COMMENTARY

Mental Illness Stigma: Problem ofPublic Health or Social Justice?

Patrick W. Corrigan, Amy C. Watson, Peter Byrne, and Kristin E. Davis

The U.S. Surgeon General s report on men-tal health (1999) and the report of Presi-dent Bush's New Freedom Commission on

Mental Health (2003) highlighted the public healthimpact of mental illness stigma. Using a medicalmodel, several education programs have sought todiminish stigmas effect on public health by de-scribing mental illness as a disease of the brain thatcan be treated successfully.This approach has beenshown to be useful for reducing blame related tomental illness. Unfortunately, such public healthmessages may also exacerbate stigma by reinforcingnotions of individual difference and defect. Alter-natively, framing mental illness stigma as a socialjustice issue reminds us that people with mentalillness are just that—people. The social justice per-spective proposes that all people are fundamentallyequal and share the right to respect and dignity.Applying this perspective to mental illness stigmaallows us to increase our understanding of the prob-lem and expands the means and targets of efforts toeliminate stigma. In this Commentary, we reviewthe assertions of the public health perspective, high-lighting some of the limitations that emerge fromthis approach. We then review stigma as social in-justice and feature ways in which this paradigmadvances understanding and changing stigma.

THE PUBLIC HEALTH MODEL OF STIGMAAND STIGMA CHANGEViewing stigma as a public health issue points tothe ways in which stigma harms people with men-tal illness.Three are particularly notable: label avoid-ance, blocked life goals, and self stigma.

Label AvoidanceEpidemiological research suggests that more thanhalf of the people who might benefit fn̂ m mentalhealth services opt not to pursue it (Narrow et al.,2000;Regier et al., 1993). One reason given is not

wanting to suffer the stigma that accompanies be-ing labeled "mentally ill" (Kessler et al., 200]).

Blocked Life GoalsPeople with mental illness frequendy are unable toobtain good jobs or find suitable housing becauseof the prejudice of key members in their commu-nities—employers and landlords (Farina, Thaw,Lovern,& Mangone, 1974;Link, 1987;Wahl, 1999).

Self StigmaSome people with mental illness internalize stigmaand experience significant decrements in self-es-teem and self-efficacy as a result (Link & Phelan,2001).

Public Health ApproachThe public health approach to decreasing mentalillness stigma largely relies on education programsdominated by the medical or disease model. Edu-cation is defined broadly in terms of any strategicformat (that is.classrooms,public service announce-ments, magazine articles) that seeks to decreasestigma by informing the public about mental ill-ness. One example is the National Alliance for theMentally Ill's (NAMI) "Mentsl Illness is a BrainDisease" campaign, in which the organization dis-tributed posters, buttons, and literature that pro-vided information about the biological basis of se-rious mental illness. On a global scale, the WorldPsychiatric Association (WPA) is sponsoring itsOpen the Doors Global Program against stigmaand discrimination focusing on schizophrenia. Nowin its eighth year, the WPA information programeducates the public about mental disease and cor-responding treatment.

There is some evidence that education may re-duce the stigma of psychiatric illness. Several studieshave shown participation in brief courses on mentalillness and treatment lead to improved attitudes about

CCC Code: 0037-8046/05 J3,00 O2005 National AssocratJon of Social Workers 363

people with mental illness (Corrigan et al., 2002;Wolff, Pathare,Craig, & Leff et al, 1996). However,research has also found that framing mental illnessin biological terms may increase other negative at-titudes about mental illness. One study found thatdiseaseexplanationsforniental illness reduced blame,but also provoked harsher behavior toward an indi-vidual with mental illness (Mehta & Farina, 1997).Read and colleagues (1999, 2001) showed thatmembers of the general public who endorsed bio-logical causal beliefs about mental illness were morelikely to agree with negative peareptions about peoplewith psychiatric disorders.These negative percep-tions include the view that people with mental ill-ness are dangerous, antisocial, and unpredictable. Athird study suggested that viewing mental illness asa genetic disorder leads to paradoxical effects (Phelan,Cruz-Rojas,& Reiff,2002). On one hand, peoplewho endorse genetic causality are less likely to blameindividuals for their mental illness. However, thissame group is also more pessimistic that people withmental illness will recover.

