The word “stigma,” stemming from the Greek, means a sign or a branding mark. Erving Goffman is best known for his classic work on asylums and on stigma. In 1963, he defined stigma as “the process by which the reaction of others spoils normal identity.”
Goffman addressed both “public stigma,” the reaction of others in the community at large toward people with symptoms of mental illness, and “self-stigma,” the self-blame and self-derogatory attitudes that people with mental illness may harbor about themselves. Two articles in this issue of Psychiatric Services examine strategies to reduce stigma and suggest agendas for future research and action. Corrigan and colleagues review efforts to challenge public stigma, and Mittal and colleagues summarize findings on self-stigma reduction. Both groups emphasize that stigma is essentially a public health problem and one of the main obstacles to access to care. Historically, stigma is a cause of insurance discrimination against treatment for mental illness, and the fight for parity has been a fight against stigma. The 2008 Kennedy-Wellstone legislation improved on the 1996 Domenici-Wellstone parity bill by establishing the principle of equal insurance coverage for psychiatric treatment with the rest of medicine.
Stigma is also present at all levels of medical education. Physicians in training are actively discouraged from pursuing psychiatry as a career. I remember medical school faculty saying, “Psychiatry? Why would you want to do that?” Some of the most overt signs of public stigma are the obstacles encountered by community mental health workers in finding suitable housing, employment, and rehabilitation opportunities for their clients. Self-stigma is one reason that we, as providers of care, have such a difficult time engaging individuals in treatment, which leads to high no-show rates in community clinics. Stigma explains why some individuals who are disabled by serious mental illness—and families who are distressed by an ill family member—do not seek care. Peer support services are an effective way to address self-stigma.
Will we ever see an end to the stigma that is associated with mental illness? No, not as long as there are untreated, delusional, disheveled, threatening, homeless individuals on our streets and in high-profile media examples of violence. The elimination of stigma is unlikely despite the best efforts to educate the public and to empower individuals in their recovery process. Great progress can be made to counter stigma by expanding access to effective care and by improving our own attitudes—that is, the attitudes of mental health professionals—as we encounter our patients, in our use of language about individuals with mental illness and mental illness itself, and in communications among ourselves and with our patients and at all levels in the treatment system.
