Understanding the Multi‐Faceted Nature of the Public Stigma of Mental Illness: Insights and Implications From a Structural Violence Perspective

ABSTRACT

The societal stigma surrounding mental illness emerges because of dysfunctional social dynamics between patients, their families and the broader community. This phenomenon, referred to as public stigma, manifests through discriminatory actions or the exclusion of individuals within power structures. Public stigma detrimentally affects the well‐being and recovery of those grappling with mental illness, impeding their quality of life. This paper discusses public stigma, examining society's negative attitudes toward individuals diagnosed with mental illness, the systemic injustices perpetuating their marginalisation and the ramifications for nursing practice. Ultimately, the authors propose a theoretical framework to educate and inform health professionals across both mental health and general medical domains, as well as policymakers, about the impact of structural violence in perpetuating public stigma and providing recommendations for remedial action.

1. Background

Mental health disorders represent approximately 14% of the global disease burden (Institute for Health Metrics and Evaluation [IHME] ²⁰²¹; Whiteford et al. ²⁰¹⁵; World Health Organization [WHO] ²⁰¹¹). Bloom et al. (2011) revealed a substantial global financial burden associated with mental health, estimated at around US$ 2.5 trillion in 2010, with projections suggesting this figure could more than double by 2030 if the current pattern of neglect persists. Individuals with mental illness continually face stigma from society, resulting in detrimental consequences. As defined by Goffman (1963), stigma entails undesirable attributes that lead to social rejection and prompt stigmatised individuals to conceal their condition.

In 2022, Gyamfi expanded on Goffman's definition of stigma as:

The product of historically rooted public attitudes and behaviors (i.e., religiocultural and structural violence perspectives) that characterize labeling, stereotyping, prejudice, cognitive separation, status loss, and discrimination that lead to responses of stress and esteem‐related appraisal of experienced, anticipated, perceived or personal endorsement of societal actions due to existing power relational differences (p. 120).

Despite the alarming statistics, efforts to address mental health issues remain inadequate due to pervasive societal stigma (Hoftman 2017; Knaak, et al. ²⁰¹⁷; Thyloth et al. ²⁰¹⁶). This pervasive societal stigma, coupled with the adverse impact of public stigma on the well‐being of patients, their families, healthcare professionals and institutions involved in mental healthcare, constitutes social injustice, otherwise known as structural violence (S. K. Gyamfi ^{2022, 2024}; Gyamfi, Forchuk, et al. ²⁰²⁵) and emphasises the pressing need for ongoing comprehensive discussion and action. Norwegian sociologist Johan Galtung (1969) introduced the concept of structural violence (SV) in his seminal work on peace and violence, defining it as a form of psychological violence that arises from indirect acts that constrain human agency and autonomy. Galtung equates structural violence with social injustice. Throughout this discourse, the term ‘structural violence’ will be consistently employed.

S. Gyamfi (2024) defines structural violence as:

The effect of historically rooted power differences (visible or invisible) embedded in religious, cultural, and political systems that enable and justify public stigmatizing behaviors toward marginalized persons, skewing their life chances and denying them of existing social services (including employment, access to education, and health services) in favor of persons regarded as ‘superior’ in society (p. 7).

Galtung's formulation of SV posits a notable absence of a discernible ‘actor,’ distinguishing it from physical violence and rendering its mitigation challenging as the source remains obscured. The perpetration of violence is not directly attributable to any visible individual; rather, it becomes ingrained within existing social structures, reflecting disparities in power dynamics, notably evident in resource allocation. This systematic imbalance results in skewed life opportunities and access to social services, including employment, education and healthcare, in favour of socially privileged groups. The entrenched nature of SV within social systems complicates efforts to challenge the status quo, particularly when injustice persists due to the ignorance or apathy of decision‐makers vested with societal authority. Structural violence often remains imperceptible until marginalised individuals or groups endure prolonged marginalisation, significantly deteriorating their quality of life. In all, Galtung advocates for the pursuit of ‘structural peace,’ which entails measures aimed at rectifying existing societal inequalities.

2. Defining Key Terms

We identify and define four types of stigma as follows:

• Public stigma refers to the phenomenon where stereotypes and negative beliefs held by society lead to discrimination against individuals with mental illness.

• Self‐stigma occurs when individuals with mental illness internalise societal prejudices, resulting in negative self‐evaluation and reduced self‐esteem.

• Stigma by association involves the stigmatisation of individuals through their association with mental health conditions or services, affecting not just those with mental illness but also their friends, family and caregivers.

• Structural stigma arises from institutional policies and societal structures that systematically limit the opportunities and rights of people with mental illness, often manifesting in employment discrimination, healthcare disparities and social exclusion.

3. Aim of the Paper

This article aims to critically analyse the multifaceted nature of mental illness stigma within the framework of structural violence by examining its origins, impact and persistence across societal and healthcare domains; and to advocate for a paradigm shift in how mental health nursing professionals perceive and address stigma.

