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Introduction

It is believed that about one in five North Americans are living with some form of mental disorder or addiction, but two-thirds will not seek help. This is not due to a lack of mental health resources or effective treatments, but too often because people fear being labelled according to age-old stereotypes of people with mental health problems.

Even clinical depression, which has arguably received the most media attention this past decade, is still stigmatized. A 2005 Australian study noted that around one quarter of people felt depression was a sign of personal weakness and would not employ someone with depression. Nearly one third felt depressed people "could snap out of it," and 42% said they would not vote for a politician with depression.

Addiction, which is a chronic and disabling disorder, is also often thought of as a moral deficiency or lack of willpower, and there is the attitude that people can just decide to stop drinking or using drugs if they want to. The study of the effects of stigma on substance use disorders is still a fairly undeveloped area, but research is revealing that social stigma and attitudes towards addiction are preventing people from seeking help.

Even the helpers aren't immune from the silence of stigma. More than 40% of family doctors, who are in a good position to detect substance abuse problems early, admit in a recent US survey that they find the topic difficult to talk to patients about—more than double the discomfort they admit feeling for depression.

The reality of discrimination has a very direct and real effect on the course and treatment of a person's mental illness or substance abuse problem. The results of the most recent Canadian Community Health Survey indicated that less than a third of people who have symptoms of mental disorders or substance dependencies sought professional assistance. Among the top three reasons why people don't seek help were that they are too afraid to ask, or are afraid of what others would think. Prejudice and discrimination have also been shown to influence treatment behaviour, from attendance at self-help or therapy groups to compliance with medication.

Discriminatory attitudes can also affect people's access to treatment for substance use problems. Someone with a problem may be reluctant to seek help (even through "anonymous" support groups) for fear of society's reaction if they were found to have a substance use problem. Another example is if someone commits a petty theft to get money to buy drugs or alcohol: the criminal behaviour is usually the focus, when what the person really needs is treatment for their addiction.

There is also evidence to suggest that community attitudes and discriminatory behaviours toward mental disorders and addictions may help determine a person's degree and speed of recovery. For example, researchers have found that schizophrenia has a better prognosis, or outcome, in developing nations not because of better medical treatment but because of societal reaction and integration of the person into the community.

The shame and discrimination associated with mental illness is the legacy of an era when the mentally ill were locked away in insane asylums, sometimes for the rest of their lives. Because of a lack of effective treatments, people with mental health needs were regarded as "mentally defective" and incurable.

Change began in the 1960s with the introduction of powerful antipsychotic medications and advances in psychotherapy. As treatments began to offer relief from the more severe symptoms of mental illness, patients were deinstitutionalized across the country and treated on an outpatient basis or in hospital for short periods.

And yet, a 2001 Canadian study of people with schizophrenia still found that social withdrawal had a 'great impact' on their lives while the hallucinatory and delusional symptoms of their illness—thanks to advances in therapy and medications—had the 'least impact' on their lives. As a society, we have done much to alleviate major clinical symptoms of mental illness, but little to alleviate the symptoms of societal discrimination.

The major ways people with mental illness or addiction cope with the effects of self-shame or stigma—by hiding it, by educating people individually, or by withdrawing from potentially stigmatizing social situations—are not only generally ineffective but can be emotionally costly because they affect interpersonal relationships furthering one's social isolation. They also increase fears and worries of being discovered, and maintain a person's negative self-image of themselves. A 2005 study of patient attitudes towards depression found that 29% of people felt their families would be disappointed to know about their depression, 46% would be embarrassed if their friends knew, and 67% felt their employers should not know about their conditions. The study even found that more than a quarter of young adults surveyed did not accept their physicians' diagnosis of depression.

These findings apply to individuals across the societal spectrum. Physicians, for example, often deny their own mental health needs and hide their conditions to protect their careers. A study of medical students revealed that concerns about confidentiality, stigma, notation on academic record, and forced treatment were among the top barriers to mental health care for those in the medical community. As a result, the rate of completed suicides among physicians is much higher than in the general population.

Jane, a 30-year-old biologist who didn't want to use her real name, says that before she sought treatment for clinical depression, she often committed to projects that she could have done if she weren't experiencing mental illness.

"At the time I didn't want to label myself as being depressed," Jane says, adding that she did not reveal her illness to her employers because she feared they would view her as "apparently defective."

Many people do not want an official record that identifies them as having mental illness or an addiction. They fear others might find out, treat them differently and judge them based on these problems. Sadly, in many cases, they are right. Subtle and overt discrimination against mental disorders and addictions continues to be documented by social scientists in the arenas of employment, education, housing, parenting, criminal justice, immigration, and other areas of social and community life.

Jane says that during her illness, her friends and family offered little understanding or support when she was feeling fragile. "People's judgments were really hard for me to accept and take," she says.

