Erving Goffman defined stigma as ‘an attribute that is deeply discrediting’ and reduces the bearer from ‘a whole and usual person to a tainted discounted one’ [8]. Building on the work of Goffman [8] as well as others [9], Link and Phelan [10] defined stigma as a process consisting of five interrelated components that, when they converge, result in status loss and discrimination for members of stigmatised groups. The process begins with the recognition, labelling, categorising and associating of human difference with negative meanings through stereotypes or cognitive linkages to undesirable qualities. Next, is the separation of ‘us’ from ‘them,’ with ‘them’ being the stigmatised and ‘us’ being the stigmatisers. This results in status loss and discrimination for those who have been stigmatised. Underlying this process is the exercise of power that allows the process to unfold. Without the exercise of power, labelling, stereotyping and separating ‘us’ from ‘them’ will not produce status loss and discrimination.

When powerful others engage in the process of stigmatisation, they possess the capacity to deny opportunities to stigmatised persons to participate fully in community life and citizenship [10]. For persons with mental illnesses, this may result in barriers to social relationships; discrimination in employment, education and housing; disparities in access to quality health care and blocked opportunities for full civic engagement. It may lead to label avoidance, in which people delay or opt to not seek mental health services when distressed in order to avoid the egregious effects of public stigma [11].

The stigma of mental illness may appear in interactions between people and groups (public stigma), within stigmatised persons themselves (internalised stigma or self-stigma); and in institutional and social structures (structural stigma).

Public Stigma. Public stigma has been the focus of social cognitive models and researchers and advocates are working to understand and reduce mental illness stigma [12]. In these models, the stigma process is understood in terms of four cognitive structures: cues, stereotypes, prejudice and discrimination. The process begins with cues from which members of the public infer that a person has a mental illness. Cues that identify a person as a member of the group ‘mentally ill’ may be related to psychiatric symptoms, social skill deficits, physical appearance and labels [13, 14]. Research has shown that many of the symptoms of severe mental illness – inappropriate affect, bizarre behaviour, language irregularities and talking to self aloud – tend to produce stigmatising reactions from the public [7, 15, 16]. Likewise, social skill deficits present in some psychiatric disorders [15,17–19] potentially mark a person as having a mental illness and cue the stigma process. Moreover, poor hygiene or other aspects of appearance may be assumed to indicate mental illness and lead to stigmatising responses [20, 21]. Even prodromal symptoms (of psychosis) may cue stigma, long before a person is clinically labelled. Finally, people may be publicly labelled as having a mental illness if others are aware of their diagnosis, psychiatric hospitalisation or see them entering or leaving a facility that provides psychiatric treatment. (Locating EI services in ‘neutral’ settings may therefore reduce the risk of cueing stigma for those accessing services).

These cues activate stereotypes, which are knowledge structures that are learned by most members of society [22–27]. Stereotypes are especially efficient means of categorising information about social groups. Not everyone with the knowledge of stereotypes about a group agrees with them [28–30]. People who are prejudiced, however, endorse these negative stereotypes (e.g. I agree, I think people with mental illnesses are dangerous) and generate negative emotional reactions as a result (e.g. I am afraid to have them live in my neighbourhood) [26, 31–35]. Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioural reaction [36]. Discriminatory behaviour manifests itself as negative action against members of the stigmatised group. For example, if I believe that people with mental illnesses are dangerous and I am afraid to be near them, I may protest supportive housing in my neighbourhood. I may also advocate for more coercive commitment laws and take other action to keep them out of my community.

Self-Stigma. Self-stigma includes the same components as public stigma, although, the components interact within the stigmatised person him or herself [37–39]. First, long before the onset of symptoms, individuals are fully aware of cultural stereotypes about mental illness and may even endorse them. Thus, with the onset of illness, these stereotypes become self-relevant. For example, a college student experiencing a first episode of schizophrenia may tell himself: ‘people assume I am incompetent and cannot finish college because of my illness.’ Second, prejudice consists of individuals agreeing and internalising stereotypes: ‘they are right, I cannot accomplish anything.’ Third, discrimination includes individuals reacting to prejudice with a behavioural response. In the case of our example, ‘there is no point in even trying to go back to school – I just cannot do it.’