4. Design and Methods

This paper discusses the means of mental illness stigma within the public space, with implications for nursing. By integrating theoretical perspectives and reviewing existing literature, the paper highlights the bidirectional relationship between mental illness and societal stigma, emphasising how structural violence perpetuates this stigma and discriminates against individuals with mental illness. Ultimately, the paper advocates for a paradigm shift in how mental health nursing addresses stigma, proposing actionable strategies for nursing education, practice and research to mitigate stigma and promote a more inclusive, equitable and compassionate approach to mental health care.

5. Theoretical Perspectives of the Means of Public Stigma Associated With Mental Illness

Emerging theories recognise structural violence as a crucial factor that maintains societal stigma toward marginalised groups, including persons with mental illness (S. Gyamfi ²⁰²⁴; Gyamfi, Forchuk, et al. ²⁰²⁵). According to the Dynamic Stigma Theory proposed by S. Gyamfi (2024), public stigma aimed at PWMI constitutes a ‘violence’ and an ‘infringement on their human rights’ that is likely to impact the family and professional caregivers, who may potentially transfer the perceived threat of stigma onto the PWMI during care. Overall, the Dynamic Stigma Theory emphasises the complex, cyclical and evolving nature of mental illness stigma. It further highlights the interplay between individual experiences, societal influences and broader power structures that shape caregiving and its outcomes. This interaction results in the ongoing internalisation of stigma processes, an increased oppressive system, social suffering and the anticipation of discrimination in social contexts, contributing to maladaptive coping mechanisms (for survival) (S. Gyamfi ²⁰²⁴; Gyamfi, Forchuk, and Luginaah ²⁰²⁴; Gyamfi, Forchuk, et al. ²⁰²⁵).

Over the years, numerous investigations have confirmed the existence of societal stigma surrounding mental illness, impacting not only patients but also their immediate family members and caregivers (Pryor et al. 2012; van der Sanden et al. ²⁰¹⁶). Mental illness stigma, as defined by Klarić and Lovrić (2017), includes negative labeling, marginalisation and avoidance solely based on the presence of a mental health condition. It can also be described as the process through which entrenched societal labels (stereotypes) diminish the social standing of persons with mental illness (PWMI), resulting in decreased acknowledgment and acceptance.

While Goffman (1963) initially theorised stigma as a one‐dimensional concept tied to social context, contemporary theories now consider stigma from both social and psychological perspectives. For instance, the ‘Identity threat model of mental illness stigma’ (Major and O'Brien ²⁰⁰⁵) elucidates the psychological and social ramifications of stigma on PWMI, impacting various aspects of their lives, including self‐esteem, academic performance and overall health. This paper, however, focuses exclusively on the social aspect of stigma to clarify the mechanisms of public stigma development and its subsequent outcomes. Goffman's seminal work serves as the cornerstone around which all conceptualisations of stigma revolve. Thus, Goffman's work is examined alongside the conceptualisations of stigma by Link and Phelan (2001) and those of Corrigan et al. (2010) to elaborate on the development of public stigma surrounding mental illness and its ensuing consequences.

Link and Phelan (2001) conceptualise mental illness stigma through five interrelated components: labeling, stereotyping, separation, status loss and discrimination. They argue that labeling arises from the societal process of categorising PWMI, leading to perceived differences within society. These undesirable labels associated with PWMI separate them, thereby facilitating the development of stereotypes. Subsequently, separation occurs and manifests as hierarchical categorization characterised by segregation, social distancing and exclusion, which reinforces the ‘us’ (public) versus ‘them’ (people with mental illness) dichotomy. Goffman (1963) similarly describes such social categorizations as ‘normals’ (the public) versus ‘stigmatised’ (PWMI), in which the latter are perceived as ‘non‐humans,’ resulting in a significant reduction in life opportunities. Consequently, unequal power dynamics ensue, empowering the ‘normals’ (the public) to dictate the position of the ‘stigmatised’ (people with mental illness). PWMIs are devalued by society and relegated to the bottom of the social hierarchy, leading to status loss and subsequent discrimination.

Similarly, proponents of the social‐cognitive model of mental illness stigma (Corrigan et al. 2010) have emphasised three key components: stereotypes, prejudice and discrimination, as prerequisites for public stigma against individuals with mental illness. They posit that society must first stereotype individuals, labeling them with terms such as ‘dangerous,’ ‘violent,’ ‘crazy,’ ‘insane,’ ‘criminal,’ or ‘unpredictable,’ which foster enduring negative perceptions about the ‘mentally ill’. These perceptions eventually give rise to prejudice, culminating in discriminatory behaviours such as disrespect, devaluation and ostracisation.

