Public Stigmatization	Self-Stigmatization
Stereotype:	Negative belief about a group, e.g. dangerousness, incompetence, character weakness	Negative belief about the self, e.g. character weakness, incompetence
Prejudice:	Agreement with belief and/or negative emotional reaction, e.g. anger, fear	Agreement with belief Negative emotional reaction e.g. low self-esteem, low self-efficacy
Discrimination: Behaviour response to prejudice	e.g., avoidance of work and housing opportunities	e.g., failure to pursue work and housing opportunities

Source: Amy C. Watson and Patrick W. Corrigan, “The Impact of Stigma on Service Access and Participation,” a guideline developed for the Behavioural Health Management Project.

The development of stereotypes is a key part of the process of stigmatization of, and discrimination against, people with mental illness. Stereotyping involves using selective perceptions to place people in categories and exaggerating the differences between these various groups[82] (‘them and us’). As with racial prejudice, stereotypes also make people easier to dismiss and, in so doing, the stigmatizer maintains social distance. In this regard, Ms. Hall also told the Committee that:

…as [a] Mental Health Advocate, nine out of ten people told me that once their diagnosis was acknowledged, once they were open about their diagnosis, people treated them systematically differently.[83]

Stigmatizing stereotypes can be so strong that stigmatized people are thought to “be” the thing they are labeled.  For example, some people speak of persons as being epileptics or schizophrenics rather than describing them as having epilepsy or schizophrenia.  This is revealing with regard to mental illness because it is different for other diseases.  A person has cancer, heart disease or the flu — they are one of “us,” a person who just happens to be beset by a serious illness. But the person is a “schizophrenic.” Thus the whole person is stigmatized,[84] as Ms. Pat Capponi told the Committee:

A mental patient is just that in the eyes of many. We are not entitled to be full human beings behind that label, not expected to have basic personalities that mirror those in the greater population — good, bad and everything in between. A schizophrenic is a schizophrenic and every action is attributed to that disease and not to the underlying nature of the individual or his circumstances. A person who is bitter and angry or who is addicted to crack or other drugs does something terrible and a chorus of voices is raised against all who carry the same label.[85]

There are a number of stereotypes that are commonly identified in the literature as being widely held about persons with serious mental illness. These include:

1.      People with mental illness are dangerous and should be avoided. 

2.      People with mental illness have brought their problems upon themselves and are to blame for their disabilities since they arise from weak character.

3.      They are incompetent or irresponsible and require authority figures to make decisions for them.

4.      They are viewed as childlike and needing parental figures to care for them. 

5.      Poor prognosis: the view that there is little hope for recovery from mental illness.

6.      Disruption in social interaction: the view that people with mental illnesses are not easy to talk to and have poor social skills.

7.      People with mental illness are not as intelligent as others.

However, a very recent (June 2004) scientific survey of public perceptions of mental illness that was undertaken in Houston, Texas, (the first of its kind in a major metropolitan area)[86] produced some interesting and encouraging findings, that the study’s authors believe are representative of mainstream attitudes in the United States as a whole. In the words of the study:

The data indicate that an overwhelming majority of the public at large has come to believe that mental illness is essentially a physiological disorder that ought to be treated like any other physical illness. Only a tiny minority continues to believe that mental illness can be attributed to any sort of morally relevant defect of character.[87]

Moreover, by 56 to 31 percent, more than half of Harris County residents believe that most people being treated for mental illness are able to live a normal life. A clear plurality (47 percent) would not be concerned if they discovered that a person under treatment for a mental illness were living in their neighborhood, and a majority (by 51 to 42 percent) would be willing to pay higher taxes to improve access to mental health services in the Houston area.[88]

3.2.1     Self-Stigmatization

Self-stigmatization can be defined fairly easily. It is simply agreeing with the negative attitudes about mental illness and turning them against oneself. Persons living with mental illness who believe that other people devalue and reject people with mental illness will most likely fear that this rejection will be applied to them personally. Such a person may wonder, “Will others think less of me, reject me, because I have been identified as having a mental illness?” Then, to the extent that it becomes a part of their worldview, that perception can have serious negative consequences.  Expecting and fearing rejection, people who have been hospitalized for mental illnesses may act less confidently, be more defensive, or they may simply avoid a threatening contact altogether.[89]

Self-stigmatization takes the form of “I am” statements such as the following:[90]

·        I really am unable to care for myself.

·        I’m dangerous and could snap at any minute.

·        I’m no different than a child.

·        I can’t handle responsibility.

·        Don’t give me money. I’ll only blow it.

·        I’m a bad person.

·        Who would want to live next to a person like me?

·        Everyone can plainly see I’m weird.

·        I’m not worth the investment of time and resources.

·        I have a weak personality.

·        I am not able to do…

Self-stigmatization has a broad and deleterious impact on the person with mental illness, and can worsen the course of his or her disorder. Persons who self-stigmatize are likely to have more problems and disabilities with their mental illness than people who do not internalize statements like those above. One reason is that people who self-stigmatize have poor self-esteem, and with the deprivation of self-esteem comes a loss of hope. Not only do such people believe they are not worthy of respect now, they believe things will not change in the future.[91] Ms. Rena Scheffer, Director, Public Education and Information Services, Centre for Addiction and Mental Health, told the Committee that:

On an individual level, stigma not only leads to low self-esteem, isolation and hopelessness, but all of those characteristics also have been found to be predictors of poor social adjustment, so people end up in an endless cycle of poorer quality of life.[92]

People with diminished self-efficacy due to self-stigmatization are less likely to apply for jobs or apartments (“Someone who is mentally ill like me can’t handle a regular job!”).[93]  Other people with mental illnesses try to avoid discrimination by simply concealing their illness. In doing so, however, they can incur more stress from the continuous fear of being discovered, from endangering their mental health by tending not to take time off even when they need it, and from remaining ineligible for appropriate accommodations for their disability that might have made their working lives easier and more enjoyable.

