Stopping Mental Illness Stigma: Changing Attitudes, Language, and Policies

Abstract

Stigma has been a pervasive and stubborn part of the mental illness landscape, but it need not be. This article explores the nature of mental health stigma, where it comes from, how it is manifested, how it harms people, and what can be done about it. The article articulates the need to clearly understand three major levels of mental health stigma—structural (e.g., laws and policies in society, institutions, and organizations), social (e.g., biases and attitudes toward others), and self (e.g., beliefs and feelings that those with mental health conditions have about themselves). Psychiatrists, psychologists, medical doctors, and counselors have, unfortunately, too often reinforced these mental health stigmas through policies, practices, and discourse. This article provides tips and strategies for collective and individual stigma reduction, with a particular focus on what mental health practitioners can do attitudinally, linguistically, and behaviorally.

The stigma surrounding mental illness and substance use disorders causes tremendous grief and pain among patients and their loved ones. This stigma also prevents individuals from seeking, obtaining, and maintaining needed care. This article offers a brief exploration of the nature of stigma, explains how it is manifested in many corners of society, illustrates the pain and suffering it brings, and offers several specific tactics that can be implemented to reduce stigma.

Let me begin by providing my own vantage point. I am not a mental health professional but rather a professional who studies mental health. Specifically, I am a management professor who has researched stigma and identity for more than 25 years. For the past 3 years, I have been part of the leadership team of a nationwide mental health antistigma initiative (Stop Stigma Together [SST], found at https://stopstigmatogether.org), which has led me to apply my scholarly work to a critical real-world problem. I am also a person with lived experiences in mental illness. My hope with this article is to blend my professional and personal insights on stigma in a way that will be useful and actionable.

What Is Stigma?

Stigma is a discrediting social evaluation that devalues an individual or group. The seminal work on stigma by renowned sociologist Erving Goffman characterized it as a discrediting attribute or mark that reduces an individual from a whole person to a discounted one (1). Pause for a moment to reflect on the inhumanity of stigma. Instead of viewing another human being as whole and valued, stigmatization fractures and devalues that person. It fractures them by focusing on a slice of their identity (e.g., mental illness or substance use disorder), and it devalues them by deciding that they are less important than other humans. In the mental health world, stigma has historically been affixed—to varying degrees—to mental illness and substance use disorders.

Not all stigmas are created equal. Stigmas vary on multiple dimensions, including

• Concealability—the extent to which the stigma is hidable; for example, mental illnesses that are visible versus invisible

• Controllability—the degree to which the stigmatized person or group is seen as responsible for having, creating, or retaining the stigmatized condition; note that this facet plays a major role in mental illness and substance use disorder stigma

• Centrality—the extent to which the stigmatized attribute is at the core of the individual’s identity or self-concept; note that this can vary across time and context

• Disruptiveness—the degree to which the stigma is seen to be a threat to others; note that this perception varies considerably from one mental illness to another

• Malleability—the extent to which the stigma can change over time or be “cured”; note that education on this facet has had mixed results in reducing stigma (e.g., sometimes learning that the brain is causing a disorder actually increases stigma because it is seen as an unchangeable problem) (2).

Where Does Stigma Originate?

Many researchers look to evolutionary theories to explain the origin of stigma. This lens takes a disease-avoidance function perspective and argues that stigma can have a useful value in society, allowing humans to avoid contact with individuals with a potentially infectious physical disease. To be sure, history shows a plethora of cases in which groups of people were stigmatized because their bodies deviated from the norm in terms of form or function (e.g., physical disabilities, infectious diseases, birth defects). Building on these evolutionary theories, Erving Goffman categorized three forms of stigma: moral (e.g., character based), physical (e.g., body based), and social (e.g., relationship based) (1). More recently, stigma scholars have argued that all three forms of stigma have morality-based undertones, given that the stigmatization process inherently involves passing values-based judgment on others (3).

