Why should we care about stigma?
Stigma affects many people in society, from race and gender inequality through to people living with mental health problems like bipolar disorder. It is a huge issue with myriad consequences, not least that individuals may experience knock-on effects of stigma that can even outweigh those of the mental health disorder itself. By extension, family and friends may also experience stigma, also known as ‘courtesy’ or ‘association stigma’.
How might an individual be affected by stigma?
An individual experiencing stigma may form negative attitudes and behaviours about him or herself (self-stigma), and may:
• be less likely to acknowledge and recognise illness
• be less likely to seek, accept or complete treatment
• have reduced self-esteem and self-efficacy
• have more problems at home
• have more problems with employment
• have more problems socially, in turn leading to isolation. An individual might notice friends and family withdrawing, or alternatively being overbearing / patronising, or not believing in his or her abilities.
Isn’t stigma decreasing?
Despite the globally large number of public campaigns, high school education and media coverage about mental health, one might think that stigma would be less prevalent. However, according to the General Social Survey which collects data about U.S. residents, the public is in fact more stigmatising – despite increased knowledge about mental illness – than back in the 1950s.
The reasons for this surprising worsening of public opinion include:
• Exposure to the public of high numbers of people with untreated mental illness
• Lack of strict regulation on media portrayal of the mentally ill, such as over-emphasis on diagnosis in violent crime reports, use of prejudicial words such as “crazy”, inaccurate representation of mental illness in film (a study of various horror films concluded, “Homicidal maniacs are the most common stereotypes. Misinformation is often communicated. Familiar horror tropes are used to stigmatize mental health care environments.”
• Stigmatisation and trivialisation of mental illness such as the common use of terms like “schizo”, “psycho”, inaccurate self-description as “bipolar” for normal mood swings or “depressed” for being simply sad.
What is stigma?
Ostracisation of members of society has existed as far back in history as ancient Greece. For example, in Athens, traitors and slaves were physically branded with ‘the mark of shame’ – ‘stigma’ in Greek.
Nowadays stigma is less visible, but most affected are those with mental illness, the homeless, and substance abusers. In one study, it was found that although people with bipolar disorders 1 and 2 experienced the same personal experience of stigma as those with unipolar depression, the impact (in terms of quality of life, social and familial relations and self-esteem) was much worse in people with bipolar disorder.
Stigma can include one or more of the following:
• Stereotyped thinking (through ignorance or misinformation)
• Prejudice (emotional response e.g. disgust, negative attitude)
• Discrimination (behavioural response)
• Globalising (generalising about the whole group an individual is deemed to be part of)
A survey by the Royal College of Psychiatrists in the U.K. looked at public perception of people with severe depression.
The most commonly held beliefs were that these people:
• Were unpredictable (56%)
• Were unable to recover, even with treatment (23%)
• Were dangerous (23%). This is disappointing as studies show people with mental illness are in fact more likely to be victims than perpetrators of violence.
• Could pull themselves out of it (19%)
• Had only themselves to blame (13%)
Dr Kay Redfield Jamison, Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, U.S.A. is well known for her work on bipolar disorder as well as her autobiographical account of her own experience of the condition. She states that these study figures are even higher when applied to people with bipolar disorder.
It is possible bipolar disorder may appear unpredictable due to its sometimes-fluctuating nature, depending on whether the individual is relatively well and getting treatment and support, or experiencing a period of depression, mania or mixed state.
A little more about self-stigma
It is not uncommon for an individual with bipolar disorder to experience negative beliefs about him or herself, which may reduce self-esteem and self-confidence. Worse still, this state of mind may lead to avoidant behaviours like not pursuing opportunities, or not challenging negative self-beliefs by gathering evidence to the contrary.
Even within the medical profession there is stigma from, and towards, other healthcare providers. Compassion without sufficient knowledge may be a contributing factor in some cases.
Dr. Jamison offers an interesting observation that the ‘silently successful’ get well because they have sought and received good care, yet they remain silent for fear of personal or professional reprisal. This in turn perpetuates the public’s misconception that the mentally ill don’t get better.
Where to from here?
Fortunately, clinicians and researchers in many countries are increasingly aware of the rise of stigma and driving ongoing important work in this field. Though there is no one simple solution, here are some helpful, evidence-based suggestions for moving forward.
A Canadian study recommended six approaches to stigma reduction:
• Contact-based education
• Legislative reform
• Stigma self-management
Education could be directed at the public or specific groups such as within schools or the workplace. Protest could be in the form of formal objection to stigmatising individuals or groups. Contact-based education has been found to be particularly useful, where a member of the public hears the personal story of someone with mental illness; this person should be doing well and be successfully managing their condition. It is not necessary for the contact to be in person, and could be via an online video, though this may be less effective. Stigma self-management should include education (for example peer-supported self-learning and recovery-orientated supports and services).