Self-stigmatization is also one of the factors that contributes to the fact that many people with diagnosable mental disorders do not seek treatment. When people fear being identified and labeled as having a stigmatizing condition, they may then delay or avoid seeking treatment. According to Ms. Scheffer:

Estimates are that two-thirds of people who require treatment for a mental illness do not seek help, largely because they are either unaware of the symptoms or because of the stigma associated with the illness or its treatment.[94]

Dr. Richard Brière, Assistant Director of the Canadian Institutes of Health Research Institute of Neurosciences, Mental Health and Addiction offered the following analogy to the Committee:

People who need help often do not seek help because they are ashamed of what happens to them. If we can do something about the stigma attached to mental illness, you will have people bragging about it the way they do about heart disease, saying, “Well, I had a bypass.” People will tell their friends about that, but many people will not talk about their mental illness problem.[95]

Families of individuals living with mental disorders can also take on board the fear of stigmatization, with potentially serious consequences. In her brief to the Committee, Ms. Stuart referred to a case in which a mother whose daughter’s mental health was deteriorating initially avoided treatment out of fear that her daughter would be branded as “crazy” by medical personnel. Ultimately, the police had to intervene when the daughter’s worsening condition degenerated into a full-blown crisis.[96]

Stigma is not a new phenomenon. In fact, stigmatization of people with mental disorders has persisted throughout history.[97] In this regard, Ms. Scheffer, in her brief to committee, referred to the renowned sociologist Erving Goffman who pointed out that the word stigma in the original Greek was used “to refer to bodily signs designed to expose something unusual and bad about the moral status of the signifier.”[98] While the exact content of the mythology that contributes to the stigmatization of people with mental illness has no doubt changed in the intervening millennia, it is striking the extent to which the term still describes a situation in which the person being stigmatized is being set apart (and de-valued) because of certain behavioural or physical traits.

In general, given the significance of the phenomenon of stigma, the Committee agrees with Mr. John Arnett, Head, Department of Clinical Health Psychology, Faculty of Medicine, University of Manitoba, who argued that the process of stigmatization itself has a real and profound impact on individuals living with mental disorders. This is how he put it in his testimony:

We know that stigmatization is characterized by bias, distrust, stereotyping and so on. It frequently reduces an individual's access to resources and opportunities for housing and jobs and ultimately leads to low self-esteem, isolation and hopelessness. There is no question that this occurs in many cases independently of the limitations that may be imposed by the mental health disorders themselves. In other words, stigmatization seems to have an independent capacity to do this.[99]

3.2.2    The Role of the Media and the “Attribution of Dangerousness” to Individuals Living With Mental Disorders

One factor that has often been cited as contributing to the persistence of stigmatization of persons with mental disorders is media coverage. About a third of people identify the media — including print, radio, television, and internet-based news, advice, entertainment and advertising — as their main source of information about people with mental illnesses.[100] Unfortunately, the media often reinforces myths and stereotypes about people with mental illnesses. Analysis of ways in which film and print represent mental illness have shown that, in particular, two of the stereotypes of persons with mental disorders are spread by these sources: people with mental illness are “homicidal maniacs who need to be feared”, and they are “childlike and need to be protected by parental figures.”[101]

Content analyses of American television have shown that over 70% of major characters with a mental illness in prime time television dramas are portrayed as violent; more than one fifth are shown as killers.[102] The typical newspaper depiction of individuals with mental illnesses shows them to be psychotic, unemployed, transient, and dangerous—not as productive members of a family or community. Similar studies of newspapers in Canada and Britain have shown that stories featuring violent acts by people living with mental disorders appear more frequently and are given greater prominence than articles containing a more positive portrayal.[103]

Negative conditioning towards people with mental disorders that encourage stigmatization may begin at an early age. The first study of children’s television programming in New Zealand and the U.S., published in 2000, concluded that “the frequent and casual use of fundamentally disrespectful vocabulary such as crazy, mad, nuts, twisted, wacko or loony demonstrated for children that such expressions are acceptable or even funny.”[104] The researchers responsible for this study actively looked for, but were unable to identify, any positive attributes associated with those who were depicted as mentally ill, nor did they find any understanding of the suffering that mental illness involves.

Some of the stereotypical depictions of people with mental illness that occur regularly in the media include the following: rebellious free spirit; violent seductress; narcissistic parasite; mad scientist; sly manipulator; helpless and depressed female; and comedic relief.[105] Most often such characters have no identity outside of their stereotypical “crazy” behaviour, and are primarily identified by an inferred mental illness.

At the centre of media accounts and public misperceptions is the attribution of a propensity for violence to individuals living with mental disorders. For example, 88% of participants in focus groups conducted by the Ontario Division of the Canadian Mental Health Association in the early 1990s believed that people with a mental illness “are dangerous or violent.”[106] Not only is this a persistent problem, but it would appear that it is getting worse over time. In the United States, attitudes toward mental illnesses have apparently become more infused with concerns about violence associated with these illnesses. Thus, between 1950 and 1996, the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behaviour nearly doubled.[107]

According to the U.S. Surgeon General this attribution of a propensity towards violence on the part of individuals living with mental disorders is a key factor in explaining the persistence of stigmatizing attitudes:

Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past.[108]

It is important to note that this fear of violence rests on what is largely a misperception of the facts. In the words of a Health Canada sponsored study, “there is no compelling scientific evidence to suggest that mental illness causes violence”.[109] Some American studies have argued that at most 4% of all violent incidents have any connection to mental illnesses.[110] At the very least this strongly suggests that public fears are largely misplaced, although they are clearly widespread.