The loss of friendships and socio-economic status can affect people's lives long after their symptoms are treated and they are able to resume their daily activities. "Friends and family see you as a depressed person or a potentially depressed person," Jane says.

Negative stereotypes of people with mental illness—that they are lazy, have nothing to contribute or cannot recover—fuel misconceptions about these disorders and perpetuate prejudice and discrimination.

The Royal College of Psychiatrists in London, studying negative views about people with mental illness, found that two-thirds of people surveyed felt that those with schizophrenia and alcoholism—and three-quarters with a drug addiction—were dangerous to others. Over one half felt that those with substance use disorders had themselves to blame. A sizeable minority also indicated they felt people with severe depression, panic attacks or eating disorders could simply pull themselves together.

For some people who are recovering, this can lead to feelings of emptiness, alienation and rejection. The isolation and loneliness may even trigger a depression, substance abuse problems, or a relapse. This drives up the personal cost of mental illness, which is already too high. Prejudice and discrimination are based largely on ignorance, myth and intolerance. The best antidote to this is targeted, community-based education coupled with direct positive contact with individuals who have experience with mental illness.

The knowledge that people can recover from these illnesses and contribute to society can help dispel society's fears and misconceptions about them and encourage more people to open up their hearts to themselves and others who develop a mental disorder.

It's also time to start calling stigma what it is—prejudice and discrimination. Stigma implies there is something wrong with the person while discrimination puts the focus where it belongs: on the individuals and institutions that practice it. Liz Sayce, a researcher from UK's Mind charity who has written extensively on the topic of social exclusion asks why the mental health movement should be any different from other human rights movements; it's not as if we talk about the "stigma of being black—no, we talk of racism." People with mental illness and addictions and their families have been blaming themselves for far too long. It's time to put that energy towards examining society's attitudes, structures and policies.

Facts About Mental Illness

• one in five Canadians has or will develop a mental disorder

• mental illnesses affect people of all ages, educational and income levels, and cultures

• mental illness affects a person's thinking, feeling, judgment and behaviour

• mental illness is not contagious

• although there are no cures for mental illnesses, treatments can reduce the symptoms and help people lead productive and fulfilling lives

• the onset of most mental illnesses occurs during adolescence and young adulthood

• a complex interplay of genetic, biological, personality and environmental factors causes mental illnesses

People with mental illness need caring support: these illnesses can place enormous emotional and financial strains on the person with the illness and their family and friends.

Facts About Addiction

• addictions occur in people of diverse ages, education levels, socio-economic situations, and culture

• addiction is not caused by moral weakness, or lack of self-control or willpower

• no one knows what causes addiction, but there are many factors that increase a person's risk of experiencing problems with substance use: these include biological factors, family situation, school/peer group influences, other social factors, and what sort of tools a person has to cope with stress or other life difficulties

• many people with addictions can't "just stop" using drugs or drinking – they need treatment

Recovering addicts need support from their families, friends, workplaces, and other community groups – such support can help with recovery and decrease the chances of a relapse.

Public Perceptions of Stigma

The Centre for Addiction and Mental Health asked Canadians questions about stigma and its effects. The responses they received:

What does stigma mean to you?

• negative judgment

• judgment based on one aspect of a person's life

• long-lasting labels

• disgrace

• embarrassment and shame

• something you are not proud of and want to hide

• being treated differently from the rest of society

How does stigma affect people?

• violation of human rights (e.g., being treated with less consideration and respect when seeking medical care and housing)

• lack of employment (losing jobs and difficulty getting jobs if substance use problems are known)

• negative feelings about themselves (internalizing negative beliefs of others)

• avoiding services (e.g., disrespectful treatment)

• continuing substance use (to cope with other people's negative attitudes and their own feelings)

Fighting Stereotypes and Developing an Open Mind

One of the best ways to fight stigma and develop an open mind towards people with mental illness is to get to know someone with mental health problems and discover that the illness is only one aspect of his or her life.

Another way is to speak up when friends, family or the media use language that discriminates against people on the basis of mental health problems.

Here are some common signs of prejudice:

• stereotyping people with mental illness (treating them as a group rather than as individuals)

• trivializing or belittling people with mental illness and/or the illness itself

• offending people with mental illness through insults

• patronizing people with mental illness by treating them as less worthy than other people

• reinforcing common myths about people with mental illness: for example, saying they are dangerous, weak, beyond hope, etc.

• labelling people by their diagnosis; the concept of the person as an individual is lost, and the illness is the only relevant characteristic when terms such as paranoid schizophrenic, manic depressive and bulimic are used

• using slang words such as "insane," "schizo" and "psycho," which are often used in news headlines to grab readers' attention

• sensationalizing or accentuating myths about mental illness: for example, a headline such as "Psychotic Bear Kills Camper" links wild animal behaviour with mental illness

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Authors

Special thanks to the BC Partners for Mental Health and Addictions Information for permission to reproduce this article.