Individuals, friends and family
On an individual level, it should be noted that self-stigma can manifest and be managed in different ways. In CREST.BD’s Stigma123 Webinar, Natasha Kolida, a student and researcher with bipolar disorder, encourages education as well as being holistic and self-compassionate in one’s journey. More about CREST.BD in a moment.
Dr. Jamison advises:
• Patients and family members should be aware of their political strength as they make up a large percentage of voters.
• There needs to be more work with medical and mental health communities, including open discussion and change. In particular, work needs to be done in the area of medical care for health care providers, who currently risk penalties in disclosure that are often not in keeping with their quality as practitioners.
• Public campaigns should be on a more positive note, with more emphasis on neuroscience research and the benefits of treatment.
In 2014 Dr. Roumen Milev, Professor of Psychiatry and Psychology at Queen’s University, Canada ran a CREST.BD webinar about overcoming stigma in bipolar disorder. In this presentation, he describes a fascinating community-based recovery-orientated course provided to 8-10 participants with mood and anxiety disorders. Comprising seven closed two-hour sessions, content included education about stigma (covering self-stigma, family, friends and medical settings; education, housing and the workplace); some sessions taking the form of group workshops with brainstorming and role play.
Perhaps this is the sort of course we could make widely available in Australia to complement our current inpatient and community programmes for those with bipolar disorder.
Who is CREST.BD?
CREST.BD describes itself as “The Collaborative RESearch Team that studies psychosocial issues in Bipolar Disorder…CREST.BD is a multidisciplinary collaborative network of researchers, healthcare providers, people living with bipolar disorder, their family members and supporters.” Bipolar Life’s patron, Professor Greg Murray, is Deputy Lead and a key researcher with this inspiring international team.
CREST.BD’s website includes excellent resources and tools including videos on stigma, cognition, sleep, mood, physical health, home, self-esteem, leisure, relationships, spirituality, money, independence, identity, work and study for people with bipolar disorder.
Media and beyond
Finally, looking at how we can make a difference on a larger scale, StigmaWatch is a constructive program run by national mental health charity, SANE Australia. Its aim is to promote responsible reporting of mental illness and suicide in Australian media and is supported by Mindframe, an Australian Government initiative. This is a great example of protest being used as a tool to improve public perception of mental illness. SANE encourages anyone to report to StigmaWatch if they see inaccurate or inappropriate terminology or reporting of mental illness or suicide.
SANE’s website states that “Mindframe has also developed resources for media professionals, journalism students, scriptwriters, police and courts, and conduct briefing sessions with media organisations to discuss issues relating to mental illness and suicide”.
With so much research and an increasingly evidence-based approach to combatting stigma, individuals have more power than ever to influence how bipolar disorder is seen in society. In addition, the many tools available can greatly assist an individual to reduce self-stigma and embrace life more fully.
Dr Alice Lam / 17th September 2019
Alice Lam has worked as a GP both in the UK and Australia. She has a particular interest in mental health, and is a member of the Australasian Medical Writers Association.
YouTube. 2019. Discrimination and Stigma Against Patients with Depression and Bipolar Disorder. Johns Hopkins Medicine. [ONLINE] Available at: https://www.youtube.com/watch?v=9Hc0NF89ryg. [Accessed 17 September 2019].
YouTube. 2019. Bipolar Disorder Stigma, Suicide & Families. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=_eE8YSSo-tA&t=1582s. [Accessed 17 September 2019].
YouTube. 2019. Overcoming Stigma in Bipolar Disorder: Challenges and Opportunities. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=yDJ4DSZ0Id0&t=2258s. [Accessed 17 September 2019].
YouTube. 2019. CREST.BD’s Stigma123 Webinar Jan2016. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?time_continue=234&v=LKkpvPD903Y. [Accessed 17 September 2019].
Goodwin, J., 2014. The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty‐First‐Century Horror Film (Part II). Perspectives in Psychiatric Care, [Online]. 50/4, 224-234. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ppc.12044 [Accessed 17 September 2019].
Arboleda-Flórez, J., 2012. From sin to science: fighting the stigmatization of mental illnesses.. Canadian Journal of Psychiatry, [Online]. 57(8):, 457-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22854027 [Accessed 17 September 2019].
CREST.BD. 2019. New directions in bipolar disorder research, treatment and care. [ONLINE] Available at: http://www.crestbd.ca/. [Accessed 17 September 2019].
SANE. 2019. StigmaWatch. [ONLINE] Available at: https://www.sane.org/services/stigmawatch. [Accessed 17 September 2019].