There is, however, evidence that suggests that people who do not receive treatment for their mental illness, or who have concurrent disorders (that is, individuals who have a mental disorder as well as a substance abuse disorder) are more likely to be violent than the general population. Still, there is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder and the overall contribution of mental disorders to the total level of violence in society is exceptionally small.[111] In this regard, Ms. Scheffer commented that, “as a predictor of violence, mental illness ranks far behind other risk factors like age, gender and history of violence or substance abuse.”[112]

And Ms. Hall noted:

…the sad thing is that actually people with mental illness are more at risk of self-harm. In my province, a person a day commits suicide. Even though the reality is that they are more at risk of doing harm to themselves, the public perception is that they are indeed a danger to others, which simply is not the normative truth…[113]

Ms. Jennifer Chambers, Empowerment Council Coordinator, Centre for Addiction and Mental Health,  also shared the following insight with the Committee:

One difficulty of shifting the discussion of the association between people in the mental health system and violence is the circular reasoning that happens. If a particularly violent crime is committed people say, “Oh, that person is sick, psycho, weird,” so there is no way to get outside the debate, even if they were not considered to have any particular mental or emotional disturbance before committing the act.[114]

The influence of media accounts can be enormous, both for the public in general and for those living with mental illnesses. One British study found that over 20% of the people they interviewed were more inclined to accept the media portrayal of people with mental illnesses as being prone to violent behaviour than they were to believe the reality they encountered in their own interaction with people living with mental disorders. An example was given of a young woman who lived near a mental hospital just outside Glasgow, Scotland, that has since closed. She had worked there as a volunteer and mixed with the patients. She told the researchers:

The actual people I met weren’t violent — that I think they are violent, that comes from television, from plays and things. That’s the strange thing — the people were mainly geriatric — it wasn’t the people you hear of on television. Not all of them were old, some of them were younger. None of them were violent — but I remember being scared of them, because it was a mental hospital — it’s not a very good attitude to have but it is the way things come across on TV, and films — you know, mental axe murders and plays and things — the people I met weren’t like that, but that is what I associated them with.[115]

The same study concluded that the most powerful negative effect seemed to be in the area of self-stigmatization. As one interviewee put it: “You see a programme and it shows a very bad image of what it feels like yourself and then you think, ‘What are my neighbours going to think of it?’”[116]

3.2.3    Stigmatization of Mental Health Providers

Not only do individuals living with mental disorders suffer from misrepresentation in the media, but so too do mental health practitioners. One study indicated that since the mid-1960s, only three films portrayed therapists sympathetically (Good Will Hunting, 1997; Ordinary People, 1980; and I Never Promised You a Rose Garden, 1977). In every other instance, mental health practitioners were portrayed in one or more of the following ways: neurotic, unable to maintain professional boundaries, drug- or alcohol-addicted, rigid, controlling, ineffectual, mentally ill themselves, comically inept, uncaring, self-absorbed, having ulterior motives, easily tricked and manipulated, foolish, and idiotic.[117] Such portrayals tend to convey the idea that helping others is an unworthy vocation requiring little skill or expertise.

Witnesses repeatedly indicated that stigmatization affects those who provide care and services to individuals living with mental disorders. Dr. Gail Beck, Acting Associate Secretary General, Canadian Medical Association, remarked that, “I regularly hear jokes that I am not a real doctor. That is not related to what I do in practice; it is related to the fact that there is a stigma and discrimination about the kind of illnesses that I treat.” And Dr. Rémi Quirion, Scientific Director of the Canadian Institutes of Health Research Institute of Neurosciences, Mental Health and Addiction, told the Committee that:

Psychiatrists are still stigmatized compared with the other types of doctors. It is still often seen more as an art than a science. This needs to change. We need to make sure that the young students will be stimulated to go into psychiatry.[118]

According to Ms. Manon Desjardins, Clinical Administration Chief, Adult Ultra Specialized Services Division, Douglas Hospital, recruiting medical students to the field remains a problem:

In universities, it is still far more prestigious to go for cardiac, surgery, [or] intensive care rather than psychiatry or geriatrics. Geriatrics and psychiatry are seen to be at just about the same level: they are not very attractive.[119]

Ms. Maggie Gibson, Psychologist, St. Joseph's Health Care London, also pointed to the fact that the stigmatization of individuals living with mental disorders affects the whole range of service providers in the mental health field:

With respect to the issue of family and caregiver stress, I want to comment on the issue of stigma — in particular the neglected stigma associated with using long-term care services. We would benefit greatly from a cultural shift that takes a compassionate and pragmatic approach to identifying the best care options for both older people and their family members and allow for dependency, when it is part of the system. Systems that allow for dependency without devaluing people go a long way to improving mental health.[120]

[121]

Her insistence on the need to deal with the discrimination that is the concrete result of stigmatizing attitudes was a recurring theme during the Committee’s hearings. Mr. Patrick Storey, Chair, Minister's Advisory Council on Mental Health, Province of British Columbia, insisted to the Committee that:

…we need to recognize discrimination against people with mental illness and their family members as just as unacceptable as other forms of discrimination. We need to devote the same energy to its elimination that we devote to the elimination of other forms of discrimination.[122]

In this same vein, Mr. John Service, Executive Director, Canadian Psychological Association, told the Committee about hearing a speech by “a young congressman from Rhode Island by the name of Kennedy”[123]:

He conceptualized the discrimination against people with mental illnesses in the United States as the same kind of discrimination experienced by Black people and by women in the 1950s and 1960s. He said it is the same system, and that we can correct it in the same way. He says you solve that systemic discrimination by doing what we know works in discrimination, which includes things like significant financial investments to turn the system and for affirmative action.[124]

There are many ways that discrimination affects individuals living with mental disorders. They are routinely excluded from social life and can even be denied a variety of civil rights others take for granted. They are often denied basic rights in the areas of housing, employment, income, insurance, higher education, criminal justice, and parenting, among others.[125] People with mental illnesses also face rejection and discrimination by service providers in both the mental health and physical health care systems and discrimination by policy makers and the media.

Professors Bruce Link and Jo Phelan of Columbia University have proposed a useful way of dividing these different manifestations of discrimination into two broad categories: direct discrimination and structural discrimination.[126] In her testimony, Ms. Stuart offered a similar distinction, that between overt discrimination and “acts of omission”:

More insidious is that you may neglect to do something just by virtue of the fact that you think something is not important. You may have a negative attitude or put something on the back burner. I like to think there is as much or more damage done by those acts of omission, at every level of policy or government. We can focus on overt discrimination, and there are certainly huge issues there, but I would like to see it go farther than that. I would like to see the acts of omission addressed as well. If we could get at the stigma and the attitudes that underlie both of those things, we might be in a better position. I recognize that that is difficult to do. Sometimes the actions are easier to address.[127]

3.3.1     Direct Discrimination

Direct discrimination refers to the standard way of conceptualizing the connection between labelling/stereotyping and discrimination. It points to direct discriminatory behaviour on the part of the person who holds the stereotyped beliefs. Direct discrimination occurs most obviously when a person in a powerful role withholds an opportunity.[128] Landlords do not rent an apartment to someone because he or she was in a psychiatric hospital. Employers fail to offer a job interview because the person with mental illness has not worked recently.

The evidence indicates that this form of discrimination occurs with some regularity in the lives of people who are stigmatized. For example, in a Canadian survey of people with mental illnesses, half said the area in their life most affected by discrimination was housing. Research shows that a person’s status as a psychiatric patient means he or she is less likely to be leased an apartment.[129]

There remains a considerable amount of discrimination in the workforce, by both employers and co-workers, towards people with mental illnesses. Surveys show that employers and workers still feel justified distrusting and discriminating against people with mental illnesses. As a result, people with serious mental illness, such as schizophrenia and related disorders, have the highest rate of unemployment and underemployment of all people with disabilities, at a rate of around 90%.[130]

A number of surveys have consistently found that anywhere from one-third to one-half of people with mental illnesses report being turned down for a job for which they were qualified after their illness was disclosed, or had been dismissed from their jobs, and/or forced to resign as a result of their mental illness. Surprisingly, the figures are not dramatically lower for employment of individuals living with mental illness within mental health agencies or for volunteer positions both inside and outside the mental health field.[131]

Not only do families of people with mental illnesses have to cope with the financial, practical and emotional stressors of caring, but they face a kind of ‘discrimination by association.’ They have to deal with strained relationships with other family members or friends, fear, violence, anxiety, conflict, lowered self-esteem, and guilt. Discrimination against family members often stems from misconceptions about the family’s role in the causes of mental illness.[132]

3.3.1.1  Discrimination Within The Health Care System

The importance of dealing with discrimination against individuals living with mental disorders within the health care system itself was raised by numerous witnesses. There is much evidence, Canadian and international, that mental health professionals and health professionals in general can be among those who show discriminatory attitudes and behaviour toward their own clients. People with mental illnesses frequently note that their views are neither listened to, nor respected, and that mental health workers tend to focus on clinical issues of care to the exclusion of social issues. Studies have identified a lack of respectful treatment by GPs and emergency room clinicians as the most common complaint among people with mental illnesses.[133]

This is a somewhat puzzling phenomenon, as Ms. Stuart remarked:

Why are health care workers so stigmatizing? They are among the most knowledgeable people on mental illness that we have in our society. They are invariably identified as the people who are the worst offenders.[134]

Other witnesses concurred that the problem was widespread. Mr. Storey told the Committee:

In the discussions we had with people with mental illness, it was remarkable that they all had stories to tell of mistreatment in emergency rooms, as well as hospitals generally. Even when they were presenting complaints of a physical nature, they were treated as mental patients.[135]

Dr. Jim Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, also pointed to hospital emergency rooms as a place where discrimination occurs, telling the Committee that:

One only needs to visit the local emergency room to see stigmatization by health care providers. Mental health clients wait the longest. Their privacy is violated. Their concerns are not dealt with appropriately.[136]

This seemingly widespread discrimination within the health care system has many negative consequences for people in need of help. Ms. Pat Capponi pointed to the lack of trust that ensues:

We have learned that we cannot depend on those working within the system to advocate for us. We cannot even expect them to see us as full individuals behind our obscuring labels.[137]

3.3.2    Structural Discrimination

However, discrimination against people with mental illnesses and their families is not limited to overt acts of discriminatory behaviour by one person directed at another. It can also take the form of what Link and Phelan call structural discrimination.