THE "CURE" FOR STIGMAThere is a corollary message that often accompa-nies teaching "mental illness as a brain disorder"(that is, curing mental illness will reduce the stigma(Liberman & Kopelowicz, in press). As a person'sdisabilities vanish, prejudice against him or her basedon mental illness also disappears. Some proponentsof this approach note how the stigma of leprosy, forexample, has been erased because the illness hasbeen largely eradicated (personal communication,Sartorius, council member for Switzerland, WorldPsychiatric Association, Geneva, 2003). Research-ers in third world countries, however, might dis-agree with the claim, differing with the suggestionthat the stigma of the illness is minimal (Chatteijeeetal., 1989).

Others who promote "treating the stigma away"argue that what is labeled stigma may be a "nor-mal" response of fearful reactions to people whoare psychotic (Torrey & Zdanowicz, 2001). Thisassertion rests on two related, and tenuous, assump-tions: (1) There is a kernel of truth that underliesthe stigma of mental illness (for example, somepeople with mental illness are more violent); treat-ment programs that can reverse this "truth" willhelp to erase the stigma. (2) Putting the symptoms,and hence the disease, undercover will decrease thestigma that signals prejudice and discrimination.

Kernel of TruthStereotypes function as rational categories that"grow up from a kernel of truth" (Allport, 1954, p.22). Assessment of the kernel of truth hypothesis isa matter of assessing stereotype accuracy. Examplesof stereotype accuracy are apparent in peoples'per-ceptions of a variety of social groups. For example,professional basketball players are stereotyped as tall,and objective measures confirm that the averagebasketball professional is indeed taller than mostpeople.

In terms of ethnic group prejudice, Vinacke(1949) uncovered evidence of stereotype accuracyin students' perceptions of ethnically different peers.His research suggested, for example, that studentsaccurately perceived Hawaiians as "musical" and"easy-going." Perhaps the same is true when con-sidering stereotypic perceptions of mental illness.That is, perhaps people with mental illness reallydo possess the traits commonly attributed to them—that is, they are dangerous and unable to care forthemselves) (Nunnally, 1971).

Despite this kind of research, there are reasons toquestion the accuracy of stereotyped perceptions.History is replete with examples of inaccurate ste-reotyping that has served to justify pernicious formsof prejudice and discrimination. Armenian labor-ers in southern California, for example, were ste-reotyped as "dishonest," "deceitful," and "troublemakers." However, more objective assessments ofgroup characteristics failed to confirm the validityof these stereotypes. LaPiere (1936) found that Ar-menians in southern California appeared less of-ten in legal cases and possessed credit ratings thatrivaled those of other ethnic groups. It is clear thatmany stereotypes may possess a significant compo-nent of inaccuracy.

Psychiatry has provided several examples of inac-curate notions about mental illness. The disciplinehas generated an endless list of groundless theoriesto add to stigma—for example, influences of thewomb ("hysteria") and moon ("lunatic").But whatabout the connection between violence and seriousmental illness; might we not think this attitude restson a grain of truth? Large scale analyses of epide-mioiogic databases showed that people with mentalillness are generally more dangerous than the popu-lation as a whole (Swanson, Holzer, Ganju, & Jono,1990). However, additional analyses of the dataexamining the size of these effects found that men-tal illness, compared with some demographics, is

364 SocialWork VOLUME 50, NUMBER 4 OCTOBER 2005

actually a poor predictor of dangerousness (Corrigan&Watson,in press), in terms of group risk,men andyoung adults are three to six times more likely to beviolent than people with mental illness. Hence, theaccurate stereotype is that the size of the violenceeffect for mental illness is not large or meaningful.

No symptoms. No StigmaTreating the stigma by hiding the symptoms has acounterpoint in the history of stigma and ethnic-ity; namely, racism can be fought by becomingcolor blind (Brown, Carnoy. Currie, Duster, &Oppcnheimer, 2003). Some activists in the 1960sbelieved that Americans should be oblivious ofoutward signs that distinguish white from black andfrom other ethnic groiips-^that is, skin color. In-stead we should identify and cherish a commonset of supraracial values that serve as the bench-marks by which an individual's worth is judged.Unfortunately, the search for these supraracial val-ues frequently led to Western European standardsso that African Americans, for example, were stillbeing judged by white American values. The no-tion of erasing mental illness implies that being"normal" is somehow better. Being color blind, orhiding the symptoms, may unintentionally add tothe stigma. It may suggest that people who are nothiding their symptoms are somehow responsiblefor them.