Just like public stigma, self-stigma negatively impacts individuals in many aspects of life. Specifically, individuals engaging in self-prejudice and self-discrimination may avoid pursuing employment, housing, political, education, relationship and health care goals. By being continually bombarded with stigmatising images and behaviours, individuals may endorse these notions and experience reduced self-esteem, self-efficacy and confidence, which may lead to the lack of drive to pursue life goals [40]. Moreover, even if they do not fully endorse stigmatised views of themselves, individuals who are aware of negative stereotypes may feel less valued in society and withdraw in order to shield themselves from negative and discriminatory responses from others. Stigma may result in not pursuing social, educational, vocational and civic opportunities, often out of self-protection.

Structural Stigma. At the societal level, political, economic and historical forces create stigmatising social barriers that restrict life opportunities for individuals with mental illnesses. Structural stigma consists of two levels: institutional policies and social structures. Examples of institutional policies, based on the prejudice of leaders, include laws and regulations that discriminate against individuals with mental illnesses. For example, some states in the United States maintain laws and administrative rules that restrict the rights of individuals with mental illnesses in the areas of jury service, voting, holding public office, marriage, parenting, and professional licensures. When government entities develop these laws and rules based on the label of mental illness rather than the severity of disability resulting from the impact of psychiatric symptoms on functioning, they are institutionalising structural stigma [41].

Second, structural stigma develops historically through economic and political injustices wrought by prejudice and discrimination. The essential aspect of this type of structural stigma is not direct intent but rather the effect of keeping individuals with mental illness in subordinate positions. There is not a specific prejudicial group in power maintaining structural stigma; rather, it is the product of historical trends in mental illness discrimination. For example, in the United States, structural stigma long maintained a political and economic environment which made it very difficult to achieve parity between mental and physical health insurance coverage (parity of esteem). For decades, insurance benefits for treatment of somatic illnesses were less restrictive than benefits for treatment of mental illnesses. Another example of structural stigma includes mental illness research, which receives minimal federal dollars when compared to other health care research. Since agencies fund physical health research at a much higher rate, knowledge that reduces mental illness stigma and enlightens mental health policies cannot match the same rate of knowledge growth in physical health conditions.

Numerous studies have documented the public’s widespread endorsement of stigmatising attitudes [35, 42, 43–46]. While recent studies suggest that the publics’ understanding of mental illnesses may have become more nuanced, perceptions of dangerousness and fear have increased [7] and the desire for social distance from persons with mental illnesses remains strong [35, 42, 43]. Thus, social attitudes may be moving further away from social inclusion and community integration.

The consequences of public mental illness stigma are severe and touch all aspects of a person’s life. Here, we briefly discuss three critical life domains, education, employment and housing, however, it is important to keep in mind that stigma has the potential to invade and negatively impact all facets of the lives of persons with mental illnesses (e.g. relationships, health care, interactions with the justice system and participation in civic groups). Education is critical to the pursuit of many life goals and is related to a myriad of health and mental health outcomes [44]. Post-secondary education is also a prerequisite for many jobs with reasonable benefits and adequate salary. Because the onset of severe mental illness often occurs during the late teens and early 20s, completion of high school and the pursuit of higher education may be disrupted. Individuals that experience educational disruptions due to illness may be discouraged from returning. Those who persevere in their pursuit of college education report that they experience significant stigma in the college environment [45, 46].

Work provides a vehicle for social integration and a sense of self-worth and social identity. For people with mental illness, employment provides structure, social connections, goals and income – essential components of recovery [47]. Unfortunately, research confirms that stigma creates barriers to obtaining and keeping good jobs [48–53], when employers refuse to hire a person with a mental illness or to provide reasonable accommodations that allow that person to be successful in the job. It is not only employer stigma that creates barriers to employment for persons with mental illness. Competitive employment has not traditionally been a focus of the mental health system [47] and clinicians have discouraged individuals from considering employment for fear that the stress of employment would exacerbate the illness.

Another life domain key to recovery (and to general healthy living in the community) is access to safe and affordable housing. A safe place to live is an important goal for all of us. Here again, research confirms that stigma blocks opportunities to lease safe housing [54, 55] and site groups homes and other types of housing for persons with mental illnesses [56]. As a result, persons with mental illnesses may end up living in substandard units in unsafe neighbourhoods, isolated from family and positive social activities. This puts them at risk for a variety of negative outcomes, including victimisation, substance misuse and criminal activity.

As discussed above, stigma processes may also occur within the individual who is stigmatised in the form of self- and perceived stigma. Both self- and perceived stigma lead to a loss of self-esteem and self-efficacy and limit prospects for recovery as individuals constrict their social networks and opportunities in anticipation of rejection [57–61]. For example, college students experiencing mental illness may withdraw from academic settings for fear of loss of confidentiality and discrimination [62]. Likewise, adults with mental illness may also choose not to pursue intimate relationships to avoid rejection due to their mental illness [59, 63].