Deconstructing Goffman's definition of stigma reveals parallels with the conceptualisations of stigma by Link and Phelan (2001) and Corrigan et al. (2010), particularly concerning aspects of labeling, stereotyping, separation, status loss and discrimination. While Goffman does not explicitly outline the concept of ‘prejudice,’ it can be inferred from his work as well as from that of Link and Phelan (2001) and Corrigan et al. (2010). Link et al. (2004) critiqued the earlier work of Link and Phelan (2001) for overlooking the emotional reactions (prejudices) of the public that lead to attitudes of separation and status loss, advocating for greater attention to the emotional evaluative aspect of stigma development and outcomes. Therefore, prejudice serves as a precursor to instances of separation and status loss. Consequently, this paper consolidates the concepts of prejudice, separation and status loss under one framework, exploring their interplay within the realms of power and its influence in the development of public stigma against mental illness.

Furthermore, Link and Phelan (2001) assert that social, economic and political power imbalances must be present to foster a sense of ‘otherness’ and distinct categorization within the social realm before stigma can manifest. This perspective informs the discussion of structural violence as it relates to public stigma against mental illness. Thus, this paper examines the components of public stigma as outcomes under three major subheadings: labeling and stereotyping behaviours by the public, prejudice, separation, status loss and public discrimination.

6. Labeling and Stereotyping Behaviours by the Public

Dudley (2000) characterises public stigma as the manifestation of stereotypes or negative attributions directed toward individuals or groups whose characteristics or behaviours deviate from, or are perceived as inferior to, societal norms. The social reaction theory, as proposed by Lemert (2000), emphasises the socially constructed nature of stigma related to mental illness, asserting that members of society tend to label individuals with mental illness (PWMI) based on perceived deviations from societal norms; thereby fostering stereotypes and ultimately leading to prejudice.

Labeling emerges as a crucial factor in mental illness stigma, as evidenced by Parcesepe and Cabassa's (2012) systematic review of 36 articles in the United States. The review revealed widespread public stigma, with PWMI often portrayed as dangerous, incompetent, violent and criminal. Similar findings have been documented worldwide (e.g., Schomerus et al. ²⁰¹²; Sorsdal et al. ²⁰¹²; Hansson et al. ²⁰¹³; Igbinomwanhia et al. ²⁰¹³; Yuksel et al. ²⁰¹³), illustrating the widespread negative perceptions of PWMI among the public.

The perpetuation of labeling and stereotyping has led to widespread societal calls for the segregation of PWMI from communities, resulting in the establishment of psychiatric hospitals at considerable distances from urban centres to align with public sentiment. For example, Igbinomwanhia et al. (2013) documented the attitudes of Christian and Muslim clergy in Nigeria, revealing a substantial proportion advocating for the isolation of PWMI and expressing discomfort with their presence in residential neighbourhoods. These sentiments reflect entrenched public stereotypes regarding PWMI. Furthermore, a prevailing belief among certain segments of the public holds that PWMI are inherently incapable and, therefore, require control, leading to informal authoritarian practices within healthcare and community settings. This has resulted in unwarranted infringements on patients' human rights, where assertive individuals who challenge the status quo are often subjected to coercive measures, such as readmission to psychiatric hospitals as a form of punishment.

Moreover, due to widespread labeling and stereotyping, the public is more likely to mistakenly associate violent crimes with PWMI, perpetuating the cycle of stigma. Torrey (2011) identifies the enduring belief that PWMI are predisposed to violent behaviour as a significant factor fueling public stigma, a notion supported by McGinty et al.'s (2016) analysis of news coverage in the United States. However, Torrey (2011) also assert that effective treatment of PWMI can reduce violent behaviour, emphasising the importance of evidence‐based treatment modalities, interdisciplinary collaboration and individualised care plans in improving clinical outcomes (Talisman et al. 2015). To effectively address mental illness stigma, it is crucial for all stakeholders to prioritise and ensure the delivery of comprehensive treatment in both community and hospital settings, thereby challenging and reducing the impact of societal stereotypes and prejudices.

7. Prejudice, Separation and Status Loss

Prejudice refers to a negative evaluative stance characterised by cognitive and emotional reactions in the public sphere, which facilitates segregation and diminishes social status. These prejudices often consist of unfavourable preconceived notions held by the public, which may not necessarily align with the actual behaviours exhibited by PWMI. Klarić and Lovrić (2017) have suggested that a lack of understanding of mental illness and associated misconceptions, such as myths and fear, serves as the basis for perpetuating negative public perceptions of PWMI. These entrenched stereotypes manifest in various forms of unjust treatment toward PWMI, ranging from overt hostility and physical violence to neglect fuelled by anger‐based prejudice, as well as social exclusion, distancing and isolation prompted by fear or distrust. These issues lead to detrimental outcomes such as unemployment, marital dissolution and social marginalisation. Parle's (2012) systematic review highlights the persistence of public aggression toward PWMI, partly due to prevailing public prejudices exacerbated by ignorance, as argued by Klarić and Lovrić (2017). Instances of physical and verbal attacks, social ostracism and property destruction directed at PWMI by community members are not uncommon, especially in low‐ and middle‐income countries (LMICs), where such behaviours often occur with impunity, resulting in profound relational breakdowns between PWMI and their social circles (Gyamfi, Owusu, et al. ²⁰²⁵).

