Challenging the Stigmaof Mental Illness

“This book starts with a personal approach to stigma especially its horrendousconsequences for individuals and families and ends with the important

pronouncement that stigma is an example of social injustice. Along the way,it provides conceptually driven yet highly practical and useable strategies for

combating stigma at multiple levels. An invaluable resource for anyoneinterested in countering the huge issue of mental illness stigma; bravo!”

—Stephen Hinshaw, Professor and Chair, Department of Psychology,University of California, USA

“This is a book for everyone for our patients, healthcare professionals and

the general public. The issues surrounding stigma are raised withoutunderestimating complexity, while still making the concepts understandable.

Challenging the Stigma ofMental Illness explores the promising pathways, aswellas those that will have unintended consequences. It ends, as all books on this

subject should, with a rallying call for parity for those with mental illness.”

—Til Wykes, Professor of Clinical Psychology and Rehabilitation,

Institute of Psychiatry, King’s College London, UK

Challenging the Stigmaof Mental Illness

Lessons for Therapists and Advocates

Patrick W. CorriganDavid Roe

Hector W. H. Tsang

This edition first published 2011� 2011 John Wiley & Sons Ltd.

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The right of Patrick W. Corrigan, David Roe, Hector W. H. Tsang to be identified as the author of thiswork has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means, electronic, mechanical, photocopying, recording orotherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the priorpermission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Corrigan, Patrick W.Challenging the stigma of mental illness : lessons for therapists and advocates /

Patrick William Corrigan, David Roe, Hector W.H. Tsang.p. ; cm.

Includes bibliographical references and index.ISBN 978-0-470-68360-6 (cloth)1. Mental illness–Social aspects. 2. Mentally ill–Public opinion. 3. Stigma (Social psychology)I. Roe, David, 1966- II. Tsang, Hector W. H. III. Title.[DNLM: 1. Mental Disorders–psychology. 2. Mental Disorders–therapy. 3. Attitude to Health.

4. Mentally Ill Persons. 5. Prejudice. 6. Social Perception. WM 140]RC455.C66 2011362.196089–dc22

2010035848

A catalogue record for this book is available from the British Library.

Set in 10.5/13pt Minion by Thomson Digital, Noida, IndiaPrinted in

1 2011

We dedicate this book to those fightingthe good fight against stigma.

Contents

About the Authors ix

Foreword: Robert Lundin xi

Preface xiii

Acknowledgments xxi

1 Stigma is Personal 1

2 Understanding and Measuring Stigma 23

3 Challenging the Public Stigma of Mental Illness 55

4 Addressing Self-Stigma and Fostering Empowerment 115

5 Addressing Structural Stigma 169

6 Stigma as Social Injustice 189

References 199

Learn More About It: Resources and Chapter References

by Jennifer D. Rafacz 207

Index 225

About the Authors

Patrick W. Corrigan is Professor and Associate Dean for Research at theInstitute of Psychology, Illinois Institute of Technology in Chicago. Prior to

that, Corrigan was Professor of Psychiatry and Executive Director of theUniversity of Chicago Center for Psychiatric Rehabilitation for 14 years.

Dr. Corrigan has spent most of his career working to provide and evaluateservices for peoplewith psychiatric disabilities and their families. Realizing that

the effects of psychiatric rehabilitation are limited by mental illness stigma, hehas spent the past decade broadening his research agenda to include the

prejudice anddiscrimination ofmental illness.Hiswork has been supported byNIMH for much of this time to, among other things, develop and lead the

Chicago Consortium for Stigma Research; he is its principal investigator.Recently, the Consortium evolved into a national collection of researchers withsupport from an NIMH developing center grant. The National Consortium

includes colleagues from Yale, UPENN, and Rutgers. Corrigan has authoredmore than 250 journal articles and 10 books. He is also editor-in-chief of the

American Journal of Psychiatric Rehabilitation.

David Roe is Associate Professor and Chair of the Department of Community

Mental Health, Faculty of Social Welfare and Health Sciences, University ofHaifa, Israel. His research focuses on the psychosocial processes of recovery

from serious mental illness and the evaluation of psychiatric rehabilitationinterventions and services. Dr. Roe’s research has been funded by local and

international sources, including NIMH, The Israeli Ministry of Health, TheIsrael National Institute for Health Services Research and Health Policy, the

Israeli National Insurance Institution, and the Tauber and Rich foundations.Dr. Roe has published nearly 100 peer-reviewed journal articles and book

chapters. He serves on the editorial board of the Psychiatric RehabilitationJournal,American Journal of Psychiatric Rehabilitation, and the Israel Journal of

Psychiatry and Related Sciences.