Parity Not PityResearch suggests that educational programs thatfocus on biological causes may increase pity, or sym-pathy, for people with mental illness (Corrigan etal., 2001; Corrigan et al., 2002; Watson, Otey,Corrigan, & Fenton, 2003). But pity yields bothpositive and negative results. Weiner (1995) arguedthat sympathetically viewing a person as victim-ized by a health condition is associated with will-ingness to provide help to that person. Researchspecific to mental ilhiess has shown that membersof the general public who pity individuals withmental illness are more willing to offer a helpinghand to them (Corrigan et al., 2002).

However, pity from the public may also producenegative effects because, in trying to elicit sympa-thy, there is an overreliance on or dramatization ofwhat people with mental illness cannot do. As aresult, viewing people with mental illness as piti-able has been associated with the benevolencestigma (Brockington, Levings & Murphy, 1993;

Madianos, Mandinou, Vlachonikolis, ik Stefanis,1987); because people with mental illness areviewed as unable to competently handle life's de-mands, they need a benevolent authority who canmake decisions for them. Mental health advocateshave argued that a major problem with the mentalhealth system is dis empower ing practices that pre-vent people with psychiatric disabilities from pur-suing life goals (Beers, 1908; Chamberlin 1978).Hence, antistignia advocates need to be very cau-tious about programs that make appeals to pity.Antistigma advocates need to cultivate empathythat leads to parity, not to condescension and ex-aggeration of difference.

MENTAL ILLNESS STIGMA ASSOCIAL INJUSTICEThe public health approach may have some valuein reducing label avoidance and limited impact onaspects of blocked opportunities and self-stigma.However, in other ways it may exacerbate stigma-related problems. What might we learn from otherperspectives on stigma that will diminish its im-pact? When not discussing health disorders, genericideas of stigma are typically defined as social injus-tice; this general definition reus on the idea of dis-credited difference (Goffnian, 1963;Link tk Phelan,2001). Prejudice of any sort rests on human differ-ences.Although the vast majority of human differ-ences are irrelevant to prejudice—handedness,eyecolor, foot size—history shows some differencessuch as skin color and sexual orientation are salientand often paired with negative attributes.

Highlighting InstitutionsStigma is promulgated in part, through rules, prac-tices, and processes of "liberal''institutions; for ex-ample, educational, medical, i:riininal justice, andsocial service agencies. A social justice perspectivewould target institutions that traditionally may notbe considered worthy goals for change because theyseek good ends (such as health care providers orpolice officers) but do so in ways that marginalize,exploit, or, in the worst case, victimize people withmental illness. A social justice perspective wouldscrutinize the means and the unintended effects ofhow institutions and larger political arrangementsdo not enable or empower people with mentalillness.

Many institutional practices inhibit people withmental illness, for example, from cultivating basic

CORRIGAN, WATSON, BYRNE, AND DAVIS / Menial Illness Stigma: Problem ofI^blic Health or Social Jwlice? 365

capabilities necessary to human achievement (edu-cational institutions), from gaining access to re-sources that will improve their well-being (healthcare), troni allowing people to define themselveson their own terms (places on media advisoryboards),and from making decisions about their owncare, and so forth. Hence, any institutional practicethat marginalizes, exploits,or victimizes people withmental illness would be a viable topic of researchand a just cause for advocacy.

Expanding Means and TargetsLooking at mental illness stigma from the perspec-tive of social justice increases tbe means throughwhich stigma is targeted to include more overtlypolitical processes: for example, organizing arounda political identity; that is, "mental illness and psy-chiatric disability"; changing decision-making pro-cesses within institutions, for example, health care;and getting "discreditable" people to do poHticalwork for thf discredited (Stefan, 2001). Discredit-able people arc those wbo can hide their symp-toms.The practice shifts change targets from preju-dicial beliefs to institutional practices tbat areinformed by and often perpetuate beliefs. Hence,although educational efforts to debunk myths wouldbe part of a social justice solution, they would notbe the sum total of attempts to challenge what wouldbe seen as unfair treatment based on an inessentialdifference from otber groups,and thus open to socialsolutions that have worked in the past to elimmateunfair treatment.

Consider a lesson from the women's movement,which targeted health care services that systemati-cally denied their participation in decisions abouttheir health through creating women-run services(for example, domestic violence centers and rapecrisis lines). So too, may groups of consumers wantto create a network of consumer run communityservices.

