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In recent years, the stigma surrounding mental health and mental illness has undoubtedly diminished, yet it persists in our society. Those brave enough to fight stigma by sharing their experiences openly may face discrimination in both personal and professional spheres.
This prevailing stigma arises from our inclination to rely on mental shortcuts, leading to hasty judgments and the perpetuation of stereotypes. These stereotypes, in turn, give rise to prejudice and discriminatory behavior.
What is stigma?
As clinical psychiatry profession Wulf Rössler writes, stigma operates on three distinct levels: the macro level, encompassing mass media and society at large; the intermediate level, involving mental healthcare professionals; and the micro level, which includes immediate family members and the individuals themselves. Each level contributes to the complex web of stigma that individuals with mental illnesses face daily.
Why does stigma exist?
It all stems from stigma. Stigma likely forms over time from beliefs that propose the mentally ill are a threat, or as being in control of their illness and just too weak to combat it(Arboleda-Flòrez, J. 2002 Feb. "What causes stigma?" World Psychiatry. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489829/). According to Wulf Rössler, a professor of clinical psychiatry, stigma exists at three main levels: (1) the macro level, which includes mass media and the rest of society, (2) the intermediate level, which includes mental healthcare professionals, and (3), the micro level, which includes immediate family members and the patients themselves.
Overcoming this stigma is crucial for creating a society that is accepting, supportive, and empowering for those with mental health challenges. By raising awareness, fostering understanding, and encouraging open dialogue, we can collectively challenge the stigma surrounding mental illness and work towards building a more inclusive and compassionate world.
stigma at the macro level
When they diagnosed me with bipolar, I dove headfirst into the literature...well, that and Reddit. Scientific literature for the definitions and facts, and social media to learn about other people's experiences. I basically knew nothing about it. All I had was a vague idea that being bipolar meant you had a "crazy" side — an alter-ego, a wild personality bubbling beneath the surface, an evil twin. Of course, this came from my limited exposure to the disease through TV shows and movies. I was ignorant, like so many others. 😔 I've heard people use the word "bipolar" as an adjective to describe someone who is acting in an unpredictable way, someone who's acting "crazy." I've almost certainly done the same at some point.
Why do people have such a particular view of mental illness? Although I think there's been some improvement in recent years, representation of the mentally ill in media has generally been poor (post coming later). Poor media representation is not only discouraging for the mental illness patients themselves, but can also affect public attitudes and understanding towards the mentally ill. When I opened up to a colleague about my condition, she jokingly threw her hands up and exclaimed, "Don't stab me!" 😐 I forgave that statement, because what else could I do? I can't say it made me feel very good. But it wasn't her fault. She just didn't understand bipolar like I did; she only understood it how it had been presented to her in the past. Until I started experiencing stigma myself, I had never considered that this is what people with mental illnesses deal with.
I'm lucky that I live and work in an environment that is accepting of mental health, and luckier still to have open-minded colleagues and friends. But I still deal with stigma, just less of it and sometimes in the opposite direction (people who over-correct, and perhaps are too accommodating to the point of ableism). Stigma can manifest in a multitude of ways, and dealing with it is frustrating and can even hinder recovery. Mental illness patients who experience stigma report lower self-esteem, rockier relationships, and less motivation to apply for jobs (Stuart, H. 2006. "Media portrayal of mental illness and its treatments: what effect does it have on people with mental illness?" CNS Drugs. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16478286). Another study found that perceived stigma can also negatively impact medication adherence(Sirey, JA et al. 2001 Dec. "Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence." Psychiatric Services. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11726752). It's clear that society-level stigma is a real problem that can negatively impact the well-being of mental illness patients and exacerbate symptoms. We need to pursue a gentler, kinder environment that doesn't target, harm or generalize against people with mental illnesses.
stigma at the intermediate level
Mental illness care providers make up the intermediate level. As Rössler writes, "In theory, one might expect that mental healthcare professionals would hold at least neutral attitudes towards patients with mental illness. However, they display at least equal, or in some cases, even stronger negative beliefs and attitudes than persons within the general population." It could be because mental healthcare professionals have dealt with patients at their worst, leading them to make assumptions about other patients based on extreme experiences. Remember what I was saying about our brains taking shortcuts?