Hector W.H. Tsang is Professor and Program Director of the BSc(Hons) for

Occupational Therapy at the Department of Rehabilitation Sciences, theHongKong Polytechnic University. His research interests focus on supported

employment, social and independent living skills training, and stigma pertain-ing to people with psychiatric disabilities. His research on social skills in the

workplace won the Best Cross-regional Case Study Award in 1996 at the XIVthInternational Conference on the Social Sciences andMedicine organized by the

International Forum for Social Sciences in Health (IFSSH), Scotland, UK.Prof. Dr. Tsang has received research grants from various local and inter-national funding bodies, including the Research Grants Council, Quality

Education Fund, Health and Health Services Research Grants, and NIMH. In2007, he spent a sabbatical at Yale focusing his research on neurocognition

and schizophrenia. He has published more than 100 peer-reviewed journalarticles and co-authored 15 books. Prof. Dr. Tsang is now serving as editorial

member or reviewer for prestigious journals such as Schizophrenia Bulletin,Schizophrenia Research, Psychiatry Research, American Journal of Occupa-

tional Therapy, and American Journal Psychiatric Rehabilitation.

x About the Authors

Foreword

It’s satisfying that Corrigan, Roe, and Tsang understand that mental illnessstigma should be reduced to the personal story. True, stigma cuts a wide swath

on certain issues such as insurance parity, the bias of media reporting, andemployment and housing discrimination. But Corrigan and colleagues un-

derstand that it is in the world of stories, down to the individual person, and tothe individual event, that stigma comes into sharp focus.

Inmy personal experience, as a personwith a schizoaffective disorder, broadissues tend to have less immediacy than a specific occurrence that happened to

mepersonally. The conceptionof employment discrimination as an issue is onething, butwhen Iwasfired fromadataprocessing jobbecause itwasdetermined

that, as a mentally ill person, I was untrustworthy and likely to hack the main-frame computer, that stung. These days, when I put a face on employmentdiscrimination, this is theexperience Iuse. In thisbook, theauthorsexhaustively

chronicle the stories of individuals. The reader should read on for that alone.That said, while this book is comprehensible by the nonprofessional,

Corrigan and colleagues do not overlook the scientific studies that haveunderpinned the understanding of mental illness stigma. There is a substantial

body of scientific literature on stigma, labeling, and discrimination. Theauthors have contributed much to these studies. I’ve had the opportunity to

workwith Pat Corrigan on some of his best studies on stigma reduction, that is,ways to ameliorate stigma in the general population. The authors present thesein detail in this volume.

Otherwise, to understand Corrigan et al., look at their choice of language.They use powerful adjectives in condemnation of the phenomenon:

venomous, poisonous, criminal, discriminatory. The authors are passionateabout their work to reduce stigma in society; they recognize the pain and

suffering forwhich stigma is responsible. Repeatedly, Corrigan, colleagues, andmany in the anti-stigmamovement refer to stigma as something of an animate

object. It is the snake that spits venom; it is a criminal that robs people of theirdignity. Thus stigma is looked upon as an enemy, an opponent, a villain out to

rob people of their self-respect and make the lives of innocents, who neverchoose to have these no-fault disorders, miserable and wretched.

Are these proper attitudes to be taken by researchers? Is the research done bythe authors subject to bias because of their priorities? By all means no! Mostinvestigators in the field ofmedicine take on a disease or affliction with the bias

of eradicating it. The only difference that lies in psychiatry is that the symptomsof the disorder are behavioral. For instance, a person with bipolar disorder

spends toomuchmoney. A personwith paranoid schizophrenia wears amuletsaround his neck to protect him from evil spirits who are chasing him. These are

indeed symptoms of an underlying disorder but they are behavioral and notreadilymeasured by a CAT scan or a blood test. Likewise, society’s stigmatizing

behaviors are the targets of Corrigan, Roe, and Tsang’s attacks. Their mind-setis equally as valid as the attack mentality that other researchers have heaped

upon HIV, tuberculosis, and polio.This book will bring out the truth about mental illness stigma and the

terrible effect that it has on people stigmatized by it. In co-writing Don’t Call

