April 25, 2011
Harvard Medical School
In our society, it is common to hear disparaging remarks and jokes about mental illness or the clinicians who treat psychiatric disorders. Every October, the National Alliance on Mental Illness reports on insulting Halloween costumes, such as those looking like straitjackets or the ones with names like "Dr. Malice" and "Cell Block Psycho." Aside from being distasteful, they add to the persistent stigma associated with and stereotype of people with mental illness.
For the mental health clinician, stigma is important because it causes many people to delay seeking help and getting treatment. Consider this:
One national survey found that only 51% of Americans with symptoms of major depression in the previous year were receiving any kind of treatment, whether with antidepressants or psychotherapy.
Another survey found that only about half of people with social anxiety disorder ever receive treatment.
The average person with symptoms of depression waits at least 10 years before seeking help. In both of these studies, stigma was cited as an important factor.
How Stigma Harms People
The term stigma comes from the Latin word that refers to a tattoo placed on slaves or criminals to mark their inferior status. In much the same way, the stigma surrounding mental illness also "marks" people.
Dr. Erving Goffman, a sociologist who spent much of his career at the University of Pennsylvania, is credited with first explaining the modern concept of stigma. He saw it as a personal characteristic that society views negatively. In his 1963 book, Stigma: Notes on the Management of Spoiled Identity, he described someone with a stigmatized condition as being "deeply discredited" in society.
People who are stigmatized are made to feel that they don't have the same value in society as other people. Thus, stigma is harmful because:
It has a negative impact on self-esteem and psychological well-being. This, in turn, affects a person's academic and professional achievement.
Stigma is like racism in that it promotes institutionalized forms of discrimination, such as restriction of voting rights.
It reinforce and intensifies the suffering of mental illness.
Stigma and "Social Death"
Dr. Arthur Kleinman, a psychiatrist and medical anthropologist at Harvard University, has made the case that stigma has become such an overused term that it has lost any real meaning. Instead, he proposes a new term: social death. This term underscores how people with stigmatized conditions, such as mental disorders, are treated like social outcasts or — in the extreme — treated as less than human.
People may react to them as non-persons, so they experience a social death in relation to their communities. In China, psychiatric patients are made to wear outfits similar to prisoners. They can't participate in family gatherings. In the worst cases, authorities severely violate their human rights, for example, by putting them in chains.
Dehumanizing conditions exist in the United States, too, although to a less drastic degree. Consider the large number of Americans with psychiatric disorders who are living on the streets or in jails due to lack of proper treatment.
A Problem Worth Solving
Stigma is not just a theory. It is a real problem that is worth solving.
If stigma is primarily psychological, then reducing its bad effects may involve psychotherapy to boost self-esteem. If it is more social in nature, the way to fight it is through awareness campaigns to change public opinion and policies. And if stigma is a moral issue, then it may be necessary to advocate for basic human rights. Much of this work is underway, thanks to mental health advocacy organizations.
Given that stigma about mental illness is so persistent, it's likely that all of these efforts may need to be redoubled before psychiatric disorders are seen as illnesses rather than as jokes or personal failings.
Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.