The phenomenon of social distancing and avoidance of PWMI has been extensively documented (Schomerus et al. 2012; Sorsdal et al. ²⁰¹²; Hansson et al. ²⁰¹³; Igbinomwanhia et al. ²⁰¹³; Yuksel et al. ²⁰¹³), with severe ramifications for those stigmatised. Deliberate efforts to shun and exclude PWMI from routine social interactions contribute to their social isolation and profound feelings of loneliness, perpetuating a cycle of discrimination rooted in an entrenched ‘us‐them’ dichotomy (Corrigan et al. 2010). In certain LMICs, mental illness is often perceived as a curse or divine punishment, leading to the ostracisation not only of affected individuals but also their entire familial lineage, exacerbating challenges such as marital difficulties and economic hardships, particularly for women in these families (Gyamfi et al. 2018; Gyamfi, Forchuk, Booth, and Luginaah ²⁰²⁴; Gyamfi, Owusu, et al. ²⁰²⁵).

Consequently, many PWMI experience feelings of worthlessness, condemnation and profound loneliness, accompanied by psychological anguish and enduring misery, which often culminate in suicidal ideation as an escape from relentless feelings of hopelessness exacerbated by the burden of mental illness stigma (Warrel 2018). It is imperative for every member of society to take responsibility for safeguarding the well‐being of individuals grappling with mental illness. PWMI are affected through no fault of their own and should not bear the brunt of societal repercussions stemming from their condition.

Due to stigma, individuals who experience it tend to avoid or limit disclosing their identities, become socially isolated or shy away from situations that could lead to embarrassment (Bruckert and Hannem 2012; Goffman ¹⁹⁶³). This contributes to the development of what Bruckert and Hannem (2012) refer to as stigma consciousness, the ‘hidden’ cost of stigma where the experience of stigma ‘colors individuals' interpretations of their daily interactions and [affects] their way of being in the world’ to the extent that the stigmatised denies their own personal identity (p. 4). The stigmatised person (PWMI) feels diminished because of their stigmatised trait, leading to a loss of status and feelings of disadvantage (Roberts and Weeks 2017).

8. Public Discrimination of People With Mental Illness

Discrimination can be defined as the act of disadvantaging an individual or group due to their mental health condition. Individuals with mental illness often encounter discrimination, which is evident in the social, economic and political power disparities present in society (Link and Phelan 2001). Consequently, the devaluation, ostracization and exclusion from community activities faced by PWMI arise from deep‐rooted structural biases. Link and Phelan (2001) contend that structural discrimination negatively affects individuals diagnosed with mental illness, including contributing to insufficient funding for mental healthcare. This is demonstrated by the disproportionately low allocation of healthcare budgets to mental health services globally, typically amounting to < 1% (Rosenberg 2017).

Discrimination driven by stigma adversely affects the social standing, psychological well‐being and physical health of people with mental illness (PWMI). Numerous studies, including those by Major and O'Brien (2005) and Munn‐Rivard (2014), highlight the widespread discrimination that stigmatised individuals face in various areas, such as education, housing, healthcare, employment, the justice system and participation in social and political activism. Major and O'Brien's conceptual framework on identity threat clarifies how public stigma and biased attitudes limit involvement in significant life events, thereby lowering their societal status. Through repeated exposure to societal stereotypes, PWMI internalise and adapt to the collective perception of their social position, thus acknowledging their devaluation and discrimination.

Parle's systematic review in 2012 revealed that individuals with mental illness encounter discrimination during job searches, often facing employment rejections. Those who secure employment often endure workplace mistreatment, including bullying, ridicule, demotion or salary reduction. The fear of social ostracisation, coupled with apprehension of ridicule, discrimination and judgement, deters many PWMIs from disclosing their mental health issues to others (Gyamfi, Owusu, et al. ²⁰²⁵).

The evidence suggests that ignorance and inadequate social support exacerbate public stigma. Therefore, effective community‐based anti‐stigma initiatives should prioritise spreading knowledge. Educating the public about the biological underpinnings of mental illness is crucial for fostering understanding and garnering support for PWMI, thus laying the groundwork for combating stigmatising behaviours within society.

9. Structural Violence and the Stigma of Mental Illness

Individuals diagnosed with mental illness often fall within the societal classification of inferiority, necessitating an examination of public stigma through the lens of SV. Existing literature suggests that SV not only instigates but also enables mental illness stigma, thereby perpetuating the exploitation and oppression of marginalised individuals. It is increasingly clear that public stigma is intricately intertwined with the underlying structures of SV, serving as a foundational mechanism for the flourishing of stigma.

Historically, individuals with mental illness have suffered the most from SV, as shown by chronic neglect and underinvestment in mental healthcare infrastructure. Governments and non‐governmental organisations demonstrate minimal interest, as evidenced by disproportionately small budget allocations for mental health services worldwide. The societal significance and role of mental health are largely overlooked as a civic concern, contributing to worse mental healthcare outcomes. Addressing mental health issues as a civic duty is essential, given the widespread nature of mental illness across all societal layers.