Me Nuts: Coping with the Stigma of Mental Illness (Recovery Press, 2000) withPat Corrigan, I discovered how deep his expertise runs. In the last two decades,

Corrigan and colleagues have done serious and voluminous research onmentalillness stigma, and in the pages of this book a great deal of that expertise can be

absorbed. I can’t emphasize enough how, for many people with mental illness,in all countries and cultures, stigma is to blame for a great amount of their

angst and suffering. A thorough examination of the topic is not onlywarranted,it is fundamental.When Pat Corrigan askedme to write a foreword to a book on stigma for an

international market, I had a moment’s hesitation, primarily because I hadbeen away from academia for five years. But then again, in that interim, as the

consumer member on two different Assertive Community Treatment (ACT)teams, I have worked on dozens of real-life cases. I’m no longer in an ivy tower.

I am learning a fascinating but heartbreaking education into the real stigmasfacing people in America who must cope with chronic and severe mental

illnesses. Their lot and mine are different but much the same. This book iswritten for us all.

Robert Lundin

Glen Ellyn, Illinois

xii Foreword

Preface

The stigma of mental illness robs people of their rightful opportunities inwork, relationships, housing, health care; all arenas in which a full life is

achieved. Just as research has uncovered some best practices for helpingpeople with serious mental illness1 overcome their disabilities, so there are

similar “treatments” for erasing stigma, replacing it with affirming beliefsand actions. Interventions that promote stigma change are obviously dif-

ferent from what has been developed for the illness. Still, there is a collectionof principles and practices that can stop the harmful effects of stigma, justlike evidence-based skills manuals that help people live independently.

Evidence is beginning to coalesce, suggesting strategies that are effectivefor challenging the public or self-stigma of mental illness. The distinction

between public, self, and structural forms of stigma is key to the organizationof the book and discussed more fully in Chapter 2. Briefly, public stigma is

the harmful effect that occurs when the general population endorsesprejudice and subsequently discriminates against people with mental illness.

Self-stigma occurs when people internalize the stigma and beat themselvesup with. Structural stigmas are the social forces that emerge after many yearsof public stigma.

1 Language is a major consideration in understanding mental illness stigma. Referring to

psychotics or patients frames people in a light that perpetuates discrimination. Alternatively,

and consistent with the zeitgeist, we use person first language. Hence, instead of schizophrenic we

write persons with schizophrenia, not thosemental patients but people consumingmental health

services. Person first language reminds members of the public about personhood, namely, that

the individual is first known as a person and all its intricacies with illness taking a distant backseat.

Advocates of all stripes have come to understand the harmful impact ofstigma over the past decade and have joined together to challenge it. Since

1996, the World Psychiatric Association has been a leader in developing anti-stigma programs with its Open the Doors program. Professional groups of

psychiatrists adopted the WPA model with programs emerging in more than30 countries. More recently, the World Health Organization convened a 2005

meeting in Helsinki solely on the issue of stigma and discrimination againstpeople with mental illness. Individual countries have also recognized the call

for change and provided significant resources for broad anti-stigma pro-grams. In 2000, Australia launched beyondblue, a grass-roots program meantto increase public understanding about such disorders as depression, anxiety,

and substance abuse. Other countries have only jumped into the fray in thepast year or so: New Zealand’s Like Minds, Like Mine; Britain’s Time to

Change; Canada’s Opening Minds; and the US’ What a Difference a FriendMakes. Of many benefits, common to all of these are websites where the

interested viewer might learn more about mental illness and obtain more andpersonal help.