In contrast to the evolutionary approach to stigma, more contemporary approaches emphasize that stigma is less about an inherent or unchangeable physical quality or objective attribute but rather more about subjective evaluations that are socially constructed by observers (4). (Indeed, the social construction approach to stigma notes that an individual need not even possess the stigmatizing quality but could instead be perceived to possess it or have a relationship with those who do possess it.) Through this lens, stigma results from an interaction between the observer and the stigmatized individual. This reframing from the objective approach to the social construction approach is tremendously important, not just from a research development standpoint but from a practical one. Knowing that the stigma does not inherently reside within the individual but rather in the relationship between stigmatized and stigmatizer means that the social perception process can be disrupted to destigmatize individuals and groups. Indeed, this framing allows a focus on the processes of stigmatization and destigmatization rather than the more static notion of an inherent stigma. An important implication then becomes clear: Because stigma is socially constructed rather than fixed, it can be reduced and even eliminated by changing how people think and behave. Indeed, studies on cultural and historical variations in stigma demonstrate stigma’s malleability—a key ingredient in destigmatization efforts (5).

Another tremendously helpful development in stigma research is the recognition that stigma requires some kind of social categorization—that is, the placing of individuals into categories—not simply casual attitudes about a person. Through this lens, one can recognize that for stigmatization to occur, an observer needs to classify another person in terms of an unwanted social category and then ascribe to them the negative stereotypes associated with that category. As I show later, this insight provides a key mechanism for destigmatization—helping people shift from an us-versus-them framing to a mental health continuum framing.

How Is Mental Illness Stigma Manifested?

To stop mental health stigma, one needs to have a sufficiently nuanced understanding of where it shows up in society, in the medical world, and in social systems. Numerous conceptualizations of mental health stigma exist, among both academics and practitioners, but for simplicity, I collapse several types of stigma into three broad categories: structural, social, and self. This three-pronged approach is consistent with major influencers in the mental health stigma space, including the 2016 report from the National Academies of Sciences, Engineering, and Medicine on ending mental health discrimination (6). Stigma occurs across these three levels, and they can be mutually reinforcing (e.g., structural stigmas reinforce social ones and vice versa).

Structural Stigma

Structural (or institutional) stigma is reflected in regulations, laws, and policies at many levels of society (e.g., national, state, and local governments; criminal justice systems; workplaces; school districts; and universities) (6). These can be found in economic, organizational, political, and social systems. Laws can prohibit individuals with mental illness from accessing needed services, education, housing, and employment. SST is currently undertaking a legal mapping study in the United States to document laws that either reinforce or dismantle mental health stigma; this will allow us to tailor lobbying efforts for change. The medical world is not immune to these challenges; for example, 22 U.S. states currently allow medical schools to ask applicants whether they have ever been treated for a mental illness—information that could be used against the applicants during admissions decisions.

Organizational policies can also (even inadvertently) reinforce mental health stigma by reifying the us-versus-them paradigm rather than the mental health continuum paradigm, such as when benefits programs have discrepancies between general medical health and mental health conditions (e.g., in access, copays) or when employers have separate (or perhaps more stringent) criteria for days off for mental health than for general medical health.

It is critical to recognize that structural stigma leads to many of the downstream effects that other sections of this article address. Addressing structural stigma first and foremost involves changing policies, which then affects behaviors, which then lead to attitude change. By contrast, most efforts aimed at social and self-stigma take the opposite approach.

Social Stigma

Also known as public stigma, social stigma includes the cultural and subcultural perceptions of society (6). Social stigma has three main components (as first popularized by Sir Graham Thornicroft, who has written extensively about mental health stigma) (7): knowledge (misinformation), attitudes (prejudice), and behavior (discrimination).

Thornicroft’s model proposes a process in which knowledge leads to attitudes, which lead to behavior. On the stigmatizing track, misinformation about mental health leads to prejudice about people with mental illness or substance use disorders, which then leads to discriminatory behavior. On the destigmatizing track, correct information (e.g., education, social contact) leads to compassion, which then leads to acceptance and belonging.