Despite Galtung characterising SV as primarily latent and inherent within social structures, Chopra (2014) identifies various factors—including institutional frameworks, prevailing ideologies, social relationships, discriminatory legislation, classism, gender disparities and racism—as crucial in shaping SV within societal frameworks. Anayika further asserts that while social power dynamics affect all members of a given social order, marginalised groups, such as individuals with mental illness, experience disproportionate suffering regarding disease burden, mortality rates, unemployment, educational inequity, homelessness, limited healthcare access and poverty. The marginalising influence of social institutions manifests through ideological biases that perpetuate discriminatory laws, impeding the agency of marginalised groups. The consequences of SV create entrenched inequalities, fostering ongoing psychological anguish, which Merrill and Erickson (2011) term ‘social suffering.’ For instance, in many countries, including the United States, health insurance coverage often excludes individuals with mental illness, depriving them of essential healthcare services. PWMI face significant barriers to accessing medications and necessary care, exacerbating their already vulnerable situation. Studies such as Tristiana et al. (2018) underscore the dire conditions confronting PWMI, including prolonged wait times for medication and inadequate facilities in psychiatric hospitals. These deficiencies stem from public stigma and governmental neglect, indicative of systemic failures in policymaking regarding mental healthcare. It is crucial to recognise that national laws, health policies and resource allocation decisions reflect societal values and norms. Therefore, the lack of emphasis on mental health care should be viewed as a deliberate strategy aimed at marginalising PWMI.

10. Conceptualising a Structural Violence and Stigma Framework

Drawing on the knowledge gathered from the literature, we propose an explanatory framework of structural violence and stigma to enhance understanding of the impact of public stigma and structural violence on professional healthcare and outcomes. This ‘structural violence and stigma (SVS) model’ outlines the complex and layered ways public stigma operates at societal, interpersonal, individual and systemic/institutional levels to influence care outcomes. The model provides insights into how negative societal attitudes toward PWMI are internalised, transmitted through relationships and reinforced by sociopolitical systems, ultimately affecting health outcomes, care quality and systemic disparities in mental health services. Additionally, the model indicates that public stigma is the foundation of all forms of stigma, leading to self‐stigma, stigma by association, structural/institutional stigma and structural violence, all of which influence health professionals' attitudes and behaviours, including care and outcomes for PWMIs.

At the societal level, public stigma fosters widespread acceptance of negative stereotypes, prejudiced attitudes (emotional responses that stem from stereotypes), and discriminatory behaviours among the general population toward PWMI. Public stigma is sustained through societal mechanisms such as misinformation, cultural myths, sensational media portrayals and prevailing socio‐political narratives that portray individuals with mental illness as dangerous, unpredictable or incompetent (Hu et al. 2024; Stangl et al. ²⁰¹⁹). These negative public attitudes shape societal norms and influence public policies, often leading to social exclusion, decreased civic participation and underinvestment in mental health infrastructure. Public stigma and structural violence are interconnected. This bidirectional relationship impacts PWMI at interpersonal, individual and systemic/institutional levels, leading to their exclusion and marginalisation in everyday interactions, including service provision (Gyamfi, Forchuk, Booth, and Luginaah ²⁰²⁴).

At the interpersonal level, public stigma fosters stereotypes, biased attitudes and discriminatory behaviours between PWMI and their caregivers. This results from interpersonal stigma, where caregivers or nurses may stigmatise the client. Interpersonal stigma impacts the quality, empathy and effectiveness of clinical interactions, contributing to patients' perceived and actual experiences of discrimination within healthcare settings. Individuals close to PWMI, including family members, caregivers and healthcare professionals such as nurses, can also encounter stigma in public spaces. This may lead to emotional exhaustion, avoidance behaviours and decreased motivation to provide empathetic and sustained care for individuals with mental health issues (Martínez‐Martínez et al. ²⁰²²). Caregivers may face stigma by association, often referred to as courtesy stigma or associative stigma. Stigma by association frequently results in self‐stigma among nurses, leading to increased interpersonal stigma (also known as health professional or health practitioner stigma) toward PWMI. Health professional stigma is characterised by negative attitudes, beliefs and biases held by professional caregivers toward their clients, which can hinder the quality of care and access to treatment. This stigma also impacts both patients and healthcare professionals and can manifest in various ways, including prejudice, discrimination and even denial of care, leading to negative outcomes such as delayed diagnoses, inadequate treatment and a reluctance to seek help for mental health conditions (Crockett et al. 2025; Ng et al. ²⁰²⁴). Professional caregivers play a critical role in mental health systems by shaping perceptions and influencing attitudes toward PWMI. They are essential in the care and recovery of PWMI, serving as potential agents of stigma or allies in stigma reduction by either reinforcing or challenging it. They can help reduce stigma by using non‐stigmatising language, actively challenging stereotypes and promoting inclusivity, while also potentially reinforcing it through their actions, words and biases. Interpersonal stigma may be influenced by nurses' internalised beliefs, clinical/professional training in stigma‐sensitive care and the prevailing institutional culture surrounding mental illness. Stigma at this level may result in weakened therapeutic alliances and compromised care delivery (Rossler 2016). Interpersonal stigma can also diminish empathy and create emotional distance between providers and patients, negatively impacting the quality and depth of therapeutic engagement.