One of the most interesting, and perhaps unintentional, anti-stigma effortsoccurred in Japan. In 2002, the Japanese Society of Psychiatry and Neurology

replaced the standard term for mental illness “Seishin-Bunretsu-Byo” (Mind-Split Disease) with “Togo-Shitcho-Sho” (Integration Disorder). They rea-soned that, among other things, public stigma ofmental illness would decrease

with a more disorder-sensitive term.Many of the national anti-stigma programs mentioned in the preceding

paragraphs are society-wide, adopting media-based approaches to changingthe message. Experts call this social marketing and frequently include public

service announcements (PSAs), support materials, and online guidance, allfor the general population. These provide factual information about mental

illness and witness to first-person testimonies, life stories by real people withmental illness and their experiences with recovery. PSAs and related cam-paigns have benefits and limitations. They offer a venue to disseminate a

message to the largest possible group of people. For example, the program inLondon logged more than 100,000 hits on its webpage in the month after

Time to Change was rolled out. The US Substance Abuse and Mental HealthAssociation, sponsors of What a Difference a Friend Makes, found an

exponentially higher hit rate. PSAs often have dramatic voice that motivatesthe masses. “Singing to the choir” is one effect of social marketing campaigns.

PSAs have little effect on people who are of unaware of problems due tostigma: “Not me! I don’t discriminate against the mentally ill.” Instead, PSAs

sing to the choir; they are a clarion call to socially active people who arealready sensitive to issues of prejudice and discrimination on any minoritygroup. These calls organize people who, for example, are already mindful of

xiv Preface

social ills like racial injustice, teaching this motivated group that mentalillness stigma is also an issue of prejudice and discrimination. In this light,

PSAs provide direction for nascent advocacy groups to challenge stigma andspread affirming messages.

Stigma Change is Targeted and Local

Alternatives to PSAs and social marketing may be understood in terms oftargeted and local. TipO’Neill, speaker of theUSHouse ofRepresentatives from

1977 to 1987, used to say “all politics are local.” He meant that successfulelection to government office is achieved only by pressing the flesh andmeeting

constituents in one’s district. Mr. O’Neill, now deceased for 15 years, mightquestion the twenty-first century’s fascination with marketing and media to

spread the message and get out support. He would say advocacy groups shouldalso consider targeted and local approaches to change. Targeted means the

program attempts to change stigmatizing attitudes and behaviors of key groupsin the lives of people stigmatized for their mental illness; for example, employ-ers, landlords, health care professionals, teachers, police officers, and legislators.

These groups are defined in terms of relative, potential power over the personwith mental illness. Employers might have power regarding the person getting

back towork, the property owner in terms of housing, and legislators in terms ofresources for mental health programs. Targeted anti-stigma programs have

significant effects because they are crafted to include content and processesrelevant to the interests and concerns of a particular group. A program for

employers might include activities that address whether a person with mentalillness will be a risk to co-workers ormay not be able tomeet productivity goals.Employer “peers” are likely to sway attitudes and behaviors more than other

group leaders, because of their automatic credibility with business leaders.The stigma of mental illness will likely interact with other prominent social

forces. Prominent amongwhat we call local effects are ethnic differences whichcombine with mental illness stigma for compound effects. People of African

backgrounds living in Western Europe experience a different sense of cultureand opportunity from the majority. “If you think being mentally ill is hard, try

also being black and poor!” One project by Corrigan on African AmericanChicagoans showed their faith communities to have amarkedly greater impact

on stigma than experiences of people with European roots. “Admitting tomental illness is letting your church down!” Local diversity issues are notlimited to ethnicity. Gender, socio-economic status, education, and sexual

orientation are also factors that may potentially impact stigma. We would

Preface xv

expect, for example, the personal decision to disclose one’s mental illnesswould be measurably influenced by gay and lesbian experiences about coming

out. Incorporating them into programs is likely to yield a program with morepotent influences on stigma change.

The focus on target and locality leads to benefits not necessarily had by PSAsand social marketing. Targeted and local provide an avenue for advocates

themselves to pursue stigma change rather than relying on more macro-,typically government-based, efforts.

It would be nice if the whole world would stop their biases but I am not sure this

can be done. At the end of the day, what I really want is for employers to hire me

and landlords to rent to me, for them to stop stigma and say, ‘‘You can do it!’’

Targeted approaches focus the critical lens from the seeminglymassive focus ofPSAs to the beliefs and behaviors of more immediate groups.