Messages from the media, family members, and clinicians often portray those with mental illness or substance use disorders as choosing their illness and therefore meriting blame and judgment as opposed to being complex individuals affected by mental illness. Furthermore, social stigma often conveys the erroneous message that the person with mental illness is the primary (or sole) cause of the affliction rather than taking the more accurate socioecological view that mental illness results from a constellation of factors (e.g., ecological, biological, and personal). SST is studying social stigma by sponsoring part of the General Social Survey (the gold standard in sociological research) as well as working with the Ad Council to measure mental health stigma on a regular basis. These efforts will allow us to track changes over time.

Too often, social stigma is created or reinforced by the very people who should be helping those with mental illness—psychiatrists, counselors, family, teachers, coaches, friends, human resources professionals, and coworkers (8). Early examples of this were documented in mental institutions by Goffman (8) and more recently addressed by Pescosolido (9). For example, individuals in these professions might use stigmatizing language, treat their clients as “less than,” blame the person for their illness, or reinforce us-versus-them thinking. Posters, fliers, or signage in offices might visually reinforce stigmatizing imagery (such as depicting a person with depression as the stereotypical head-in-hands person sitting in a dark corner). Sadly, this variant of stigma is so prevalent that some researchers have dedicated a separate category to it, what Gretchen Grappone calls “health practitioner stigma” (10). Indeed, some of the most stinging pain experienced by individuals with mental health challenges comes from those who are closest to them or from mental health professionals. Conversely, people associated with a stigmatized person can also become stigmatized themselves—a phenomenon known as “stigma by association” or “courtesy stigma” (1). This implies that the effects of stigma go well beyond the individual with mental illness or substance use disorder.

Self-Stigma

A set of negative beliefs about oneself as related to mental health is reflected in the notion of self-stigma (10). This includes accepting negative stereotypes, feeling shame, and adopting a “why try?” attitude. Self-stigma, which often operates on a subconscious level, results from internalizing the structural and social stigmas felt by those with mental illness. Experiencing mental illness is often a lonely journey. Sadly, and tellingly, a recent global study on those experiencing mental illness and substance use disorders found that 80% of those surveyed said the hurt caused by stigma and discrimination was worse than the condition itself (11). A self-perception of being flawed often co-occurs with shame, and this internalization often leads to a belief that one is unworthy of belonging, connection, friendship, employment, or love. Furthermore, this internalized stigma is one of the main deterrents to people seeking help and sticking with treatment. Indeed, individuals often avoid seeking treatment in large part because of the fear of receiving a mental illness diagnosis; such fear is driven by the stigma. With the goal of reducing self-stigma, SST is engaging in a series of qualitative studies, each focused on the lived experiences of a different part of the U.S. population (e.g., farmers, entrepreneurs, peer support specialists).

What Are the Consequences of Mental Health Stigma?

The impact of mental health stigma is well documented across a wide spectrum of academicians, including sociologists, psychologists, medical practitioners, ethnographers, legal experts, and management scholars.

Mental health stigma prevents or discourages

• Policymakers from crafting laws free from discrimination

• People from discussing their mental health challenges and potentially helping each other

• Workplaces from taking action on benefits and policies

• Students from pursuing careers in the mental health arena

• People from getting the help they need (counseling, advice, medication)

• Sufficient funding for the mental health system

• Children from getting needed developmental care.

Mental health stigma leads to increased

• Stereotyping, isolation, and discrimination by members of society

• Shame and self-loathing by those experiencing mental illness

• Suicidal ideation and suicide

• Workplace absenteeism and turnover

• Substance use disorders

• Disparities in health care for underserved groups (e.g., rural Americans; Black, Indigenous, and people of color; lesbian, gay, bisexual, transgender, queer/questioning [LGBTQ+] individuals)

• Self-blame by children regarding others’ mental illness (e.g., parental substance use disorder)

• Enmity between partners and between children and parents.

How Can Mental Health Professionals Stop the Stigma?

Having now dived into the levels of stigma and its pernicious effects, I turn to the most pressing question: What can health professionals do to stop the stigma? I outline 11 actions that can be taken, ranging from individual to collective efforts and from linguistic to behavioral changes. The more these tactics are shared, the more collective impact these efforts can have. These 11 tactics are summarized in Box 1 for ease of reference and explored in depth here.