When I was in the psych hospital, I definitely experienced prejudice. Again, I'm lucky: for the most part, my interactions with staff were positive. But at times, I felt I was treated like a child or as a typical "crazy person." For instance, it bothered me that my social worker assumed that I would continue to "resist" my medication. 🤔 She warned Josh that they were prepared to take me to court and court-order me to take my medication if I continued to resist, when at that point I had been in the psych hospital for just over a day and no medication had been prescribed to me yet. I hadn't even spoken to a psychiatrist at that point. It's true I had expressed hesitation around the concept of taking medication when the nurses and social workers asked, but I had never flat-out refused medication. I am a thorough person, and I had simply requested to discuss my treatment options and any potential side effects in detail with a psychiatrist before taking anything. For the record, I did eventually go through a list of different medications with the psychiatrist, read up on them, and select one for myself. Hearing Josh explain what the social worker had said about me was jarring; I felt like she painted me as a different person. She interpreted my actions in a certain way because she was making judgments about me. It made me realize that in a mental hospital, I had absolutely no credibility, and that I didn't have an identity. My identity was the face of every other bipolar or mentally ill person that she had dealt with before (who I wish well).
Still, I do consider myself lucky; a lot of people have worse experiences in the psych ward, and I'm not crying that a social worker hurt my feelings. But it is seriously disheartening to endure stigma and judgment from someone who is supposed to be helping you. If we can't trust our mental health care providers, how can we make progress? If you work in mental health, take some time to consider your interactions with others, including with your colleagues. Do you make fun of the patients? Do you ever judge them or make assumptions about them? I know there are people out there who care, and I also know that working in mental health is draining and can even be dangerous. It is a really tough job, but if it is your job, please try to do your best to be aware and be kind. If you aren't able to do that, then frankly I don't think it's the right job for you. I'm not saying you need to be perfect all the time, but if you're not willing to at least try, it would honestly be better for everyone if you found something else.
stigma at the micro level
At the micro level, mental health patients tend to internalize the stigma they experience, resulting in low self-esteem and self-efficacy. When the word "crazy" is tossed around so casually to describe pretty much everything under the sun, how can we expect otherwise? (I've started saying "wild" instead, by the way.) Because of widespread perceptions of the mentally ill, we might start to believe that we're not going to get that job, even if we tried. Or that we're going to destroy this friendship at some point anyway, so why bother. We might believe that we're not capable of taking on more responsibility at work. This self-stigma can extend to all areas of life. Again from the Rössler paper, "individuals reduce their social networks in anticipation of stigma-related rejection and isolate themselves." You can see how anticipatory behavior like this might exacerbate depressive episodes and cause a terrible cycle of self-sabotage.
Micro-level stigma also includes the immediate family members. Stigma can run in both directions here. On one hand, family members in denial may believe that the illness isn't real and that the patient can simply choose to "get over it." On the other hand, family members may be overly supportive and coddle the patient, and treat them as if they are weak and made of glass. This overcorrection is rooted in the best of intentions, but it may give off the impression of pity, which can be counterproductive. In my opinion, the best thing that people can do to support someone with a mental illness is ask them what they need. If they aren't sure, give them space while encouraging them to reach out if they need to. If you have your own experiences to share about this, please do drop them in the comments!
To get through the obstacle that is mental illness, one needs a really strong support system. I want to live in a world where everyone with mental health issues feels supported and empowered enough to work on themselves at their own pace. To get there, we first need to learn to break free of that self-stigmatization and accept ourselves. We need to allow ourselves to start believing that our illnesses are real, and they're tough. Having a chemical imbalance in your brain is no fun at all, and we need to start thinking about mental illness as just that: something physical, no different from any other physical illness. And we shouldn't blame ourselves for not "being stronger." Anyone living with mental illness is already strong.
how do we break free of stigma?
The National Alliance on Mental Illness (NAMI) has a great post about ways to fight mental health stigma. I echo that the easiest way to impact change is to simply talk about our experiences; that's one reason I started this blog. Even if sharing my story helps one person to feel less alone, or if one person learns something, it will have been worth it. In trying to normalize the topic of mental health, I have been very open about my illness with friends, family, coworkers, and even people I don't know very well. It's not easy for me: I feel self-conscious about it and of course, it opens up my chances of experiencing stigma. But through talking to people, I learned that so many people are going through similar things. One in four people are estimated to be affected by mental illness at some point in their lives (World Health Organization. 2001 Oct 4. "Mental disorders affect one in four people." Retrieved from https://www.who.int/whr/2001/media_centre/press_release/en/). With those numbers, there's no reason stigma should exist in our society.
It's not always easy to share. But if I want to do my part to reduce stigma, I have to take all that comes with it. To build a thicker skin against stigma, I'm reminding myself that I am not responsible for what others think of me. What others think of me does not need to affect me. As a mental health patient, it's very difficult not to feel misunderstood, but I need to remember that I'm trying to understand myself, too. And we all know that there's still a lot we still don't understand about mental illness in general. Through communication, we can build understanding and acceptance. Not only should people strive to accept those with mental illnesses, those with mental illnesses should strive to accept that those without mental illnesses may never fully understand what it's like — and that's okay.
I think the single most harmful thing is assuming we know what someone else's experiences have been like. We won't know unless we discuss — we don't know unless we ask. What has your experience been like?
© if you know you grow 2023.