At the individual level, public stigma fosters self‐stigma among PWMI and their caregivers by internalising societal prejudices. For instance, individuals with mental illness may adopt negative beliefs about themselves, viewing themselves as weak, dangerous or unworthy. Caregivers may also experience self‐stigma through stigma by association, perpetuated by members of society (Gyamfi 2016; van der Sanden et al. ²⁰¹⁶). Self‐stigma manifests among PWMI as feelings of shame, guilt and hopelessness, leading to a diminished sense of self‐efficacy. This often results in social withdrawal and reluctance to seek help. Consequently, individuals may experience delayed engagement with mental health services, non‐adherence to treatment protocols, decreased motivation for recovery and limited community participation. Overall, self‐stigma acts as a critical mediator between public stigma and negative healthcare outcomes, exacerbating cycles of psychological distress that contribute to frequent relapses and extended treatment duration.

At the systemic and institutional level, public stigma has been shown to fuel both structural stigma and structural violence. Societal conditions, including unfavourable institutional policies and organisational practices, exacerbate societal inequities, intentionally or unintentionally, limiting life opportunities, resources and well‐being for individuals with mental illness (S. Gyamfi ²⁰²⁴; Gyamfi, Forchuk, et al. ²⁰²⁵; Hatzenbuehler ²⁰¹⁶). Structural stigma can manifest as inequitable healthcare funding, exclusionary employment laws, neglect of the mental health and well‐being of PWMI in the workplace and biased clinical decision‐making during health assessments and care. Structural violence arises from the way social institutions and structures are organised. It often appears as systemic and invisible mechanisms through which social institutions legitimise and harm PWMI by infringing on their human rights without punitive measures, hindering access to basic needs, opportunities, dignity and equitable healthcare (S. Gyamfi ²⁰²⁴; Gyamfi, Forchuk, et al. ²⁰²⁵; Macassa ²⁰²³). In the context of mental health, structural violence can be characterised by poverty, homelessness, the criminalisation of psychiatric symptoms and disparities in care access and quality based on race or gender. Structural stigma and violence reinforce institutional barriers to mental health equity, maintaining social hierarchies and perpetuating stigma through formal mechanisms embedded in sociopolitical policies.

Overall, the SVS model posits that the interplay of stigma at societal, interpersonal, individual and systemic levels can collectively impair therapeutic relationships and mental health care outcomes between caregivers (nurses) and their clients (PWMI). This situation can foster cycles of marginalisation, poor health, social exclusion and increased barriers to education and employment, as well as other recovery‐oriented supports, resulting in a low quality of life and challenges to community integration for PWMI (Gyamfi, Owusu, et al. ²⁰²⁵; Knaak et al. ²⁰¹⁷; Ricciardelli et al. ²⁰²⁰). For instance, public stigma may limit both societal and political willingness to invest in mental health infrastructure, while structural violence may indirectly legitimise and obstruct access to timely and appropriate care for those in need. Additionally, self‐stigma can reduce an individual's engagement with the healthcare system and adherence to treatment. Furthermore, stigma by association and self‐stigma may cultivate stigma among health professionals toward PWMI, adversely affecting caregiver resilience and effectiveness, including therapeutic relationships and overall care output. In health facilities, manifestations of health professional stigma can range from outright denial of care and substandard treatment to physical and verbal abuse. More subtle forms of health professional stigma may also include reduced eye contact or shorter appointment times for some individuals with specific health conditions, longer wait times for care, or, more explicitly, a refusal to offer certain treatments or services in the health facility (Lagunes‐Cordoba et al. ²⁰²¹; Nyblade et al. ²⁰¹⁹). In some instances, professionals may delegate their care duties to less experienced colleagues (Nyblade et al. 2019), all due to stereotypes about mental illnesses. See Figure 1 below for details on the Structural Violence and Stigma Model (SVSM).

FIGURE 1.

The structural violence and stigma model.

11. The Implications of Structural Violence for PSMI

The ramifications of structural violence (SV) in perpetuating stigma surrounding mental illness stem from its reinforcement of prevailing cultural norms, which legitimise and rationalise social disparities present in the societal framework. According to Galtung (1990), cultural elements that uphold social inequities constitute cultural violence. Cultural influences greatly shape public attitudes toward mental illness and the stigma that accompanies it in society, likely arising from deep‐seated historical and religious beliefs from periods such as the demonological era, when mental illness was attributed to malevolent spirits. Consequently, there is a pressing need for proactive cultural intervention, a counteractive approach aimed at interrogating and addressing stigma alongside its associated disparities. Care providers, including family members of patients and healthcare professionals, must recognise harmful cultural practices and their potential impact on the therapeutic process. This awareness facilitates the implementation of appropriate interventions to protect the therapeutic journey, thereby enhancing patient recovery and reducing societal stigma. It emphasises the importance of assessing and addressing social responsibility related to mental illness, advocating globally and taking concerted action to promote mental health inclusivity.