BOX 1. Tactics for destigmatization

• Help patients reframe mental health identity.

• Recognize the intersectionality of mental health stigma.

• Promote mental health continuum thinking rather than us-versus-them thinking.

• Increase social contact.

• Educate oneself and one’s peers.

• Educate the public.

• Connect patients with allies and peer support specialists.

• Replace stigma-reinforcing language and images.

• Share your own mental health journey.

• Advocate for legislative and policy change.

• Join the online Stop Stigma Together community.

Help Patients Reframe Mental Health Identity

People’s self-concepts can be greatly damaged by mental health stigma. As individuals internalize the negative structural and social stigmas around them, their identities can be deeply harmed. Mental health professionals can help buffer the effects of stigma by helping patients reframe their mental health identity. Specifically, professionals can help patients reframe thoughts such as “I am a bad person” or “I am a weak person” to “These bad things are happening to me” or “My environment and my biology have been negatively affecting me.” Such replacement thoughts help patients adopt a more useful (and scientifically sound) socioecological model of health lens rather than the harmful (and out-of-date) self-blame lens. Similarly, professionals can encourage thoughts such as “I am the same person as I was before my substance use, but I want to change my behaviors” or “I am responsible for my actions, but mistakes don’t equate to being a bad person.” Note how these reframing statements focus on the behavior change rather than holistic condemnation of the patient’s identity. They also help to preserve the person’s dignity while suggesting a positive path forward.

Recognize the Intersectionality of Mental Health Stigma

Having a mental health condition is only one part of a person’s overall identity. Yet, a stigmatized identity can negatively spill over into other aspects of a person’s identity (e.g., a professional whose mental illness dampers their self-efficacy at work) (12). This is important for mental health professionals to keep in mind for at least two reasons: first, to avoid dehumanizing or oversimplifying a whole, complex person into one monolithic image and, second, because the particulars of the person’s other identities (e.g., race, ethnicity, sexual orientation, socioeconomic status, occupation, disability, religion) will often intersect with their mental health identity. These intersections create unique circumstances for each patient—for example, it is likely that a Black man in Atlanta will not experience mental health stigma in the same way as a White woman in rural Wyoming. Furthermore, if a patient has other stigmatized identities in addition to mental illness, they are likely to experience a compounding (and often mutually reinforcing) negative effect. Hence, mental health professionals should be especially attuned to patients from underserved and marginalized communities, taking care to understand and show compassion for their unique lived experiences and how they might affect treatment plans. They should also realize that intersectionality implies a potentially wide array of responses to treatment, based on the particular constellation of identities faced by any given patient.

Promote Mental Health Continuum Thinking Rather Than Us-Versus-Them Thinking

As noted earlier, stigmatization occurs through social categorization—placing people into discrete categories of good or bad. Traditional modes of thinking regarding mental health are overly dichotomous—either you have a mental illness or you do not. This kind of black-and-white thinking foments stigma by creating an enmity between those who are seen as healthy and those who are seen as unhealthy. By contrast, and as shown in Figure 1, mental health professionals can educate and emphasize that everyone falls on a continuum of mental health, from healthy on one end to severe illness on the other, with moderate mental health conditions in the middle. Doing this replaces us-versus-them thinking with a shared-boat mindset. Patients and their friends and family members can all be taught that each of them is somewhere on this mental health continuum and that their location on that continuum often changes—sometimes from day to day and sometimes over longer periods. This is a powerful tool for destigmatization because it helps people realize that part of being human is to experience variability in their mental health—and that anyone could find themselves on the more difficult side of the continuum at some point in their life.

FIGURE 1.

