Mental Illness Stigma: Problem of Public Health or Social Justice?

Abstract

The U.S. Surgeon General's report on mental health,(1999) and the report of President Bush s New Freedom Commission on Health (2003) highlighted the public health impact of mental illness stigma. Using a medical model, several education programs have sought to diminish stigma's effect on public health by describing mental illness as a disease of the brain that can be treated successfully. This approach has been shown to be useful for reducing blame related to mental illness. Unfortunately, such public health messages may also exacerbate stigma by reinforcing notions of individual difference and defect. Alternatively, framing mental illness stigma as a social justice issue reminds us that people with mental illness are just that--people. The social justice perspective proposes that all people are fundamentally equal and share the right to respect and dignity. Applying this perspective to mental illness stigma allows us to increase our understanding of the problem and expands the means and targets of efforts to eliminate stigma. In this Commentary, we review the assertions of the public health perspective, highlighting some of the limitations that emerge from this approach. We then review stigma as social injustice and feature ways in which this paradigm advances understanding and changing stigma. THE PUBLIC HEALTH MODEL OF STIGMA AND STIGMA CHANGE Viewing stigma as a public health issue points to the ways in which stigma harms people with mental illness. Three are particularly notable: label avoidance, blocked life goals, and self stigma. Label Avoidance Epidemiological research suggests that more than half of the people who might benefit from mental health 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 being labeled mentally ill (Kessler et al., 2001). Blocked Life Goals People with mental illness frequently are unable to obtain good jobs or find suitable housing because of the prejudice of key members in their communities--employers and landlords (Farina, Thaw, Lovern, & Mangone, 1974; Link, 1987; Wahl, 1999). Self Stigma Some people with mental illness internalize stigma and experience significant decrements in self-esteem and self-efficacy as a result (Link & Phelan, 2001). Public Health Approach The public health approach to decreasing mental illness stigma largely relies on education programs dominated by the medical or disease model. Education is defined broadly in terms of any strategic format (that is, classrooms, public service announcements, magazine articles) that seeks to decrease stigma by informing the public about mental illness. One example is the National Alliance for the Mentally Ill's (NAMI) Mental Illness is a Brain Disease campaign, in which the organization distributed posters, buttons, and literature that provided information about the biological basis of serious mental illness. On a global scale, the World Psychiatric Association (WPA) is sponsoring its Open the Doors Global Program against stigma and discrimination focusing on schizophrenia. Now in its eighth year, the WPA information program educates the public about mental disease and corresponding treatment. There is some evidence that education may reduce the stigma of psychiatric illness. Several studies have shown participation in brief courses on mental illness and treatment lead to improved attitudes about people with mental illness (Corrigan et al., 2002; Wolff, Pathare, Craig, & Leff et al., 1996). However, research has also found that framing mental illness in biological terms may increase other negative attitudes about mental illness. One study found that disease explanations for mental illness reduced blame, but also provoked harsher behavior toward an individual with mental illness (Mehta & Farina, 1997). …