To see what they mean, suppose that because it is a stigmatized illness, less funding is dedicated to research on schizophrenia than for other illnesses and less money is allocated to adequate care and management. As a consequence, people with schizophrenia are less able to benefit from scientific discoveries than they would have been if the illness they happened to develop were not stigmatized. To the extent that the stigma of schizophrenia has created such a situation, a person who develops this disorder will be the recipient of structural discrimination regardless of whether or not anyone happens to treat him or her in a discriminatory way. 

There are many ways in which this kind of structural discrimination based on stigmatization can occur. Stigma may influence access to treatment by creating undesirable conditions in treatment settings that make seeking help far less desirable than it would otherwise be. For example, there exists a fear of people with psychosis that is out of proportion to the actual risk that people with psychosis pose. To the extent that this fear increases recourse to the use of guards, locked wards, searches and the like, stigma produces very negative circumstances in the treatment environment that could easily make people want to avoid those settings.

Structural discrimination can also be manifested in the general levels of funding that are made available for research and treatment of mental illnesses (see Chapter 9, below). Moreover, within the health care community in general, mental health professionals often feel treated as second-class citizens by their professional peers, and mental health services, programs and research themselves still tend to be given a lower priority than physical health care issues.

 

3.4       REDUCING THE IMPACT OF STIGMA AND DISCRIMINATION

There are both individual and community- or socially-based approaches to reducing the impact of stigma and discrimination. On the one hand, individuals with mental illness can seek out strategies that allow them to cope with, or contest, the stigmatization and discrimination they encounter. On the other hand, socially- or community-based strategies can be developed to attempt to reduce the overall extent and impact of stigmatization and discrimination. In this section we will concentrate almost exclusively on the latter, but, before doing that, a few words on individual approaches are in order.

Broadly speaking, the literature identifies three strategies that are available to individuals living with mental illness:

1.     They can attempt to completely conceal their illness from others with whom they interact; ;

2.      They can practice selective avoidance, limiting their social interaction to people they know to be non-stigmatizers;

3.      They can attempt to educate everyone with whom they come into regular contact about the nature of their illness.

As noted earlier, maintaining secrecy about one’s mental illness can have many negative consequences. According to one study that explored the value of all these individual approaches, it is not just the first strategy listed above that can be counter-productive. Rather, the study concluded unequivocally that all three were harmful and that “using these methods made rejection more likely.”[138]

Given the difficulties associated with these strategies based on individual action it would seem clear that, if there is to be progress in reducing both stigma and discrimination, some form of community or socially based intervention will be necessary. This follows from the fact that both stigma and discrimination are thoroughly social phenomena. They rely on the propagation of myths about individuals living with mental disorders within the institutions of society (schools, workplaces, the media, etc.), and take hold in discriminatory practices that can be enshrined or condoned by law and by tradition.

There is, however, likely no simple or single strategy to eliminate the stigma associated with mental illness.[139] In the first place, stereotypes such as those that sustain the stigmatization of people with mental illness are complex phenomena. They have components that are somewhat changeable but they also have some that are fiercely resistant to change.[140]

As noted earlier, the persistence over time of pervasive stigma attached to mental illness, despite growing knowledge and public awareness of the nature of these disorders, raises an important question with regard to the efficacy of education alone to reduce the effects of stigmatization on the lives of people with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved.[141]

Since stigmatizing opinions are not always closely related to the extent of knowledge about mental illness in general, it follows that campaigns to reduce stigma must be carefully planned and probably have to do more than simply increase knowledge of the stigmatized conditions.[142] One hypothesis that has been advanced to explain why information alone is unlikely to eliminate stigmatizing attitudes holds that stigmatizers need a new emotional experience rather than, or in addition to, a new explanatory model, before they would be likely to call into question any stereotypes they may have taken on board.[143]

Thus, the effectiveness of mass advertising campaigns in reducing stigma and discrimination has been challenged.[144] This is how Ms. Stuart put it:

With respect to anti-stigma interventions, how do we stop stigma and discrimination? We are learning from the World Psychiatric Association work that one size does not fit all. It is a waste of time and energy to embark on a large, public education campaign that is designed to improve literacy as an anti-stigma intervention because segments of the population have different views. They understand their risks differently depending on the diagnostic group.[145]

Results are more promising when media campaigns are backed by ongoing community-based education and action. The general consensus internationally seems to be that public education campaigns are most effective when they are locally based and focused on the anxieties of their target groups.[146] In Ms. Stuart’s words:

We are now talking about more focused and targeted interventions. We have had the best success in all of the things that we have tried by going into high schools and working with young people because they are more malleable.[147]

Reducing stigma will therefore require campaigns that are carefully focussed and targeted to specific audiences. Two recent articles indicate that such carefully targeted campaigns can indeed alter attitudes towards people living with mental health disorders. An evaluation of mental health awareness workshops directed at secondary school students in Britain concluded that “educational workshops with young people can have a small but positive impact on students’ views of people with mental health problems.”[148] An assessment of another British effort directed at police officers also indicated that workshop programs had a positive impact on attitudes, and that “targeting a group in the work-place provides the opportunity to challenge negative stereotypes while addressing specific work-based training needs, thus creating a more favourable learning environment for addressing attitudes and behaviours.”[149]

One leading anti-stigma researcher, Otto F. Wahl, Professor of Psychology at George Mason University in Fairfax, Virginia, put it this way: “If we are going to truly eradicate stigma, we need to have a more concrete, practical and personalized understanding of its effects – that is, how stigma makes people feel and how it affects treatment and recovery.”[150]