Don’t Call Me Nuts! Coping with the Stigmaof Mental Illness

Whether it is local or society-wide, there is an armamentarium of strategiesfrom which advocates might select to challenge stigma. In 2001, one of us

(PWC) partnered with Robert Lundin to write Don’t Call Me Nuts! CopingWith the Stigma of Mental Illness.2 The first pages of Don’t Call Me Nuts

accepted the premise that the quality of life of people with mental illness iswounded by stigma. From that assumption, we focused on an array ofstrategies that might diminish mental illness stigma. A decade has passed

since then and the research evidence on stigma has increased by about fivefold,from 52 in 1988 to 247 in 2008. These data have begun to be used, in part, to

identify the strengths and limitations of anti-stigma programs.Challenging the Stigma of Mental Illness is an update of many of the ideas in

Don’t Call Me Nuts. Some sections were taken directly from Don’t Call MeNuts. It was then colored by what is known about stigma change in the recent

research literature. Investigator and practitioner were sometimes odd bed-fellows in writing Challenging the Stigma of Mental Illness. Scholarly booksoften lose the practical reader in esoteric consideration of methods and

analyses. For this reason, we purposefully decided to keep research references

2 The last section of the book – Learn More About It: Resources and Reference – provides

information on relevant references including recommended readings.

xvi Preface

in Challenging the Stigma of Mental Illness to a minimum and in favor of “howto” prescriptions.3We direct interested readers to existing research-based texts

including two by our group (Corrigan, 2005; Corrigan & Shapiro, 2010).

For Whom is this Book Written?

We have thus far referred to advocates as the agents of change in anti-stigmaprograms. The book is primarily meant for the doer, for the activist per se, a bit

of a different readership from most professional books target. Advocate is amulti-level term, however. It includes several different kinds of stakeholders.

Prominent among these is the group charged in most cultures with addressingpsychiatric illness and disease: the mental health service provider, the

“therapist.” This is the provider who, through their education, experiences,and commitment, builds personal and therapeutic relationships with peopleseeking assistance for mental illness. We define therapists in terms of their

helper role and challenge them herein to broaden their approach from just theproblems of the person to those of the community in which the person lives.

“Therapist” is broadcast in the book’s title because it is an important group forcomprehensive stigma change.

Therapist is a complex idea frequently split into professionals and para-professionals. Some professional disciplines seem to naturally be in touch with

the stigma problem: social workers, for example, because of their sensitivity toproblems “in the world” and psychologists who have learned the kind of social

cognitive ideas that are basic to mental illness stigma. Challenging the Stigmanaturally corresponds with readers of this kind. But psychiatrists, nurses, andother medical personnel have an equally important role, if not more so, as

therapists taking on the stigmamantle. They are the groups inmanyparts of theworld with legal authority over services provided to people withmental illness.

This legal role reflects our assertions about social injustice. Alternatively thereare paraprofessionals. These are non-degreed providers who often work in the

trenches and hence are more available to people as they struggle with theirmental illness and the stigma that accompanies it.

There is irony in including therapists in such an important role. Researchoften suggests mental health professionals are among the most stigmatizinggroups of the general population. At first thought, this seems counter-intuitive,

that the group of people who choose themselves for such a therapeutic

3 Still, we do cite important papers where corresponding evidence-based ideas are available. We

start these citations in Chapter 1.

Preface xvii

relationship should be among the more prejudiced. One reason might be theskewed picture drawn of therapists. Simply put, the mental health provider

only sees people when they are acutely ill.When they seembetter, theymove onfrom the helping relationship. This is especially noticed at inpatient settings

where people are psychotic.Whatever the reason, psychiatrists, social workers,and others need to be actively recruited to assume their rightful place in the

stigma change movement.Obviously, then, a prominent group of readers are people in the helping

professions. The message of the book has relevance to both in-service and pre-service efforts for them. Grand rounds and other programmatic activity inpublic and social psychiatry are natural venues for in-service programs. Of

equal, if not greater, importance is the agenda to educate early career profes-sionals so they are not tainted by some of the stigma that has already infected

the professions. Hence, the book has a role in graduate courses in social work(especially in clinical social work and adult psychiatry) and advanced courses

in both clinical and rehabilitation psychology. Advocates have put specialefforts into medical students and residents, often presenting first-person

accounts of recovery to medical students.As said earlier, stakeholder is multi-level. We have just described the role

of therapists in the anti-stigma agenda. Also important, in fact the lead agent,are people with mental illnesses themselves. They are the group directlyharmed by stigma and hence most invested in stigma change. Still, even the

idea about person is complex, and varies with the way the person frames hisor her mental illness. One way this has been defined is in terms of user (or

consumer in some places), ex-patient, and survivor. Users are people withmental illness who are choosing, at a specific time, to meet with a

professional or paraprofessional to address some problem or goal relatedto the mental illness. Ex-patient sometimes refers to people who, at another

time, are not consuming services. Note that the person with mental illnesscan move back and forth between user and ex-patient roles depending onneed. Other advocate groups, however, view ex-patients as an angry term;

they are people who, not only are no longer in need of services, but believe“breaking off ” from such services is an important step in recovery. Survivor

reflects this anger even more. In most advocacy communities, survivors donot represent people who have survived the illness, but rather the treatment.