Improving UnderstandingLast, and perliaps least obvious, a social justice per-spective allows for a more complex understandingof stigma, because it may account for the intersect-ing stigmas of race and poverty that exacerbate theinjustices faced by people with mental illness. Byconcentrating on the experience of and conse-quences for people with mental illness, a social jus-tice perspective brings into relief the intersectingidentifications and situations of people with men-

tal illness so that the impact of potentially multiplestigmas can be explained. People with mental ill-ness who f^ct^ the most egregious injustices are mostoften those who are also stigmatized because ofthese additional stigmas. For example, tbe issue ofwho is able to keep his or her behavior and symp-toms private—that is, who is not forced by circum-stances to make their behavior public—is also asocial justice issue. This is not to say that peoplewith mental illness who have enough money andcredibility to maintain privacy and confidentialityoppress those who do not, but that socioecononncstatus affects how people with mental illness expe-rience their mental illness.

Insofar as racial discrimination has led to a legacyof poverty, making it difficult to move out of disad-vantaged neighborboods, people of color are vis-ible and unable to hide or pass. A social justice per-spective on mental illness stigma would includepoverty and homelessness as problems to be ad-dressed in eliminating the injustices with whichpeople with mental illness live.

AN INTEGRATED PERSPECTIVEBy no means are we implying that viewing stigmaas a public health problem is categorically distinctfrom social injustice; an integrated perspective of-fers tbe most potent approach to understanding,and ultimately erasing, the phenomenon. We be-lieve that it was important to highlight the limita-tions of framing mental illness stigma as solely ahealth problem because of the dominance of medi-cal and public health models in addressing the harmassociated with mental illness. These models haveclearly enhanced our understanding of mental ill-nesses and ways to treat it. Moreover, we acceptthat stigma is a public health problem: It keepsmany people from pursuing psychiatric serviceswho might otherwise benefit from it and blocksthe life opportunities of those labeled "mentallyill."

Unfortunately, trying to erase the stigma bysolely adopting the medical model might uninten-tionally worsen the prejudice and discrimination.Concerns about social injustice frame the stigmaof mental illness as another example of in group-out group biases. It explains stigma as a power is-sue and incorporates the various social and eco-nomic processes that are frequently the foundationofthese issues. As a result, it opens the antistigmaprocess to the same political processes that have

366 SocialWork VOLUME 50, NUMBER 4 OCTOBER 2005

been used to address the injustices found acrossethnic and gender lines.

What implications might this have for stigmachange? It suggests that traditional focus on educa-tion-based interventions may not be sufficient.Contact between a sometimes prejudicial publicand people with mental illness is an antistigma ap-proach that seems to effectively augment educa-tion {Corrigan et al, 2001; Corrigan etal, 2002).Moreover, stigma change agents might want toconsider the protest and boycott strategies that haveproven effective in diminishing discrimination inother arenas. The ultimate proof of the antistigmapudding will be when people with mental illnessreport fewer hurdles to life opportunities and morewillingness to seek help, kiyj

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CORRIGAN. WATSON. BYRNE, AND DAVIS / Mental Illness Stigma: Problem of Puhlk Health or Social Ju.mei' 367

Wahl, O. F. (1999). Mcuul ht-akh consumers' cxpt-nenceofstignia. Schizopltrciii/i Biilleiiii, 25,467-478.

Watson, A.. Otey. E,. t:orrigan, P. W, & Femon,W. (2003).The sciena- of menial illtics!: Challftiging tnenial illueisiti^rna irilh a middle school .science cutriailum. Unpub-lished manusLTipt.

Weiner, B, {\^93).judjifine»ts of reiponsibility: A foundationfor a tlKOry of social coiiducl. New York: Guilford Press.

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Patrick W. Corrigan, PsyD, is professor of psychology,

Joint CctiWr for Piydiiairit: Rcliabititatioii, Illinois Institute

ofTechnolii^y. 3424 South State Street, Chicai^o, IL 60616;

e-mail:corrigan@iit.cdii. Amy Watson, PhD, is assistant

professor, Department of Psychiatry, Northwestern Univer-

sity. Evanston. IL; Peter Byrne, MD, is senior lecturer,

Department of Mental, Uniivrsity College, London,

England; and Kristin Davis, PhD, is assistant research

direclor,Tlircsholds Psyihosocial Rehabilitation Center,

Chicago. Please address all correspondence to Patrick W.

Corrigan.

Original manuicript received January 12, 2CM14Final revision received May 21, 2004Accepted Nouember 15. 2004

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