One possibility would therefore be to explore destigmatizing strategies that provide forums for the expression of fears that exist amongst the target group, in which people can ask questions and communicate their worries.[151] According to Ms. Stuart:

When we talked about targeting things, we were trying to target experiences. We figured out we had to get them at an emotional level. We had to make them aware that their whole system of beliefs was somehow ill-founded. One of the best ways to do that was to construct situations in which people who have a mental illness could meet people who have perhaps never met someone with a mental illness, under controlled and constructive kinds of situations. They would talk about their mental illness. They would convey factual information, but more important, they would convey information at a human level. That is what made the difference.[152]

Indeed, it is contact with people with mental illness that appears to yield the best prospects for improving attitudes about mental illness.  There is research that shows that members of the general public who are more familiar with mental illness are less likely to endorse prejudicial attitudes.[153] In this respect, Ms. Scheffer told the Committee that:

The most promising strategy for impacting negative perceptions is increasing contact with mentally ill persons. No other strategy has been shown to be more effective.[154]

This conclusion was further reinforced by the results of the Houston area survey of public perceptions of mental illness referred to earlier. Its authors wrote that:

We have been struck continually throughout these analyses by the dominating importance of personal knowledge in shaping public attitudes toward mental health issues. When respondents were asked if they knew of “anyone among your friends or family who has been diagnosed with a mental illness, including clinical depression,” the 38 percent who answered in the affirmative were consistently and significantly more likely than the 62 percent without such personal experience to support both corporate and tax policies to ensure access to mental health services, to be unconcerned upon learning of a neighbor being treated for a mental illness, and to believe that most people undergoing treatment for mental illness are able to live a normal life.[155]

However, recent research also suggests that the way in which contact with individuals living with mental disorders takes place may have a bearing on the extent to which stigmatizing attitudes are challenged. A study by researchers at the University of Chicago Center for Psychiatric Rehabilitation[156] reached a number of interesting conclusions. In the first place, the researchers confirmed previous work that showed that contact with individuals living with mental disorders “yields significant change in attitudes about mental illness.”[157] As well, and contrary to their original expectations the researchers did not find any noticeable difference in the extent of the impact of the contact when contact was via videotape rather than in vivo. 

However, they did find that stereotypes were not called into question when the contact with the person living with serious mental illness highlighted the symptoms of that illness rather than the possibility of recovery. Moreover, they concluded that their research offered a plausible explanation for why many health care providers remain vulnerable to embracing stigmatizing attitudes. In their words:

Meeting a person with mental illness whose symptoms and other problems are highlighted is not likely to challenge one’s stereotype. This may be one reason why mental health service providers are likely to endorse the stigma of mental illness so highly. Treatment providers, especially inpatient clinicians, largely interact with people with mental illness when they are acutely ill, a status which is likely to confirm the stereotype rather than challenge it. Most of these people are frequently discharged before recovery is evident so that the treatment provider does not have an experience that disconfirms the stereotype.[158]

Ms. Scheffer also suggested that the most effective strategy “in creating understanding and acceptance is a comprehensive health promotion approach combined with a social marketing approach” that would “raise awareness, encourage seeking help and promote positive understanding.”[159]

Mr. Service indicated that stigma can be reduced as a result of the successful treatment and care of individuals living with mental disorders. He told the Committee that:

Stigma is reducing significantly in certain populations. It is the populations who can access and use the service who do not have a problem because their neighbour, their friend, brother or cousin have accessed services and had a good experience. That is how you break down stigma. In our business that is also one of the best referrals. It is not from another professional, it is from somebody saying, “I went to see Mr. Service and he did not a bad job so you might want to try him out.” That is how you get most of your referrals and that is how you break down stigma.[160]

The need to involve individuals living with mental disorders in all aspects of efforts to eliminate stigma and discrimination, was further emphasized by witnesses. Ms. Chambers recommended to the Committee that:

a national education program…directed and delivered by survivors, should be launched to challenge the devastating prejudice and discrimination that exists in our community.[161]

Ms. Capponi pointed to the broad anti-stigmatizing impact of facilitating the participation of individuals living with mental disorders in meaningful and productive undertakings:

We began to tackle poverty and powerlessness directly through the creation of psychiatric-survivor-run businesses. Led by my sister Diana, who had battled mental illness and heroin addiction, they lobbied and developed survivor businesses in the Province of Ontario — a radical departure from traditional vocational rehabilitation. Our community began to see that there were possibilities out there for us. We began to have role models and leaders. We were achieving, breaking myths and assumptions about who and what we were, and we were forming community. Chronic psychiatric patients showed commitment in reporting to work on time. In acquiring new skills, lasting friendships were created and people grabbed every opportunity to learn from each other's experiences. We were successfully attacking the stigma within and without the mental health system where millions of dollars spent on elaborate advertising campaigns had failed.[162]

Several witnesses also pointed to the importance of learning from other communities that have had to confront issues relating to stigma and discrimination. Ms. Scheffer pointed to some of these in her testimony:

If we look to other groups who have suffered the effects of social stigma, like the gay and lesbian community or those with AIDS or cancer, they have successfully ended or minimized stigma by creating widespread change in attitudes.[163]

And Mr. Brian Rush, Research Scientist, Social Prevention and Health Policy, Centre for Addiction and Mental Health, noted in the same vein:

The mental health field could learn a lot from the developmental disability field and the kind of investment it might take to support people in the community, which would still save money in addition to providing people with dignity, respect and a choice to live in the community and not in psychiatric institutions.[164]