A mental health continuum

Increase Social Contact

Study after study has shown that, for many people, the most effective way to reduce mental health stigma is increased social contact with those who have mental health challenges (11). This contact helps to break down knowledge, status, and interpersonal barriers that create and reinforce stigma. When individuals meet and learn from those with a mental illness, a more human experience is shared that personalizes rather than depersonalizes mental illness. Interestingly, indirect social contact (such as an online workshop) is often as effective as in-person social contact—a major insight, given the ease and availability of online training. A key implication of the social contact approach is that training (and speeches, presentations, and webinars) needs to be done not only by mental health professionals but also by those with deep involvement and lived experiences. Indeed, the “nothing about us without us” mantra often invoked in the disability world directly applies here. Moreover, and in line with other recommendations, when the mental health professional is also a person with lived experience, sharing both perspectives can be especially helpful for destigmatization. Many destigmatization programs across the globe now use ambassadors—people with lived experience—in their education programs to provide structured and meaningful social contact. Peer support specialists also provide contact with those having lived experiences.

Educate Oneself and One’s Peers

Mental health professionals can all benefit from staying up to date on the latest findings regarding destigmatization, including language usage. Establishing continuing education is essential and could include coaching, role plays, and online or in-person training. Such education could be done informally within a practice or facility or more formally through invited lecturers.

Educate the Public

Many misconceptions about those with mental illness and substance use disorder continue to permeate society, for example, the belief that those with mental illness are more violent than the general population or that someone who uses substances is to blame for their situation. Education—whether through formal mechanisms (such as workshops, webinars, and white papers) or informal mechanisms (such as conversations or instructions to patients)—presents fact-based information about mental illness and substance use disorders to reverse misinformation, stereotypes, and myths. Education can address stigma directly or provide practical information for locating mental health services (such as the 988 hotline in the United States). Formal initiatives include the recently launched “Love, Your Mind” campaign cosponsored by the Ad Council and the Huntsman Mental Health Institute at the University of Utah. This campaign invites people to begin and deepen the relationship with their own mind, normalizing conversations about mental health. Other campaigns across the globe include Scotland’s “See Me” and Denmark’s “One of Us.” Generally speaking, education changes adolescents’ attitudes about mental health more than adults’, whereas social contact (described earlier) is more effective for adults (13, 14). That said, there is evidence for the effectiveness of mass media campaigns (15).

Connect Patients With Allies and Peer Support Specialists

Despite differences in how health care operates around the world, there is now widespread agreement among global mental health advocacy groups that it is not possible to respond to the grand scale of mental health needs only through traditional clinical care solutions. Rather, community is key. Traditional psychiatric and psychological care needs to be augmented by developing specialized care among community members. The past several years have seen a burgeoning of formal and informal programs that help those with mental illness find such social support. Informally, connecting patients to allies and advocacy groups (either specific to their diagnosis or more general) can have a powerful effect on sense-making and recovery. Formal programs include peer support specialists, now found in many countries and in most U.S. states, that pair patients with individuals who have been trained to deliver mental health services, drawing on their own lived experiences of illness and recovery. Research supports the effectiveness of peer support specialists, who provide mentoring, self-empowerment, community connections, and empathy to their clients (16). For example, peers can help provide cognitive and emotional resources for those with mental illness by providing examples of new ways to see themselves in the recovery process.

Replace Stigma-Reinforcing Language and Images

Words matter. Language can be a major mechanism through which to either reinforce or dismantle stigma. Although mental health professionals are broadly familiar with that principle, it is often easy to inadvertently use language that reinforces mental health stigma. Such language can perpetuate stereotypes and reinforce negative beliefs. The way practitioners speak to each other, as well as the way they address patients and their family members, can either uplift or tear down identity. As a general guide, using person-first language (in which the illness or condition is mentioned second, putting the person first) and strengths-based language (focusing on the patient’s capabilities rather than only on the problem) can destigmatize mental illness. Table 1 provides several examples of ways to replace stigmatizing language.

TABLE 1.