Obviously the level of energy and assertiveness varies depending on the waythe person sees him- or herself. Keep in mind that there are many people

who do not find this three-group definition meaningful. Patient is promotedmore by some research participants and in many others, just person with

mental illness is sufficient.The book also interchangeably refers to mental illness and serious mental

illnesses. In part, this lack of precision represents our mixed opinion about

xviii Preface

mental illness stigma. Some research has shown that public stigma varies withdiagnosis, with alcohol and substance abuse viewed most negatively and

depression more benignly. Research of this ilk illustrates an interesting point;namely, that the type of stigma varies across diagnoses. One diagnostic group is

not universally disparaged. It is not surprising to find substance abuse viewedas more dangerous than schizophrenia, which in turn is judged more harshly

than anxiety disorders. However, prognosis (The person won’t get better!) isanother important stigmatizing attitude. In this case, people with develop-

mental disorders are viewed most negatively. In addition to the difference ofstigma across diagnoses, there is also evidence of a nonspecific effect. Namely,regardless of the diagnosis, there are negative judgments about people merely

known as having a mental illness. Considerations about nonspecific anddiagnostic effects are important processes in developing anti-stigma programs,

especially self-stigma efforts.There are additional stakeholder groups relevant to understanding stigma

and developing anti-stigma programs. Families, for example, are important.Namely, many cultures in the world view family members as blameworthy in

terms of their relative’s mental illness, or disgusting and an important group toavoid. Family stigma varies by family role. Parents are stigmatized differently

from siblings, who are different from spouses. Already in existence are familyprograms (e.g., Enosh, Israel’s Mental Health Association; Rethink in the UK;Norway’s People to People Foundation; and the National Alliance on Mental

Illness in the USA) which may be natural avenues in recruiting relatives foranti-stigma efforts.

Stigma is an international problem. Note the paradox. As a local enterprise,stigma is an international problem.We know of no society where the stigma of

mental illness is not present and potent. Althoughwemight expect stigma to bea common phenomenon across cultures, in fact local mores are essential to

consider. We would expect stigma to be similar across societies, but find thatstigma notably varies across cultures. For that reason, the book is written byauthors from North America (PC), the Middle East (DR), and Asia (HT). It

was written especially for Western European and other English-speakingreaders including advocates from the United Kingdom. But we suspect the

lessons here are applicable in most other nations. Our decisions on authorshiphave influenced the many examples in the book meant to illustrate our

assertions. This decision brings diverse perspectives to the material.Webegan the prefacewith themessagewe revisit here at the end: Stigma is an

issue of social injustice! It is not a product of disease, an end point of disability,or a flaw in the personwithmental illness. Resolution ofmost of the symptoms

and disabilities focuses on the person with mental illness. The focus of stigmachange rests with the community and society. There are times in the bookwhere we examine changes in self-stigma, where cognitive therapies are touted

Preface xix

as a way to get rid of irrational and hurtful stigmatizing attitudes. But thisshould not lead to misguided notions that stigma is the problem of those with

mental illness and their families. Race is not the problem of people of color.Both social woes are overcome only by concerted and focused efforts to stamp

out the stigma and replace it with rightful opportunity.

xx Preface

Acknowledgments

Many people have influenced our ideas about stigma and stigma change. Theseinclude Beth Angell, Galen Bodenhausen, Thom Bornemann, Jennifer Brown,

Rosalynn Carter, Jennifer Crocker, Larry Davidson, Robert Drake, Sue Estroff,Kelvin M. Fung, Shenghua Jin, Anthony Jorm, Shlomo Kravetz, Chow Lam,

Jonathan Larson, Yueh-Ting Lee, Ada Leung, Bruce Link, Barbara Lurie, PaulLysaker, StevenMarcus, FredMarkowitz, ChrisMarshall, EmelineOtey,Victor

Ottati, Rebecca Palpant, David Penn, Bernice Pescosolido, Jo Phelan, NicolasRusch,Mark Salzer, Norman Sartorius, Jenessa Shapiro, Kan Shi, John Strauss,

Amir Tal, Graham Thornicroft, Paolo del Vecchio, Otto Wahl, Amy Watson,Perla Werner, and Phil Yanos.