Ms. Shoush reminded the Committee that different communities will have their own distinctive approaches to helping individuals living with mental disorders, and that is therefore essential to adapt efforts to these varying realities. She told the Committee that:

Aboriginal communities would say that they have a different world view and that the community is the focus. They believe that the community unit deserves to be the focus of concern and that information to help the community be whole and well should be available and shared.[165]

3.4.1     The Need for a National Strategy

Although it is clear that there will not be a miracle solution to the problems of stigma and discrimination, and that efforts to reduce their impact will have to be carefully tailored to many different circumstances, several witnesses also insisted on the importance of having a national mental health strategy. Mr. Phil Upshall, President, Mood Disorder Society of Canada, put it this way:

The move towards a federal national strategy would be incredibly anti-stigmatizing. It would be a leadership model that would say to the rest of Canada, “This is something to which we need to pay attention.” It would say to the rest of the provincial premiers and their health ministers that this is something that we will finally take seriously.[166]

This view was supported by Dr. Blake Woodside, Chairman of the Board, Canadian Psychiatric Association, who told the Committee:

The first thing is to make mental health a public priority, so a declaration by the federal government that a national action plan for mental health was being developed would be a huge step in the right direction. Out of that would fall a wide variety of public educational activities that would help combat this discrimination and stigma.[167]

Witnesses also argued that it was important to modify the Canada Health Act so that it placed physical and mental illness on an equal footing. This is not the case today since, for example, the CHA explicitly excludes psychiatric hospitals from its purview. Thus, Dr. Sunil Patel, President, Canadian Medical Association, pointed out:

Simply put, how are we to overcome stigma and discrimination if we validate these sentiments in our federal legislation? The CMA firmly believes the development of a national strategy and action plan on mental health and mental illness is the single most important step that can be taken on this issue…[168]

The CMA proposed a number of measures that would redress this situation, including, as Dr. Patel outlined:

…amending the Canada Health Act to include psychiatric hospitals; adjusting the Canada Health transfer to provide for these additional insured services; re-establishing an adequately resourced federal organizational unit focused on mental illness and mental health and addictions;[169]

For his part, Dr. Paul Garfinkel, Chair, Mental Health Working Group, Ontario Hospital Association, and President and Chief Executive Officer, Centre for Addiction and Mental Health, stressed the enormous symbolic value of reforming the CHA:

I think changing the Canada Health Act would be hugely powerful from a symbolic point of view. It would be saying that we are correcting a wrong. We did not understand mental illnesses years ago and now we realize that they are like any other form of human pain and suffering. That would be dramatic.[170]

Mr. Service also insisted on the significance of not treating mental health, mental illness and addictions as if they were fundamentally different from other health issues:

If we conceive of mental health, mental illness and addictions as part of and central to the operations of the entire health system, we then make an extremely important structural change that brings mental illness into prime time as opposed to it being ghettoized over here with just the “crazy people” that nobody has to really deal with or the “worried well” for whom we have no time to deal with.[171]

Ms. Chambers stressed to the Committee that in order to assist individuals living with mental disorders to take full advantage of their rights, it was necessary also to provide specific resources at the national level. She told the Committee:

I would like to emphasize that hand-in-glove with the idea of educating people, it is important to have a national mental health legal advocacy resource that is accountable to consumers. It is not just prejudice in the general community, but particularly prejudice and discrimination in the mental health system itself — it is allowed under the law — that needs addressing. It is critical to have both those pieces involved.[172]

3.4.2    The Need for Policy Reform

In general, witnesses suggested that policy can be easier to change than attitudes, and that every effort should be made to do so. This is how Ms. Stuart put it:

We are hoping that a third generation of research may focus on the kinds of social structure that … really perpetuate social inequity and discrimination — the structures and organizations, the policies and the programs that make this happen. It is difficult to change attitudes but you can change policies much more easily.[173]

In this vein, Dr. Patel called for a “review of federal health policies and programs to ensure the mental illness is on par, in terms of benefits, with other chronic diseases and disabilities.”[174] Mr. Storey gave the following illustration of the kinds of change that he feels are needed:

A number of policy changes are required in addition to protecting the actual dollars for mental health. Medical billing schedules and procedures, extended health benefits, pension plans, et cetera, do not recognize the special features and challenges of mental illness and create unnecessary obstacles to recovery and health. For example, in British Columbia, a family doctor can bill for only four counselling sessions per patient per year; yet, most people with depression go to see their family doctor. Though antidepressant medication is a helpful adjunct, alone it is not sufficient to help people deal effectively with that sometimes debilitating condition. Doctors are not in a position to provide the help required for a person in a depression.[175]

Finally, the need to adjust policy to changing social circumstances was stressed by Ms. Capponi:

There are more mentally ill people on the streets not because of a preference, but because the gulf between the haves and have-nots is getting wider and wider. More people are using the food banks and so the share for the chronic mental patient has been dramatically reduced. A landlord will rent his house to people who he thinks will be less disruptive than a former mental health patient. People get squeezed out. Shelters prefer to house immigrants or battered women because they will not be seen as potentially disruptive.[176]

3.4.3    Addressing the Issue of Violence

However, many believe that the most likely reason for the increase in stigma in recent years is related to the exaggerated attribution of a propensity to commit acts of random violence to people living with serious mental illness. There is a perception that an increasing number of violent crimes are committed by individuals with severe psychiatric disorders.[177]

Witnesses suggested that a starting point for counteracting this exaggerated attribution of dangerousness to individuals living with mental disorders is to recognize what the best science tells us. Mr. Arnett summed up the essence of this for the Committee:

…there does appear to be some increased risk of violence from those with mental illnesses. It is wise to acknowledge that. This occurs particularly with those with severe mental illness and is magnified significantly when the individuals are also substance abusers.[178]

Because incidents of violence do occur, some authors believe that a reduction in stigma against people with mental illness is unlikely to take place until there has been a reduction in violent crimes committed by them.[179] They argue that it is necessary to avoid the kind of situation in which the average commuter riding a bus to work will face an anti-stigma poster proclaiming that “mentally ill persons make good neighbours” while simultaneously reading a newspaper article detailing the most recent violent act committed by a mentally ill person.