Replacing stigmatizing language

Stigmatizing language	Replacement
Addict, alcoholic	Person with addiction, person with substance use disorder
Clean (regarding a person)	In remission or in recovery
Clean or dirty (regarding a drug test)	Negative or positive
Dope sick	Experiencing withdrawal (draw on more accurate terminology)
Drug	Medication or non–medically used psychoactive substances (drug can refer to legal or illegal usage of a substance)
Drug abuse	Substance use
Drug-addicted baby	Infant prenatally exposed to substances
Drug of choice	Drug of use
Former addict	Person in recovery
Opioid replacement therapy	Medications for addiction treatment or medication for opioid use disorder (typically preferred because of the possible mindset that it simply replaces one addiction for another)
Relapse (slip, lapse)	Resumed usage, returned to use, or experienced a recurrence of substance use
Substance abuse, substance misuse	Substance use

In addition to the written or spoken word, images can play a key role in the stigmatization process. Practitioners can take a look at posters and pictures in their office and on their website and handouts. Do they reinforce stereotypes, such as having everyone looking sad or in literally dark and shadowy places? Do they leave out demographic groups? Consider doing a “systems walkthrough” in which you both physically walk through your building and metaphorically walk through your practices and policies, looking for items that might reinforce stigma.

Share Your Own Mental Health Journey

A key component of destigmatization is normalization—making talking about mental illness normal. The more often—and the more authentically—people talk about their own mental health, the more likely it is that others will do the same and get the care and connection they need. Indeed, in doing so, people can also genuinely inquire how friends, colleagues, and family members are doing with regard to their mental health. Jerome Adams, the former U.S. Surgeon General, shared a compelling story about substance use in his own family:

We know that there is a stigma attached to acknowledging that you have mental health issues…. If we’d looked at it as a disease, perhaps my brother would have been given help sooner, before his addiction worsened and before he got involved in the criminal justice system. It’s a painful story to tell…. I do it because if addiction can happen to the family of the Surgeon General of the United States, it can happen to anyone. (17)

That phrase—it can happen to anyone—is a powerful sentiment that becomes reinforced when people share their own stories. Books such as An Unquiet Mind (18) and The Bipolar General (19) were written by people with lived experience with mental illness and help to normalize these conditions. In addition to these books, which feature one person’s story, recent books in the popular press (e.g., You are Not Alone [20] and Profiles in Mental Health Courage [21]) have facilitated the sharing of numerous stories. These books profile multiple individuals with mental health challenges and obtained permission to use their names, helping not only by sharing the content but also by being public about their journeys. Let me practice what I preach. In my case, I have experienced anxiety issues since I was very young. I have had seasonal affective disorder most of my adult life and have experienced clinical depression. A couple of years ago, I was also diagnosed as having attention-deficit hyperactivity disorder. I have used various medications, spiritual practices, and mindfulness practices to address the symptoms and effects of these conditions. I share my own journey with my students, colleagues, friends, and family to help them gain the courage to do the same and seek any treatment they might need. Perhaps you are reticent to share your own journey—especially in a field where discrimination might follow. If that is the case, that is all the more reason to work to change the stigma at the structural and social levels, so that you and others can experience more authenticity in your profession.

Advocate for Legislative and Policy Change

Beyond actions people can take in their own personal and professional realms, advocating for broader change can be tremendously helpful. As individuals and groups come together, their collective influence becomes more powerful, especially to combat structural stigma. For example, you could work toward policy changes not only in your own practice, but also in state licensing boards and professional associations. Other destigmatization success stories (e.g., race, physical disabilities, LGBTQ+) have shown that social and self-stigma reduction often follow structural stigma reduction.

Join the Online SST Community

As mentioned, I am part of a national initiative in the United States to end the stigma surrounding mental illness and substance use disorders. SST has created an online community for those who are passionate about ending stigma (https://www.sst.community/home), and we invite you to join us. We offer numerous resources for practitioners, policy makers, leaders, and advocates; these include tool kits, news and events, discussion threads, first-person accounts from those with lived experiences (as both patients and practitioners), and best practices. We also have numerous communities of practice—groups within the broader SST community that are focused on particular domains of interest, such as children, youths, and family; workplaces; policy; journalism; entertainment media; and rural America. These communities of practice allow members to find like-minded individuals who have specialized interests and break down the barriers that too often exist across organizations and industries.

Conclusions

In summary, people are each a part of both the problem and the solution to mental health stigma. My hope is that through a deeper knowledge of stigma—and the many ways in which it harms so many—we can apply these destigmatization techniques so that people seek, obtain, and maintain the help they need.