Special to our work are people with mental illness who have actively joinedthe battle: Jean Campbell, Patricia Deegan, Daniel Fischer, Virginia Goldrick,Martin Juricek, Robert Lundin, Jay Mahler, Joseph Rogers, Susan Rogers,

Yvette Sangster, and Ilil Tzin.Finally, appreciation goes to our families, who have supported us through

our interminable scholarship. We are only able to bring our messages alivethrough your love. Tomywife Georgeen, and children Abraham and Elizabeth

(PC), my wife Galia, and children Shanee, Eyal, Alon, and Netta (DR), and tomy wife Wai Ming and child Kevin (HT).

1

Stigma is Personal

All great things are simple, and many can be expressed in single words:

freedom, justice, honor, duty, mercy, hope.Winston Churchill

Stigma is not some kind of heady abstraction experienced by an overly sensitive

few. It is a social injustice that discredits many people with serious mentalillness, terribly harming them in the process. Resulting injury is broad and

cutting. Public endorsement of the prejudice and discrimination of mentalillness robs people of such rightful opportunities as a good job, agreeable

housing, and intimate relationships. Internalizing the stigma of mental illnessand directing stereotypical negative attitudes towards one’s self leave people

feeling unworthy and incapable. Many people seek to avoid stigma altogetherby keeping away from places where individuals are taggedmentally ill, perhapsmost notably mental health clinics in their various guises. “That guy, Harry

Black, just came out of Dr. Johnson’s psychiatric clinic; Harry must be crazy.”The threat of stigma, and the effort to avoid the label, are so powerful thatmore

than half of the people with mental illness who would probably benefit frompsychiatric services never obtain even an initial interview with a professional.

Stigma hurts and it is personal.We seek to give voice to stigma here by considering examples of personal

stories; a collection of tales meant to illustrate private experiences of mentalhealth and stigma. These personal stories especially make sense in the mostblatant port for stigma – the media. Stigmatizing images of mental illness in

Challenging the Stigma of Mental Illness: Lessons for Therapists and AdvocatesPatrick W. Corrigan, David Roe, and Hector W. H. Tsang

� 2011 John Wiley & Sons, Ltd

movies, newspapers, television, online, and advertisements are provided asespecially poisonous sources of prejudice and discrimination. We attempt to

make sense of stigma and the media by examining key points in history relatedto public impressions of mental illness and stigma. We then jump in with our

first strategies for stigma change; sensitizing people to stigma which parallels adiscussion about appropriate language. We end this chapter by revisiting the

personal nature of stigma.We imply by the very existence of this book that stigma continues to hurt.

A series of population studies has allowed us to actually examine this assertion.In 1950, Shirley Star and colleagues from the National Opinion ResearchCenter (NORC) conducted face-to-face interviews with a representative

sample of 3,529 American adults (cf. Phelan, Link et al., 2000). Of the manygoals of the survey, Star (1952, 1955) examined public impressions of people

with mental illness. Most important to the point here was whether researchparticipants viewed people with serious mental illness as violent. In 1996,

NORC repeated items from the Star survey as part of a snapshot of NORC’sannual snapshot of contemporary life. On one hand, we expect to show a

decrease in viewing people with mental illness as violent consistent withpopular notions that the general public are more educated about mental

illness than 1950 cohorts. A more sobering response would show no change inattitudes between 1950 and 1996.What is found? Figure 1.1 summarizes relevant data analyses (Phelan et al.,

2000). Stigmatizing attitudes got significantly worse! People in 1996 were

0

5

10

15

20

25

30

35

19501996

Figure 1.1 A summary of research on the dangerousness of people with serious

mental illness. These data were collected in 1950 and 1996. Findings reflect percentage

of survey participants whose description of mental illness includes perceptions of

violence.

2 Challenging the Stigma of Mental Illness