Public stigma

Public stigma occurs when members of the general public endorse stereotypes that lead to a stigmatizing attitude and on this basis discriminate or generally devalue these individuals. In a survey of 1,444 North Americans, Martin and colleagues (2000) found that nearly seven out of ten (68.4%) say they are unwilling to have someone suffering from drug or alcohol dependency, schizophrenia, or depression marry a family member, while 58% express unwillingness to have people suffering from these problems as coworkers. Similarly, those with a mental illness and their family have their own beliefs about mental illness which affect the way they see themselves, the help they seek (or do not seek), and how they might discuss issues related to mental illness within the family.

Corrigan et al. (2000) point out that people labeled mentally ill are stigmatized more severely than those with other health conditions such as cancer. At the same time, the public discriminates among psychiatric groups; for example, people with psychotic disorders are judged more harshly than people with affective disorders (Pescosolido et al., 1999). Similarly, the general public tends to view schizophrenia as dangerous and unpredictable while considering social phobia to be a sign of personal weakness and not a real medical illness (Reavley and Jorm, 2011). Feldman and Crandall (2007) found three dimensions of the illness that lead to social rejection: when people perceive the disorder to be the individual’s own fault (as opposed to a stressful childhood or genetics), when they perceive the mental illness to be dangerous, and when the mental illness is rare. This means that stigma does not affect everyone in the same way, as some groups (including diagnosis, gender, social, and cultural) appear to be more affected than others.

In reference to families where a parent has a mental illness, public stigma appears when someone views the parent with the mental illness as “deviant” or “incompetent,” makes negative judgments about his or her parenting competence based on the parent’s mental health status, and then acts accordingly – for example, reporting the parent to the child-protection services (Figure 6.1). It needs to be pointed out that parents with a mental illness, just like other parents in the community, “can have parenting skills ranging from excellent to maltreating” (Mullick et al., 2001, p. 489), and that a parent’ s diagnosis alone is insufficient to determine parenting capacity.

Self-stigma

Self-stigma occurs when individuals with mental illness endorse and then internalize a certain stereotype about themselves. In this process, self-stigma leads to automatic thoughts and negative emotional reactions including shame, low self-esteem, and diminished self-efficacy (Larson and Corrigan, 2008). As a consequence, they may avoid social gatherings or stop looking for employment (Larson and Corrigan, 2008). Self-stigma serves as a barrier to recovery and leaves an individual susceptible to further mental health problems.

Those who have a mental illness and adopt negative public stereotypes about mental illness often feel ashamed and embarrassed. Because of this shame, they try to hide from others that they have a mental illness and do not seek assistance for their mental health issues. This means that while some people may recognize that they have mental health problems, they are often reluctant to seek help, because they do not want to be seen as a member of a stigmatized group. Those who are ashamed of their mental illness are late to admit their illness, less likely to begin treatment, and more likely to drop out of treatment prematurely (Corrigan, 2000).

A survey conducted by SANE Australia (2013) found that three-quarters of parents with a mental illness report feeling embarrassed by or ashamed of the idea of asking for help. These self-stigmatizing messages might be promoted by family members who themselves are ashamed that someone they are related to has a mental illness. As a result, many families believe that their relationship with a person with mental illness should be kept secret, or will otherwise be a source of shame to the family (Corrigan and Miller, 2004). This might lead to situations in families where everyone, including children, knows that something is wrong but no one discusses the “elephant in the room.”

Because of self-stigma, parents with a mental illness may engage in a series of unhelpful self-talk messages such as “I am not really ill; I just need to pull myself together” or “because I have a mental illness I am a terrible mother.” These beliefs then lead to the parent withdrawing and not discussing the mental health difficulties with others or seeking help. Alongside public views about mental illness (associating mental illness with violence) and laws in some countries where having a mental illness is sufficient grounds for losing custody of children (e.g., Kaplan et al., 2009), parents may be especially reluctant to ask for assistance for their mental health problems or assistance for their family.

While the person with the mental illness may experience self-stigma, relatives of the individual experience a different form of stigma, known as associative or courtesy stigma.

Associative stigma

Relatives of someone with a mental illness may be stigmatized because of their association with that individual, in what is known as “courtesy stigma” (Goffman, 1963) or “associative stigma” (Mehta and Farina, 1988). Thus, the prejudice and discrimination associated with stigma is extended to family members, because they are associated or somehow linked to a person with a stigmatized mark. In this way a child whose parent has a mental illness might be considered to be contaminated by their parent, either genetically or by association (Corrigan and Miller, 2004). In an early study in this area, Mehta and Farina (1988) found support for the notion of contamination, as those who had a depressed, alcoholic, or incarcerated father were perceived by others as experiencing more difficulty than those who had a father who was old, was frequently absent, or had only one leg. Koschade and Lynd-Stevenson (2011) found that children whose parents have a mental illness are viewed as having negative personal characteristics when people believe that the parent’s mental illness is caused by genetic or hereditary factors and the child’s risk of developing the same disorder as the parent is high.