12. Nursing Implications of the Public Stigma of Mental Illness

The ramifications of public stigma extend beyond its direct impact on individuals with mental illness to also affect their families and healthcare professionals. This phenomenon is underscored by instances where healthcare professionals grappling with mental illness refrain from disclosing their condition or seeking assistance, fearing ostracization and judgment from their peers. Such apprehensions can lead to dire consequences, including instances of suicide, as documented in various studies (Abbey et al. 2012; Knaak et al. ²⁰¹⁷).

Recognising the pivotal role nurses play in patient care decision‐making, efforts have been made to address the nursing implications of the public stigma of mental illness. We aim to identify and propose novel approaches to influence care practices in community and healthcare settings, fostering the empowerment of individuals with mental illness from an emancipatory standpoint. The forthcoming insights in this paper will enrich the knowledge base of both nurse clinicians and scholars, fostering a deeper understanding of public stigma and its multifaceted impacts, not only on healthcare professionals and those affected by stigma, but also on society as a whole. It is anticipated that this discourse will prompt reflection among healthcare professionals, compelling them to scrutinise their actions, whether overtly or inadvertently, that perpetuate stigma against individuals with mental illness, thus paving the way for corrective measures.

13. Nursing Knowledge Development (Ontology and Practice)

As conceptualised by Barbara Carper (1978), the ontology of nursing has emerged as a valuable framework for guiding the profession's ethos, facilitating the development of care theories across various levels of sophistication. This foundational understanding has been further fortified by the perspective of emancipatory knowing, as expounded by Chinn and Kramer (2008). Present endeavours in research, knowledge translation and the effective application of such knowledge in practice necessitate an ontological inquiry that acknowledges and integrates the situational intricacies of individual patient contexts alongside theoretical constructs, empirical evidence and practical considerations.

Recognising the inherent interconnectedness of theory, evidence and practice within the epistemological and ontological fabric of nursing is paramount. This nexus significantly influences every nursing action, particularly in providing care for persons with mental illness (Doane and Varcoe 2008). Moreover, the fundamental concepts of social/cultural context, personal meaning, social justice and collaborative, relational practice play pivotal roles in mental healthcare provision, underscoring the importance of understanding ‘who we are,’ ‘where we are,’ and ‘whom we serve’ in shaping dynamic nursing interventions aimed at achieving meaningful impacts.

Addressing the power differentials between nurses and PWMI, which often impede therapeutic relationships and care outcomes, requires a shift toward a more collaborative care model. Such a model, as advocated by Ricoeur (1991), fosters shared power dynamics and mutual respect, empowering patients as active participants in their care journeys. This departure from the traditional hierarchical paradigm, where nurses are perceived as all‐knowing authorities and patients as passive recipients, is crucial for harnessing patients' expertise, enhancing health outcomes and amplifying their voices within society.

The Patient‐Centered Culturally Sensitive Health Care model (PC‐CSHC), as outlined by Tucker et al. (2007), emphasises the importance of culturally informed care in addressing disparities and gaps in cultural sensitivity. Nursing, which is inherently embedded within both patient and caregiver cultures, is uniquely positioned to transcend cultural boundaries and challenge marginalising practices, thereby effecting transformative change within the socio‐political systems that perpetuate oppression against PWMI.

Considering these factors, nursing's pivotal role in leading a distinct transformation agenda requires acquiring the necessary knowledge, attitudes and skills that promote healthy practices, not only within the profession but also in the wider community, particularly in interactions with PWMI. Adopting an individualised care approach based on contextual understanding and tailored to specific patient needs offers potential for advancing the nursing care paradigm in a way that is responsive, inclusive and supportive of holistic well‐being.

14. Implications for Nursing Education

It is imperative that nursing institutions promptly revise their curricula to incorporate stigma as a fundamental thematic element. Stigma, being a multifaceted concept, significantly impacts various health conditions, including mental illness. Therefore, integrating comprehensive knowledge of stigma into educational programmes, alongside other anti‐stigma initiatives, will not only enhance the quality of nurse–patient interactions and healthcare outcomes but also serve as a catalyst for advocating for and empowering individuals affected by stigma and their families within the broader societal framework.

Nurses must possess a thorough understanding of structural violence. Therefore, it is advisable to promote nursing curricula that emphasise critical theory and foster collaboration with various sectors, including the legal system, law enforcement, traditional and religious institutions and Non‐Governmental Organisations (NGOs). This collaborative effort will facilitate the establishment of effective public education mechanisms to ensure fairness and liberation for marginalised individuals, encouraging them to assert their voices when seeking care (Crockett et al. 2025; Gyamfi, Forchuk, and Luginaah ²⁰²⁴) and garner support from policymakers within their communities.

