January 23, 2018
The Stigma of Mental Illness

The Stigma of Mental Illness

by Cecilie Bisgaard-Frantzen  

Stephen Hinshaw, PhD, is a professor of psychology at UC Berkeley and the vice-chair of psychology at the University of California, San Francisco, School of Medicine. He researches both developmental psychopathology and the stigma of mental illness, including how this "mark of disgrace" affects individuals and our society overall. Here, he answers our questions about how the stigma of mental illness might be overcome, and why it’s in our society's interest to do so.

Q: Why is mental illness subject to such stigma?

The three most stigmatized conditions in our society are mental illness, homelessness, and drug abuse. And those conditions are interlinked in people's minds. Various studies estimate that between 19 percent to 25 percent of American adults have some form of mental illness, including mild depression or phobias. But today most people encounter mental illness up close in its most severe forms. We encounter it through sensationalistic news stories or through people living on the streets.

We know a lot more about mental illness than ever before. One would think that the more we know, the less we fear. But at the same time our knowledge has increased, so has fear of mentally ill people, which I believe increases discrimination and stigma. There are probably a lot of reasons, and a key one is the de-institutionalization of mental health services. People who have mental illness have fewer places to go because many of the mental hospitals are closed down. We have seen about a 90 percent reduction in the number of people who are in mental health facilities since the 1950s. So, instead, we see them on the streets and that can be frightening.

Q: How does this stigma affect people’s lives?

The more ashamed people are of their mental illness—we call this internalized stigma—the less likely they are to seek and complete treatment.Surveys show that only about 63 percent of adults with a serious mental illness received mental health services in the previous year.

But stigma also affects nearly every aspect of daily life. Even today, in 2015, if you admit that you have a mental illness, in about half of the states in America, you cannot renew your driver's license. You can't vote, you can't serve on a jury or run for office, and you’re more likely to lose custody of your children in a custody battle. People with mental illness as a group do not have the same rights as the rest of the American population.

The Americans With Disabilities Act (ADA) tries to address parity by barring discrimination in the workplace and requiring equal health insurance coverage for people with illnesses, both mental and physical. But the vast majority of people with mental illness—because of stigma—won’t file a discrimination claim out of fear they will be shunned. In some ways the ADA is a paradoxical law; 94 percent of the claims brought under ADA are discrimination due to physical disabilities and not mental illness.

Q: What does this mean for society as a whole, and for public health?

We tend to think that mental illness is rare, but it’s quite common. Nearly 10 million adults live with severe mental illness. And 43.7 million Americans live with some form of mental illness, even if it is mild. This affects people's relationships, careers, and physical health. Research over the past couple of decades shows that mental health illnesses are linked not only to problems such as suicide and substance abuse, but also to many physical health problems, including heart disease, nutritional disease, respiratory disease, and other conditions. In fact, people with major mental illness die 14 to 32 years earlier than those in the general population.

You can’t separate the brain from the health of the body. The link between mental health problems and physical problems is quite serious and quite striking. It drives up costs and disrupts the lives of families. It affects all of us.

Q: So, should our goal be to end mental illness?

It’s probably not possible to eliminate mental illness, to somehow excise those genetic traits, and I don’t think we would want to. Some characteristics that—in the extreme—are symptoms of mental illness may actually help people succeed in life when mild. For example, we know that close relatives of people with bipolar disorder are by far the most successful people in just about every society ever studied. They probably have some amount of that energy and drive you see in the manic phase of bipolar illness, but not enough to lead to symptoms of bipolar illness. So if we think we have to somehow eliminate the genes for mental illness, we need to be aware that we might cut off much of society’s vitality.

The roots of mental illness are part of the diversity of society, and some amount of tolerance will help us all. I’m not saying that we should accept morally repugnant or dangerous behavior. But we need to change our mindset, and discourage the medieval belief that mental illness is the product of demons or solely the product of deficient maladaptive genes. Mental illness typically reflects both genetic vulnerability and life stress. We need to get people with mental illness to the right care.

Q: How can we overcome the stigma of mental health problems?

This needs to be addressed in many ways. Raising awareness is an important first step. Years ago, the American Parkinson's Disease Association engaged the actor Michael J. Fox and boxer Muhammad Ali as national spokesmen for the disease. Within a few months donations soared. Sympathy and public awareness were raised. But it's still hard in the US to find a spokesperson for mental illnesses such as schizophrenia.

We need to make it illegal not to offer people with mental illness the same quality and level of treatment as other people. If you have severe heart disease you can get bypass surgery and good follow-up care even if you're poor. But we don’t pay for extensive inpatient and outpatient care for people with mental illness.

We also need to raise empathy and promote education. A California program called LETS Bring Change 2 Mind (Let's Erase the Stigma) is a series of high school clubs that meets every week to talk and make an action plan for community awareness to end stigma to sexual orientation or mental health conditions. This is great because we know that it's during adolescence that attitudes about race, difference, and mental health really solidify.

We did a pilot study of the LETS clubs in southern California. Knowledge about mental illness increased a bit, but social distances were reduced greatly. The goal is to establish clubs like this in many public and private high schools, where students themselves are leading the agenda on how to combat stigma. This could ultimately become a part of a generational change.

Q: What role could the media play in ending stigma?

We did a study taking random US and British newspapers from 25 years ago, a dozen years ago, and recently. We looked at the headlines and read the stories about mental illness, randomized them and analyzed them. The data showed that there has been absolutely no change in the headlines and stories from the 1980s until now in terms of the stereotyped views of people with mental illness as incompetent and dangerous. The trend was absolutely flat.

The vast majority of people with mental illness live everyday lives as we all do, with minor triumphs and struggles. It's those deeply human stories, the humanization of mental illness that we need. In this 21stcentury, we do see some sensitive portrayals. Major publications such as The New York Times do exposés of some of the conditions with which people with mental illness live. We have true-life stories like the movie A Beautiful Mind where the late mathematician John Nash wins the Nobel Prize.

But most stories we hear about people with mental illness are either about the mad genius or the violent killer. People with mental illness are presented as either demons or angels. In truth, people with mental illness typically shift from phases of normality to psychopathology and back. They are not either "ill" or "well." Rather, nearly all experience phases of remission and relapse across the course of their lives. What they need is support, understanding, and responsive treatment.

This opinion does not necessarily reflect the views of the UC Berkeley School of Public Health or of the Editorial Board of berkeleywellness.com.