Stigma also creates barriers to accessing mental health services, preventing some people from accessing or fully participating in effective treatments. In fact, up to 40% of people with severe mental illnesses do not receive treatment in a given year [64]. While many factors may prevent people from obtaining services, stigma plays a role. Research indicates that people who are concerned about what others would think and those with more stigmatising attitudes themselves are less likely to seek care [65, 66]. Stigma may increase delays in seeking treatment [67, 68]. Additionally, stigma may affect participation once people enter care in terms of reducing adherence to treatment [61].

Given the wide-ranging negative impacts of stigma, it is not surprising that some people may choose not to access services and supports in an effort to avoid being labelled and experiencing the sometimes devastating consequences. However, in doing so, they forgo the benefits of effective treatments and support that could alleviate some of the distress associated with psychiatric disorders. They may also miss the opportunity to prevent or at least mitigate more serious disability. Thus, stigma has significant implications for EI services. Regardless of how promising they may be, people may be very hesitant to access treatments. Thus, it behoves EI programs to engage communities they serve in anti-stigma campaigns.

EI programs also have implications for stigma, both positive and negative. On the positive side, EI interventions may reduce ‘cues’ that initiate the stigma process. Early intervention may reduce the severity of symptoms that signal to others that a person has a mental illness, thereby reducing stigma [69]. It may also prevent stigmatising events such as hospitalizations, job loss and other crisis situations.

Negative implications may result from extending mental illness related labels sooner and to a larger group of people. Writing about the potential stigma associated with the proposed ‘high risk for psychosis’ category for the DSM-V, Yang et al. [70] caution that we do not yet fully understand what the effects will be. They note that as this high-risk designation will most likely be given to young adults who are in the early stages of identity development, concerns about stigma are heightened. The label may be understood as a pre-diagnosis and exert negative effects similar to a label of psychosis on family and community reactions as well as initiate self-stigma processes. Even in the most controlled clinical settings, over 50% of individuals identified as ‘at-risk’ do not progress to psychosis [71]. In the specialised clinical research programs currently using this designation and providing EI services, great care is taken to mitigate the impact of stigma. For example, McGorry et al. [69] located their service in a non-psychiatric setting and gave the programme a generic name. Patients and families are provided with information to decatastrophise psychotic disorders. Yang et al. [70] expressed concern that in more common community use, the rate of false positives may be even higher, with less attention to curtailing stigma. Thus, we must remain vigilant to the potential stigma consequences of EI and work tirelessly to reduce mental illness stigma. In the next section, we discuss approaches for doing just that.

Given the potential impact of stigma on EI service participation and EI interventions on stigma experienced by service users, it is critical that EI programs incorporate strategies to reduce both public- and self-stigma. First, we consider public stigma. Advocacy groups, government agencies and professional associations have launched campaigns employing a range of strategies, targeting various audiences and components of public stigma. These approaches can be categorised into three paradigms based on social psychological research: protest, education and contact [72]. We discuss each in turn followed by a discussion of effective messaging and targeting of campaigns.

Protest. Protest strategies identify specific instances of stigma and discrimination and highlight the injustice; the goal here is to shame those who are responsible [73]. Advocacy groups have used this approach to address stigmatising images in the media. For example, an organisation may identify that a television programme perpetuates a stigmatising image of mental illness, organise a letter writing campaign to the media outlet urging a boycott of the program’s advertisers. In the United States, groups such as National Alliance on Mentally Illness (NAMI) Stigmabusters and Mental Health America report some successes using protest strategies. For example, in 2010, they were successful in getting a television advertising campaign for the fast food chain Burger King discontinued. The commercials, presumably set in psychiatric hospitals, featured the ‘Crazy King’ who is described by medical types as ‘crazy’ and ‘insane’ because he wants to give away his meat for the low, low price of $3.99! While such protests may be effective for eliminating offensive representations or behaviours, they may not improve the attitudes of the people promoting them. Additionally, protest approaches risk producing rebound effects with the consequence that prejudices about a group remain unchanged or possibly, get worse [74–76]. Despite the potential for attitude rebound, protest strategies may be useful for changing behaviours. When successful, they may reduce the number of stigmatising messages the public is bombarded with and thus have a place in our arsenal of strategies.

Education.