Associative stigma may result in family members being teased or abused because of their mentally ill relative (Larson and Corrigan, 2008). Similarly, family members might be rejected, blamed, or avoided by others, resulting in hurt, disappointment, and shame (Karnieli-Miller et al., 2013; Reupert and Maybery, 2007). Some people believe that children acquire mental illness because of poor parenting or because parents did not do enough to support them (Larson and Corrigan, 2008). The subsequent shame leads family members to avoid social contact or not to want to be seen as associated with the relative with the illness. Family members may then spend energy and resources on hiding the secret from others (Larson and Corrigan, 2008). As a consequence, families learn the “art of selective disclosure” in terms of what they reveal and with whom they share information (Karnieli-Miller et al., 2013).

Some health problems are more contaminating than others. Corrigan et al. (2006) found that children whose parents had a drug-dependence problem were seen as showing more contamination than children whose parents had schizophrenia or emphysema. Compared to families of people with schizophrenia and emphysema, family members with relatives who were drug dependent were blamed more for the onset of their relatives’ condition and for relapses, and were more likely to be avoided socially. Family members of those with schizophrenia were viewed as more pitiful than the emphysema group. The idea of contamination might come from others (Koschade and Lynd-Stevenson, 2011) or from the children themselves, who see that their family is different and contaminated (Hinshaw, 2007).

The implications of associative stigma for children whose parent has a mental illness are profound. People in the community may pity them (Gladstone, 2014), avoid them, or tease them for having a “crazy mother.” If a child does present with mental health or behavioral difficulties, professionals may attribute this to the parent’s own mental illness and “blame” the parent. As a consequence, children may avoid being seen with their parent, and parents may be reluctant to discuss any concerns they have about their children.

See Figure 6.1 for all three stigma phenomena. While public stigma, self-stigma, and associative stigma are presented separately, their impact is likely to affect and augment each other (Corrigan, 2004).

Stigma, culture, and gender

Culture influences stigmatizing beliefs and attitudes by determining those behaviors considered to be normal and those seen as odd or deviant (Abdullah and Brown, 2011). For example, in some Middle Eastern cultures, it is acceptable to have visions or hear imaginary voices, but in most Western countries these incidents would be considered indicators of psychotic disorder (Rashed, 2013). This means that whether or not a certain public stereotype is endorsed is influenced by an individual’s cultural history and socialization. Likewise, people who grow up with repeated media images of patients with mental illness being violent might well endorse that view. For those with a mental illness, the same process is at play in self-stigma, meaning that they are likely to internalize stereotypes about themselves consistent with what they have been socialized to believe (Abdullah and Brown, 2011).

Moreover, stigma is a gendered construct, as men and women are subject to different social expectations and forms of discrimination. For example, men with a mental illness may be seen as not living up to masculine ideals of strength, self-sufficiency, and control (Price-Robertson, 2015). More research is required to explore potential differences in how mothers and fathers with a mental illness experience stigma as well as how others perceive them, including potential differences between community views of mothers and fathers with a mental illness.

The attitudes of professionals towards those with a mental illness

It might be assumed that because of their experience and training mental health professionals would have more positive views of mentally ill patients than the general public; research suggests otherwise. For example, in Switzerland, people with schizophrenia report the following comments made by health professionals: “you’ve got schizophrenia – you will be ill for the rest of your life” or “your illness means that you will end up committing suicide” (Schulze, 2007, p. 304). In a sample of Italian mental health professionals, Magliano and colleagues (2004) found that 54% agreed that people with schizophrenia should not get married, and 64% agreed that people with this disorder should not have children. Only 29% of nurses and 16% of psychiatrists felt it was ‘‘not true’’ that a woman with schizophrenia could recover sufficiently to be trusted as a babysitter. Even though professionals might have a significant knowledge of mental illness, this does not necessarily translate into better attitudes.

Some professional groups appear to hold more stigmatizing attitudes than others. Lauber and colleagues (2006) found that psychiatrists showed more negative attitudes than other professionals, rating persons with mental illness as more dangerous, less skilled, and more socially disturbing than did psychologists, nurses, or other therapists. As different training experiences and treatment paradigms affect attitudes, antistigma programs might need to be tailored to different groups.

Corrigan and Miller (2004) argue that instead of judging the views of mental health professionals as stigmatizing, we should recognize that some of their views, especially the idea that children with mentally ill parents experience more difficulty than other children, might be an accurate perception of the kind of psychological stressors these children endure. The research is still unclear as to whether mental health professions see these children as contaminated and so shameful and deviant, or pitiful, or as resilient young people facing adversity.