 304(11):1181-1190.

"A Disease Like Any Other"? A Decade of "A Disease Like Any Other"? A Decade of Change in Change in

Public Reactions to Schizophrenia, Public Reactions to Schizophrenia, Depression, Depression,

and Alcohol Dependenceand Alcohol Dependence

Am J Psychiatry, Published On-Line (“in Am J Psychiatry, Published On-Line (“in advance”) advance”)

September 15, 2010September 15, 2010

Bernice A. Pescosolido, Ph.D., Jack K. Bernice A. Pescosolido, Ph.D., Jack K. Martin, Ph.D., J. Martin, Ph.D., J.

Scott Long, Ph.D., Tait R. Medina, M.A., Jo Scott Long, Ph.D., Tait R. Medina, M.A., Jo C. Phelan, C. Phelan,

Ph.D., and Bruce G. Link, Ph.D.Ph.D., and Bruce G. Link, Ph.D.

Optimism, late 1990’s:Optimism, late 1990’s:scientific knowledge will scientific knowledge will

reduce stigmareduce stigma

ASSUMPTION:ASSUMPTION:

The public understanding of mental The public understanding of mental illness as a illness as a

brain disease will decrease brain disease will decrease community rejectioncommunity rejection

A Comparison of Responses to GSS mental A Comparison of Responses to GSS mental health vignettes,health vignettes,1996 and 20061996 and 2006

• the vignettes describe individuals with the vignettes describe individuals with schizophrenia, schizophrenia,

major depression, and alcohol dependencemajor depression, and alcohol dependence• 54% 54% 67% attributes major depression 67% attributes major depression

to to neurobiological causesneurobiological causes• similar increases in public endorsement similar increases in public endorsement

of mental of mental health treatmenthealth treatment• no decrease in stigma, as measured by no decrease in stigma, as measured by

the desire the desire • for social distance and perceived for social distance and perceived

dangerousnessdangerousness

Result and ConclusionResult and Conclusion

““Holding a neurobiological conception of these Holding a neurobiological conception of these disorders increased disorders increased

the likelihood of support for treatment but was the likelihood of support for treatment but was generally unrelated generally unrelated

to stigma. When associated, the effect was to to stigma. When associated, the effect was to increase, not to decrease, increase, not to decrease,

community rejection.”community rejection.”

““An overreliance on the neurobiological causes of An overreliance on the neurobiological causes of mental illness and mental illness and

substance abuse disorders is at best ineffective and at substance abuse disorders is at best ineffective and at worse potentially stigmatizing.”worse potentially stigmatizing.”

Research in Eastern Germany, Germany, Turkey, Research in Eastern Germany, Germany, Turkey, Russia, and Russia, and

Mongolia has revealed similar findings; research in Mongolia has revealed similar findings; research in Austria and Austria and

Australia showed no increase or decrease of stigmaAustralia showed no increase or decrease of stigma

The Vicious Cycles of The Vicious Cycles of StigmatizationStigmatization

(Sartorius, World Psychiatric (Sartorius, World Psychiatric Association)Association)

• affecting individualsaffecting individuals• affecting familiesaffecting families• affecting mental health affecting mental health

servicesservices

Reducing the Stigma of Reducing the Stigma of Mental IllnessMental Illness, ,

Google Books, pp. 3-4Google Books, pp. 3-4

Fear and Shame:Fear and Shame:Three Intertwined CausesThree Intertwined Causes

• StigmaStigma

• Psychiatric SymptomsPsychiatric Symptoms

• ““Normal” PsychologyNormal” Psychology

(The Human Condition)(The Human Condition)

A Proposed ModelA Proposed Model

• SOCIAL STIGMASOCIAL STIGMA• SELF-STIGMASELF-STIGMA• PSYCHIATRIC PSYCHIATRIC SYMPTOMSSYMPTOMS• SHAME AND FEARSHAME AND FEAR

STIGMA STIGMA

IMPAIRED SYSTEM IMPAIRED SYSTEM

LOWLOW

SELF-ESTEEMSELF-ESTEEM

AND AVOIDANTAND AVOIDANT

BEHAVIORS BEHAVIORS

IMPAIRED SELF-IMPAIRED SELF-CARECARE

SPIRITUAL ROOTSSPIRITUAL ROOTS

• COGNITION (IGNORANCE AND - COGNITION (IGNORANCE AND - HEADHEAD STEREOTYPING) STEREOTYPING)

• AFFECT (PREJUDICE) - AFFECT (PREJUDICE) -

HEARTHEART

• BEHAVIOR (DISCRIMINATION) - BEHAVIOR (DISCRIMINATION) -

DEEDSDEEDS

How do we learn…?How do we learn…?

……to care for each other more fully?to care for each other more fully?

……to respect each other more to respect each other more completely?completely?

Martin Martin BuberBuber

1878 - 1878 - 19651965

Buber:Buber: all dialogue depends on all dialogue depends on

the acceptance of otherness the acceptance of otherness

““Genuine conversation, and therefore every Genuine conversation, and therefore every actual actual

fulfillment of relation between men <and fulfillment of relation between men <and women>, women>,

means acceptance of otherness.”means acceptance of otherness.”

““Human life and humanity come into being in Human life and humanity come into being in genuine meetings.”genuine meetings.”

The Knowledge of Man: A Philosophy of the InterhumanThe Knowledge of Man: A Philosophy of the Interhuman, transl. , transl. Maurice Friedman and Ronald Gregor Smith (Harper & Row, Maurice Friedman and Ronald Gregor Smith (Harper & Row, NY, 1965), p. 69NY, 1965), p. 69

Henri NouwenHenri Nouwen

1932 - 19961932 - 1996

Mother TeresaMother Teresa

1910-19971910-1997

““We treat all people as children of God.”We treat all people as children of God.”

““We have been created to love and be loved.”We have been created to love and be loved.”

““Be faithful in small things because it is in them that your Be faithful in small things because it is in them that your strength lies.”strength lies.”

Exodus 22:21 Exodus 22:21 (New King James version)(New King James version)

You shall neither mistreat a stranger nor You shall neither mistreat a stranger nor oppress him, oppress him,

for you were strangers in the land of for you were strangers in the land of Egypt.Egypt.

Éxodo 22:21Éxodo 22:21  (Reina-Valera 1960)(Reina-Valera 1960)

Y al extranjero no engañarás ni Y al extranjero no engañarás ni angustiarás, angustiarás,

porque extranjeros fuisteis vosotros porque extranjeros fuisteis vosotros en la tierra en la tierra

de Egipto.de Egipto.

Internet ResourcesInternet Resources

World Psychiatric AssociationWorld Psychiatric Association www.www.openthedoors.comopenthedoors.com

www.worldpsychiatricassociation.org/www.worldpsychiatricassociation.org/sections/stigmasections/stigma

(over 50 country programs listed)(over 50 country programs listed)

• US SAMHSA's Resource CenterUS SAMHSA's Resource Center www.stopstigma.samhsa.govwww.stopstigma.samhsa.gov (over 100 state programs listed)(over 100 state programs listed)

• Canada Programs:Canada Programs:

www.mentalhealthcommission.ca/English/Pageswww.mentalhealthcommission.ca/English/Pages/OpeningMinds/OpeningMinds

Thank you.Thank you.

astern@montefiore.orastern@montefiore.orgg