3.4.3    The Media and Efforts to Reduce Stigma and Discrimination

There are no ready-made strategies available for reducing inaccurate and stigmatizing portrayals of people with mental illnesses in the media, and for encouraging the media themselves to contribute actively to the destigmatization of mental illness.

One example of an initiative directed specifically at altering the portrayal of people with mental disorders in the media was a petition which criticized media coverage of mental illness signed by three thousand psychiatrists in Britain in April 1995. Among their proposals, they called for “a major debate to take place particularly within the media, within broadcasting and the press, to question the persistent replication of stigmatizing and false images of psychiatric illness.” They also encouraged “the making of programmes which give a fair and accurate account of mental health issues [and asked] that the broadcasting and print industries produce codes of conduct to guide journalists in this area.”[180]

In Australia a National Media Strategy was undertaken, where the government worked directly with the media to promote more positive messages about mental health and suicide prevention. The Australian media strategy operates in journalism schools and universities, where journalists are taught how they should approach these issues when reporting them to the community so as not to stigmatize individuals living with mental disorders.

Research also points to the importance of highlighting stories of successful recovery that, if they are presented properly, can both educate and entertain audiences. Some examples of positive media portrayal and discussion of mental health issues include:[181]

• The September 2001 issue of Rosie magazine, which focused on depression.
• The 1997 film As Good as It Gets, starring Jack Nicholson. In this film, Nicholson plays a romantic lead who has obsessive-compulsive disorder. The film accurately portrays the symptoms of this disorder and, even more encouragingly, shows the character, with the assistance of therapy and medication, winning the woman of his dreams and learning to live with and control his illness.
• The television series Monk, which debuted in 2002. The main character is a private detective named Adrian Monk suffering from obsessive-compulsive disorder. Played by Tony Shalhoub, Monk is given a realistic and respectful treatment, according to the National Alliance for the Mentally Ill (NAMI).

The struggle for more accurate and positive representation of mental illness and of the mentally ill in the mass media is often thought to be analogous to the struggles of other minority and disenfranchised groups. In the opinion of Greg Philo of the Glasgow Media Group, “the media will not change until there is a movement that demands it.”[182]

3.5       COMMITTEE COMMENTARY

Overall, the evidence suggests that combating stigma and discrimination requires a multi-pronged effort. Any campaign to change attitudes will have to convey a complex message and be sustained over a long period of time, while rooting out the many forms of discrimination will require great determination and perseverance.

The Committee believes that there is a strong case to be made that each of the key phenomena, stigma and discrimination, must be tackled in appropriate ways. The battle can and must be waged on both fronts simultaneously. Campaigning and educating people to challenge stigmatizing attitudes should go hand in hand with resolute opposition to discrimination in whatever form it is perpetrated against individuals living with mental disorders. The Committee notes the success of other stigmatized groups in campaigning to reduce stigma and discrimination, and the real benefits this has yielded.

A number of key elements stand out from the testimony the Committee heard and the evidence it considered. First, the Committee sees much merit in the argument that the very fact of having a national mental health strategy (over and above the concrete elements of that strategy) will contribute to the struggle against stigma and discrimination. A national mental health strategy would focus public attention on mental health issues in unprecedented ways. Its adoption would indicate to people that the federal, provincial and territorial governments attach as much importance to fostering the mental health of Canadians and treating the mental illnesses that afflict them as they do to promoting the physical health of the population.

As part of establishing the parity of mental and physical health, and illness, the Committee took note of the suggestion that the Canada Health Act be opened to remove existing disparities. During its two-year study of the acute care sector, the Committee was wary of proposals to re-open the CHA because of the difficult debate that this would engender over which services should or should not come under the purview of the Act. However, with regard to this particular issue, the Committee feels that the option of modifying the CHA should be seriously examined, because of its potentially enormous symbolic value.[183]

Several elements stand out to the Committee as warranting inclusion in national efforts to reduce stigma and discrimination. First, it will be necessary to find ways of countering the attribution of an exaggerated propensity to violence to people living with serious mental illness. Second, efforts to reduce stigma and discrimination must be carefully targeted to maximize their effect. Moreover, the involvement of people living with mental disorders in the conception, design and delivery of these campaigns is essential to their success. It is also important to demonstrate the possibility of recovery and to promote better mental health in order to encourage changes in attitudes towards people living with mental illness. 

Finally, the Committee took note of the persistence of stigmatization and discrimination within the health care system in general, and even within the mental health care system itself. There are thus two levels at which it is necessary to work within the overall health care community. First, it is necessary to diminish the stigmatization of mental health workers within the broader health care community so that the structural discrimination that afflicts the mental health sector can be eradicated. Second, it is necessary to work with all health professionals to promote more positive perceptions of people living with mental illness.

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