Clinicians must address inherent biases toward individuals with mental illness, recognising this as a crucial aspect of self‐awareness in their practice. Prejudicial attitudes are likely to result in negative clinical outcomes. Therefore, educators should foster skills in nursing students to identify and mitigate potential biases during their training. This preparation will enable students to confront these prejudices before they engage in clinical care and community environments. These skills will not only help in recognising bias but will also equip students with the essential tools to navigate interprofessional collaborative activities, including nurse–patient interactions and public engagements, effectively (Gyamfi, Forchuk, and Luginaah ²⁰²⁴).

Incorporating mental health education and health promotion activities, such as regular health discussions and volunteer programmes, into the curriculum will expose students to mental health issues early in their studies while encouraging social interaction with PWMI. This framework of social engagement can play a pivotal role in combating stigma, starting from educational institutions and extending into the public sphere, thereby fostering a supportive societal shift. Social interaction gives nurses and the public the opportunity to engage with PWMI, serving as educators with firsthand testimonies of their experiences with mental illness and recovery within the healthcare system. Additionally, the social interaction approach serves as a crucial strategy for enhancing interprofessional education methods to reduce public stigma.

Furthermore, conducting periodic action‐oriented anti‐stigma workshops for nurses holds promise in augmenting their knowledge base and refining their skill set for optimal patient care. Applying this knowledge in practice will catalyse behavioural changes among nurses, discouraging attitudes that perpetuate marginalisation during the nurse–patient therapeutic process.

15. Implications for Nursing Research

Contemporary scholarly inquiry, the dissemination of knowledge, and its effective application in practical settings require an ontological investigation that recognises and incorporates the unique situational dynamics of individual patients, aligning with theoretical frameworks, empirical evidence and established practices. Achieving seamless integration of theory, evidence and practice has significant potential to influence the daily activities undertaken by nurses.

The pursuit of nursing research represents a political enterprise conducted within a framework of power relations, aiming to shape and reform the attitudes and behaviours of patients, healthcare professionals, policymakers and the broader society. Social injustices are sustained by disparities in power dynamics, often reinforced through political rhetoric and societal discourses. Consequently, nursing research must strive to challenge and mitigate linguistic and social constructs that perpetuate unequal access to healthcare and other fundamental societal resources such as housing, education and employment.

Research that aims to critically examine prevailing social structures within the context of patient and healthcare professional experiences can illuminate the socio‐political underpinnings that perpetuate disparities faced by individuals with mental illness. While it is tempting to attribute the marginalisation of such individuals solely to political and administrative decision‐making bodies, the role of the public, patient families, healthcare professionals and the affected individuals themselves in perpetuating stigma remains uncertain. Research that delineates these distinct contextual influences—public, patient families, healthcare professionals and patients—stands to make a significant contribution to stigma reduction and enhance the quality of patient care and outcomes across community and healthcare settings. Identifying the socio‐political determinants of mental illness stigma and equitable healthcare distribution can serve as a foundation for introspection among nurses while also facilitating evidence‐based interventions to empower patients and combat stigma. The concepts of ‘structural violence’ and ‘cultural violence’ have yet to be thoroughly explored within the realm of mental health and mental illness. Therefore, research that investigates these concepts in relation to the perpetuation of psychiatric stigma holds promise for advancing anti‐stigma initiatives.

16. Conclusion

In contemporary discourse, nurse scholars have developed research methodologies rooted in the critical paradigm, with the overarching goal of advocating for and amplifying the voices of marginalised populations in society. Notably, American political theorist Nancy Fraser delineates justice into two distinct yet interconnected categories: distributive justice, which pertains to the equitable allocation of resources, and the justice of recognition, which concerns the equal acknowledgment of various identities and groups within a given society (Fraser 2000). Nurses are encouraged to cultivate practical political skills to navigate both institutional and societal structures that perpetuate public stigma toward mental illness. Increased awareness regarding the pervasive impact of stigma on PWMI can facilitate the sensitisation of all stakeholders and inform strategic planning initiatives aimed at enhancing the well‐being of PWMI while providing them a platform to articulate their experiences. Such efforts can boost patients' self‐esteem and empower them to challenge stigmatising attitudes wherever they encounter them.

Author Contributions

Sebastian Gyamfi: conceptualization (lead), validation (lead), writing – original draft (lead), writing – review and editing (lead). Priscilla Boakye: conceptualization (supporting), validation (supporting), writing – review and editing (supporting). Natalie Giannotti: conceptualization (supporting), validation (supporting), writing – review and editing (supporting). Edward Cruz: conceptualization (supporting), validation (supporting), writing – review and editing (supporting).

Conflicts of Interest

The authors declare no conflicts of interest.

Gyamfi, S. , Boakye P., Giannotti N., and Cruz E.. 2025. “Understanding the Multi‐Faceted Nature of the Public Stigma of Mental Illness: Insights and Implications From a Structural Violence Perspective.” International Journal of Mental Health Nursing 34, no. 4: e70121. 10.1111/inm.70121.

Data Availability Statement

The authors have nothing to report.